Medicare Benefits Schedule - Item 92437

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Category 1 - PROFESSIONAL ATTENDANCES

92437

92437 - Additional Information

Item Start Date:
06-Apr-2020
Description Updated:
01-Mar-2024
Schedule Fee Updated:
01-Nov-2023

Group
A40 - Telehealth and phone attendance services
Subgroup
6 - Consultant psychiatrist telehealth services

Telehealth attendance of more than 45 minutes in duration by a consultant physician in the practice of the consultant physician’s speciality of psychiatry following referral of the patient to the consultant physician by a referring practitioner:

(a) if the patient:

    (i) is a new patient for this consultant physician; or

    (ii) has not received an attendance from this consultant physician in the preceding 24 months; and

(b)  the patient has not received an attendance under this item, or item 91827 to 91831, 91837 to 91839, 92455 to 92457, 91868 to 91873, 91879 to 91881 or item 296, 297, 299, 300, 302, 304, 306 to 308, 310, 312, 314, 316, 318, 319, 320, 322, 324, 326, 328, 330, 332, 334, 336, 338, 342, 344 or 346 of the general medical services table, in the preceding 24 months

Fee: $290.85 Benefit: 85% = $247.25

(See para AN.0.25, AN.0.30, AN.0.31, AN.0.75, AN.0.76 of explanatory notes to this Category)

Extended Medicare Safety Net Cap: $500.00


Associated Notes

Category 1 - PROFESSIONAL ATTENDANCES

AN.0.25

Attendance services for eligible disabilities

Intention and eligibility of this service under item 137 and telehealth equivalent item 92141

Items 137 or telehealth equivalent item 92141 are intended for diagnosis and treatment for patients under 25 years of age with an eligible disability by a specialist or consultant physician.

Definition of Eligible Disabilities is found at AR.29.1.

Referral pathways:

Early identification of, and intervention for, individuals with eligible disabilities is important in promoting positive longer-term outcomes. Symptoms can cause clinically significant impairment in social, occupational or other important areas of functioning.

Where indications of eligible disability concerns have been identified and brought to the attention of the patient’s GP to initially assess these concerns and the GP considers there are persisting indications that require more specialised assessment, they are encouraged to refer to a specialist or consultant physician for a comprehensive assessment.

Diagnostic Assessment:

The assessment and diagnosis of an eligible disability should be evaluated in the context of both a physical and developmental assessment. The specialist or consultant physician may require a number of separate attendances (through usual time-tiered or subsequent attendance items 104, 105, 110, 116, 119, 296, 297, 299, 300, 302, 304, 306, 308, 310, 312, 314, 316, 318, 319, 320, 324, 326, 328, 330, 332, 334, 336, 338, 341, 342, 343, 344, 345, 346, 347 or 349 or telehealth items 91822 to 91831, 91833, 91836 to 91839, 91868 to 91878 to 91882 to 91884, 92437 or 92455 to 92460) to complete a comprehensive accurate assessment and formulate a diagnosis, exclude other disorders or assess for co-occurring conditions.

Multi-disciplinary assistance with assessment and/or contribution to the treatment and management plan:

Depending on a range of factors, not limited to the patient’s age and nature of suspected disabilities, the specialist or consultant physician may require a multi-disciplinary approach to complete a comprehensive accurate assessment and formulate a diagnosis. 

Where the specialist or consultant physician determines the patient requires additional assessments to formulate a diagnosis, through the assistance of an Allied Health practitioner, they are able to refer the patient to an eligible Allied Health practitioner from standard attendance items 104, 105, 110, 116, 119, 296, 297, 299, 300, 302, 304, 306, 308, 310, 312, 314, 316, 318, 319, 320, 324, 326, 328, 330, 332, 334, 336, 338, 341, 342, 343, 344, 345, 346, 347 or 349 or telehealth items 91822 to 91831, 91833, 91836 to 91839, 91868 to 91878 to 91882 to 91884, 92437 or 92455 to 92460.

Whilst MBS items provide for a total of 8 Allied Health assessment services per patient per lifetime, an eligible Allied Health practitioner can only provide up to 4 services before the need for a review (the type of review can be specified in the referral to the eligible Allied Health practitioner) by the referring specialist or consultant physician, who must agree to the need for any additional Allied Health services prior to the delivery of the remaining 4 Allied Health assessment services.

