Medicare Benefits Schedule - Note A20

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Category 1 - PROFESSIONAL ATTENDANCES

A20

Psychiatric Attendances (Item 319)

Medicare benefits are attracted under Item 319 only where patients are diagnosed as suffering from:

-                  severe personality disorder (predominantly from cluster B groupings), or in persons under 18 years of age a severe disruption of personality development; or

-                  anorexia nervosa; or

-                  bulimia nervosa; or

-                  dysthymic disorder; or

-                  substance-related disorder; or

-                  somatoform disorder; or

-                  a pervasive developmental disorder (including autism and Asperger's disorder)

according to the relevant criteria set out in the Diagnostic and Statistical Manual of the American Psychiatric Association - Fourth Edition (DSM-IV).

 

It is not sufficient for the patient's illness to fall within the diagnostic criteria. It must be evident that a significant level of impairment exists which interferes with the patient's quality of life. For persons 18 years and over, the level of impairment must be within the range 1 to 50 of the Global Assessment of Functioning (GAF) Scale contained in the DSM-IV (ie the patient is displaying at least "serious" symptoms). The GAF score, incorporating the parameters which have led to the score, should be recorded at the time of commencement of the current course of treatment. Once a patient is identified as meeting the criteria of item 319, he/she continues to be eligible under that item for the duration of the current course of treatment (provided that attendances under items 300 to 308 and 319 do not exceed 160 in a calendar year). Where a patient commences a new course of treatment, the GAF score in relation to item 319 is the patient's score as assessed during the new course of treatment.

 

In addition to the above diagnostic criteria and level of functional impairment, 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. It is expected that such treatment would include, but not be limited to: shorter term psychotherapy; less frequent but long term psychotherapy; pharmacological therapy; cognitive behaviour therapy.

 

It is the responsibility of the psychiatrist to ensure that the patient meets these criteria.  the Department of Human Services will be closely monitoring the use of item 319.

 

When a patient who meets the criteria defined in item 319 attends a psychiatrist on more than 160 occasions in a calendar year, such attendances would be covered by items 310 to 318.

 

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has undertaken to establish an appropriate mechanism to enable use of item 319 by suitably trained psychiatrists. In the interim it is expected that psychiatrists whose usual practice includes long term intensive treatment of patients whose diagnoses meet the criteria defined in the item will be using item 319.

 

On the basis of advice from the RANZCP it is expected that it would be generally inappropriate in normal clinical practice for psychiatric treatment performed out of hospital to extend beyond 220 sessions in a calendar year. In this regard, the Department of Human Services will be monitoring providers' practice patterns with a view to the referral of possible cases of inappropriate practice to the Director of Professional Services Review.

 

Related Items: 319


Related Items

Category 1 - PROFESSIONAL ATTENDANCES

319

319 - Additional Information

Item Start Date:
01-May-1997
Description Start Date:
01-Nov-2007
Schedule Fee Start Date:
01-Nov-2012

Professional attendance by a consultant physician in the practice of his or her specialty of psychiatry following referral of the patient to him or her by a referring practitioner-an attendance of more than 45 minutes in duration at consulting rooms, if the patient has:

(a) been diagnosed as suffering severe personality disorder, anorexia nervosa, bulimia nervosa, dysthymic disorder, substance-related disorder, somatoform disorder or a pervasive development disorder; and

(b) for persons 18 years and over-been rated with a level of functional impairment within the range 1 to 50 according to the Global Assessment of Functioning Scale;

if that attendance and another attendance to which any of items 296, 300 to 319, 353 to 358 and 361 to 370 applies have not exceeded 160 attendances in a calendar year for the patient

Fee: $183.65 Benefit: 75% = $137.75 85% = $156.15

(See para A20 of explanatory notes to this Category)


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