Eligible Allied Health assessment practitioners include:

  • Psychologist (MBS item 82000, 93032, 93040)
  • Speech Pathologist (MBS item 82005, 93033, 93041)
  • Occupational Therapist (MBS item 82010, 93033, 93041)
  • Audiologist, Optometrist, Orthoptist, Physiotherapist (MBS item 82030, 93033, 93041)

Requirements of the referral to Allied Health practitioners

The specialist or consultant physician can refer to multiple eligible Allied Health practitioners concurrently, but a separate referral letter must be provided to each Allied Health practitioner. The referral should specify the intent of the assessment and if appropriate, specify the number of services to be provided. Where the number of sessions is not specified, each Allied Health practitioner can provide up to 4 assessment services without the need for review or agreement to provide further assessment services. 

Review requirements following delivery of 4 Allied Health assessment services

Where an eligible Allied Health practitioner has provided 4 assessment services (through items 82000, 82005, 82010, 82030, 93032, 93033, 93040 or 93041) and considers additional assessment services are required, they must ensure the referring specialist or consultant physician undertakes a review. If the type of review is not specified by the referring specialist or consultant physician an acceptable means of review includes: a case conference, phone call, written correspondence, secure online messaging exchange or attendance of the patient with the referring psychiatrist.

Inter-disciplinary Allied Health referral

Eligible Allied Health practitioners are also able to make inter-disciplinary referrals to other eligible Allied Health practitioners as clinically necessary to assist with the formulation of the diagnosis or contribute to the treatment and management plan. Inter-disciplinary referrals must be undertaken in consultation and agreement with the referring specialist or consultant physician.  Whilst they do not require the need for an attendance with the patient (face-to-face or telehealth) by the referring specialist or consultant physician, they do require an agreement from the referring specialist or consultant physician. This can be undertaken (but is not limited to) an exchange by phone, written communication or secure online messaging.

Contribution to the treatment and management plan through Allied Health referral

In addition to referring to Allied Health practitioners for assistance with formulating a diagnosis, once the specialist or consultant physician makes a diagnosis, the specialist or consultant physician may require the contribution of an eligible Allied Health practitioner to assist with the development of the treatment and management plan (before billing item 137 or 92141).

MBS items 82000, 82005, 82010, 82030, 93032[BJ1] , 93033, 93040 or 93041 provide a dual function for this purpose. It is important to note that the service limit of a total of 8 services per patient per lifetime apply regardless of whether the items are used for assistance with diagnosis or contribution to the treatment and management plan, and the referring specialist or consultant physician should be mindful of this when referring to eligible Allied Health practitioners.

Development of the treatment and management plan

Once the specialist or consultant physician has made a diagnosis of an eligible disability, to complete the item requirements of item 137 or 92141 they must develop a treatment and management plan which includes:

  • Written documentation of the patient’s confirmed diagnosis of an eligible disability, including any findings of assessments performed (which assisted with the formulation of the diagnosis or contributed to the treatment and management plan)
  • A risk assessment which means assessment of:

o the risk to the patient of a contributing co‑morbidity and

o environmental, physical, social and emotional risk factors that may apply to the patient or to another individual.

  • Treatment options which:

o Recommendations using a biopsychosocial model

o Identify major treatment goals and important milestones and objectives

o Recommendation and referral for treatment services provided by eligible Allied Health practitioners (where relevant) and who should provide this, specifying number of treatments recommended (to a maximum of 20 treatment services)

o  Indications for review or episodes requiring escalation of treatment strategies

  • Documenting the treatment and management plan and providing a copy to the referring medical practitioner and relevant Allied Health practitioner/s.

Referral for Allied Health treatment services

Once a treatment and management plan is in place (after item 137 or 92141 has been claimed) the specialist or consultant physician can refer the individual to eligible Allied Health practitioners for the provision of treatment services. Treatment services address the functional impairments identified through the comprehensive medical assessment which are outlined in the treatment and management plan. Treatment services focus on interventions to address developmental delays/disabilities or impairments.

Eligible Allied Health treatment practitioners include:

  • Psychologist (MBS items 82015, 93035, 93043)
  • Speech Pathologist (MBS items 82020, 93036, 93044)
  • Occupational Therapist (MBS items 82025, 93036, 93044)
  • Audiologist, Optometrist, Orthoptist, Physiotherapist (MBS items 82035, 93036, 93044)

A total of 20 Allied Health treatment services per patient per lifetime are available through the MBS, which may consist of any combination of items 82015, 82020, 82025 or 82035 or equivalent telehealth items. Whilst the specialist or consultant physician can refer to multiple eligible Allied Health practitioners concurrently, a separate referral letter must be provided to each Allied Health practitioner.

The referral must specify the goals of the treatment and if appropriate, specify the number of services to be provided. It is the responsibility of the referring psychiatrist to allocate the number of treatment services (up to a maximum of 10 services per course of treatment) in keeping with the individual’s treatment and management plan.

It is important to note, that a benefit will not be paid for the MBS Allied Health treatment services unless the pre-requisite items (137 or 92141) have been processed through the Medicare claiming system.

On the completion of a “course of treatment” (specified by the referring specialist or consultant physician, up to maximum of 10 services), the eligible Allied Health practitioner must provide a written report to the referring specialist or consultant physician, which must include information on the treatment provided, recommendations for future management of the individual’s disorder and any advice to caregivers (such as parents, carers, schoolteachers). This written report will inform the referring specialist or consultant physician’s decision to refer for further treatment services. Where subsequent courses of treatment after the initial 10 services are required (up to a maximum of 20 services per patient per lifetime) a new referral is required.

Related Items: 104 105 110 116 119 137 296 297 299 300 302 304 306 308 310 312 314 316 318 319 320 324 326 328 330 332 334 336 338 342 344 346 82000 82005 82010 82015 82020 82025 82030 82035 91822 91831 91833 91836 91839 92141 92437 92455 93032 93033 93035 93036 93040 93041 93043 93044

Category 1 - PROFESSIONAL ATTENDANCES

AN.0.30

Consultant Psychiatrist - Referred Patient Assessment and Management Plan - Items 291 or 92435 and 293 or 92436

Intention of Item 291 and 92435:

It is expected that item 291 or 92435 will be a single attendance. The intention of this item is to provide access to psychiatry expertise and the provision of a detailed written report to the referrer, so that the medical practitioner in general practice (including a general practitioner, but not a specialist or consultant physician) or participating nurse practitioner can provide the ongoing management of the patient. The detailed report is a fundamental component of this item and must address not only a comprehensive diagnostic assessment but also the recommended management of the patient in both the immediate and longer term.

Where a patient’s clinical needs are complex and the psychiatrist assesses it is not appropriate for the referrer to provide the ongoing management of the patient, the psychiatrist should use item 296, 297 or 299 (for a new patient) or 300, 302, 304, 306 or 308 (for subsequent attendance) or telehealth equivalent items 92437, 91827 to 91831, 91837 to 91839 (refer to Note AN.0.75).

The referrer can seek a revision of this management plan once in a 12 month period, through item 293 or 92436.

Referral:

Referral for items 291 or 92435 and 293 or 92436 are required from a medical practitioner in general practice or participating nurse practitioner for the assessment and development of a management plan of a patient with mental health condition.

Note: If a specialist of a discipline outside of psychiatry, wishes to refer a patient for this item the referral should take place through the medical practitioner in general practice or participating nurse practitioner.

Claiming other psychiatry items in association with 291 or 92435:

Whilst it is not expected that additional attendance items would be routinely used prior to item 291 or 92435, there may be circumstances where a patient has been referred (by a medical practitioner in general practice or participating nurse practitioner) for an assessment or management plan, but it is not possible for the psychiatrist to determine in the initial consultation whether the patient is suitable for management under such a plan.

In those circumstances, where the psychiatrist undertakes a consultation prior to the 291 or 92435 consultation, time based consultation items can be claimed, according to the item requirements. In these cases, where clinically appropriate, items 296, 297 or 299 (for a new patient) or 300, 302, 304, 306 or 308 (for subsequent attendance) or telehealth equivalent items (92437, 91827 to 91831, 91837 to 91839) may be used. Non-patient interview items 341, 343, 345, 347 or 349 or telehealth equivalent items 91874 to 91878, 91882 to 91884 may be used, where clinically appropriate, to assist with diagnosis assessment and preparation of treatment plans.

Claiming other psychiatry items following item 291 or 92435:

Whilst it is not expected that psychiatry time-based attendance items, such as items 300 to 308, would be used following the billing of item 291 or 92435, there may be clinical circumstances where limited follow up is required to provide short term assistance to enable the medical practitioner in general practice or participating nurse practitioner to provide the ongoing management of the patient. For example, one or two consultations monitoring the titration of a Schedule 8 medication prior to transfer of care back to a medical practitioner in general practice.  As the intention of this item is to provide detailed recommendations to the referrer to manage the patient’s ongoing care, only short-term non-ongoing management which enables this intent would be considered appropriate.  

Item 293 or 92436 provides opportunity for a comprehensive review of the management plan initiated by the referrer and can be claimed once in a 12 month period following use of item 291 or 92435.

Requirements of item 291 or 92435 - Use of outcome tools:

In order to contribute to the diagnostic assessment and monitor response to therapy, where clinically appropriate, an assessment and/or outcome tool should be utilised during the assessment and review stage of treatment. The choice of the evidence-based tool/s to be used is at the clinical discretion of the practitioner, however the following outcome tools are recommended:

  • Kessler Psychological Distress Scale (K10)
  • Short Form Health Survey (SF12)
  • Health of the Nation Outcome Scales (HoNOS)
  • DASS 21 (Depression, Anxiety and Stress)
  • BDI (Depression)
  • BAI (Anxiety)
  • BDRS (Bipolar Disorder)
  • YBOCS (OCD)
  • GRS (Older adults)
  • EPDS (Postnatal Depression)

Requirements of item 291 or 92435 - Management Plan Report:

A written copy of the detailed management plan in consultation with the patient, must be provided to the referring GP or participating nurse practitioner within a maximum of two weeks of the assessment.

It should be noted that two weeks is the outer limit and in more serious cases more prompt provision of the plan and verbal communication with the referring GP or participating nurse practitioner may be appropriate.

The detailed Management Plan should contain:

  • The findings of the comprehensive diagnostic assessment and the formulation that contributed to this assessment (including the finding of the outcome tools where clinically appropriate)
  • Relevant history and Mental Status Examination
  • Identification of any risks to the patient or others
  • Detailed management plan which includes, as clinically appropriate, not limited to one or more of the following recommendations:

o   Biopsychosocial management

o   Non-medication recommendations including (where relevant): psychoeducation; recommendations for psychological treatment (and who should provide this); social prescribing

o   Indications for review or episode and escalation of treatment strategies

o   Longer term management goals

Review of Management Plan - Item 293 or 92436:

Item 293 or 92436 is available in instances where the referring medical practitioner in general practice or participating nurse practitioner initiates a review of the plan provided under item 291 or 92435, usually where the current plan is not achieving the anticipated outcome or there has been a change in the clinical circumstances. It is expected that when a plan is reviewed, any modifications necessary will be made. Item 293 or 92436 can only be claimed once in a 12 month period, following the provision of a service under 291 or 92435.

Related Items: 291 293 296 297 299 300 302 304 306 308 91166 91167 91169 91170 91172 91173 91175 91176 91827 91831 91837 91839 92435 92436 92437

Category 1 - PROFESSIONAL ATTENDANCES

AN.0.31

Psychiatric Attendances (Items 319 and 91873)

Item 319 or 91873 provides for an attendance, by a psychiatrist, to provide intensive psychotherapy where the patient’s clinical condition requires intensive treatment. Clinical appropriateness and indications for intensive psychotherapy are determined following a comprehensive assessment and formulation of a diagnosis and should be documented in the patient’s notes. It is also expected that other appropriate psychiatric treatment has been used for a suitable period and the patient has shown little or no response to such treatment. Such treatment would include, but not be limited to: shorter term psychotherapy; less frequent but long-term psychotherapy; pharmacological therapy; and cognitive behaviour therapy. 

Once a patient is identified as meeting the criteria of item 319 or 91873, eligibility continues under that item for the duration of that course of treatment (provided that attendances under items 296, 297, 299, 300, 302, 304, 306, 308, 319, 91827 to 91831, 91837 to 91839, 91873 and 92437 do not exceed 160 in a calendar year). If the patient requires more than 160 services in a calendar year for intensive psychotherapy, then such attendances would be covered by items 310, 312, 314, 316, 318, 91868 to 91872 or 91879 to 91881. 

Related Items: 296 297 299 300 302 304 306 308 310 312 314 316 318 319 91827 91831 91837 91839 91873 92437

Category 1 - PROFESSIONAL ATTENDANCES

AN.0.75

Initial Consultation for a new patient (item 296 in rooms, item 297 at hospital, item 299 for home visits or telehealth equivalent item 92437)

Referral for items 296, 297 and 299 or item 92437 may be from a participating nurse practitioner, medical practitioner practising in general practice, a specialist or another consultant physician.

It is intended that either item 296, 297, 299 or 92437 will be claimed once on the first occasion that the patient is seen by a consultant psychiatrist.

If the patient is referred by a medical practitioner in general practice or participating nurse practitioner for an assessment or management plan, item 291 or 92435 should be utilised (refer to note AN.0.30). It is not expected that 296, 297, 299 or 92437 items would be routinely used prior to item 291 or 92435.

Use of items 296, 297, 299 or 92435 by one consultant psychiatrist does not preclude them being used by another consultant psychiatrist for the same patient. The use of items 296, 297, 299 or 92437 are identical except for the location of where the service is rendered. That is: item 296 is only available for consultations rendered in consulting rooms, item 297 is only available for consultations rendered at a hospital, and item 299 is only available for consultations rendered at a place other than consulting rooms or a hospital (such as in a patient’s home) and item 92437 is available for telehealth consultations delivered by videoconference.

For patients who have already been seen by the consultant psychiatrist in the preceding 24 months the psychiatrist can use time-tiered attendance items 300, 302, 304, 306 and 308 or telehealth equivalent consultation items 91827 to 91831 and 91837 to 91839.

Related Items: 291 296 297 299 300 302 304 306 308 91827 91831 91837 91839 92435 92437

Category 1 - PROFESSIONAL ATTENDANCES

AN.0.76

Referral to Allied Mental Health Professionals (for new and continuing patients)

To increase the clinical treatment options available to psychiatrists and for which a Medicare benefit is payable, patients with an assessed mental disorder (dementia, delirium, tobacco use disorder and intellectual disability are not regarded as mental disorders for the purposes of these items) a patient is eligible for up to 10 individual allied mental health services per calendar year by:

  • clinical psychologists providing psychological therapies; or
  • appropriately trained GPs or allied mental health professionals providing focused psychological strategy (FPS) services.

Referrals from psychiatrists to allied mental health professionals must be made under eligible MBS items. While such referrals are likely to occur for new patients seen under item 296, 297, 299 or 92437 or a referred psychiatrist assessment and management plan under item 291 or 92435, they are also available for patients at any point in treatment (under items 104 to 109, 293, 296, 297, 299, 300, 302, 304, 306, 308, 310, 312, 314, 316, 318, 319, 320, 322, 324, 326, 328, 330, 332, 334, 336, 338, 341, 342, 343, 344, 345, 346, 347, 349 or telehealth equivalent items, as clinically required, under the same arrangements and limitations as outlined above). 

The ten individual services may consist of:

  • psychological therapy services (items 80000 to 80015 or telehealth equivalent items 91166, 91167, 91181 or 91182) - provided by eligible clinical psychologists; and/or
  • focused psychological strategies - allied mental health services (items 80100 to 80115 or telehealth equivalent items 91169, 91170, 91183 or 91184; 80125 to 80140 or telehealth equivalent items 91172, 91173, 91185 or 91186; 80150 to 80165 or telehealth equivalent items 91175, 91176, 91187 or 91188) - provided by eligible psychologists, occupational therapists and social workers.

Within the maximum service allocation of ten services, the allied mental health professional can provide one or more courses of treatment.

Group therapy services

In addition to the above services, patients will also be eligible to claim up to ten separate services within a calendar year for group therapy services (involving 6-10 patients) to which items:

  • 80020 or 80021 (psychological therapy - clinical psychologist)
  • 80120 or 80121 (focused psychological strategies - psychologist)
  • 80145 or 80146 (focused psychological strategies - occupational therapist); and
  • 80170 or 80171 (focused psychological strategies - social worker) apply.

These group services are separate from the individual services and do not count towards the ten individual services per calendar year maximum associated with those items.

Referral Requirements for Allied Health services

A referral for treatment must be in writing (signed and dated by the psychiatrist) and may include (unless clinically inappropriate):

  • the patient’s name, date of birth and address;
  • the patient’s symptoms or diagnostic assessment;
  • the patient needs and goals of treatment (if clinically appropriate);
  • a list of any current medications (if appropriate);
  • the number of sessions before a psychiatry review is required; or the allied health practitioner should provide a written report back to the psychiatrist following the completed course of treatment, confirming the patient’s need for a subsequent course of treatment if clinically needed.

Maximum session limit for each course of treatment apply:

Initial course of treatment – a maximum of six sessions. Subsequent course of treatment – a maximum of six sessions up to the patient’s cap of ten sessions (for example, if the patient received six sessions in their initial course of treatment, they can only receive four sessions in a subsequent course of treatment).

Related Items: 104 109 291 293 296 297 299 300 302 304 306 308 310 312 314 316 318 319 320 322 324 326 328 330 332 334 336 338 342 344 346 80000 80015 80020 80021 80100 80115 80120 80121 80125 80140 80145 80146 80150 80165 80170 80171 91166 91167 91169 91170 91172 91173 91175 91176 91181 91182 91183 91184 91185 91186 91187 91188 92435 92437


Legend

  • Assist - Addition/Deletion of (Assist.)
  • Amend - Amended Description
  • Anaes - Anaesthetic Values Amended
  • Emsn - EMSN Change
  • Fee - Fee Amended
  • Renum - Item Number Change (renumbered)
  • New - New Item
  • NewMin - New Item (previous Ministerial Determination)
  • Qfe - QFE Change