Medicare Benefits Schedule - Note AN.3.1

The current regulations prohibit the payment of Medicare benefits for subsequent attendance items 105, 116, 119, 386, 2806, 2814, 3010, 3014, 6009 to 6015, 6019, 6052, 16404, 91823, 91825, 91826, 91833, 91836, 92611, 92612, 92613 and 92618 if a claim is made for any Group T8 item (30001-50952) with a schedule fee of equal to or greater than $330.20 on the same day. Non-compliance with the regulations can result in a referral to an appropriate regulatory body – such as the Professional Services Review. Subsequent attendance items (111, 117, and 120) can only be claimed on the same day as Group T8 items with schedule fees of equal to or greater than $330.20, if the procedure is urgent and not able to be predicted prior to the commencement of the attendance.  It is therefore expected that these items would be claimed only in exceptional circumstances.

Subsequent attendance item 115 can only be claimed, if the nature of the attendance was not able to be predicted prior to the procedure. 

Item 115 should not be claimed if the consultation relates to the booked Group T8 procedure.  Any consultation component related to the booked Group T8 procedure is considered to be covered under the fee for that procedure, if the Schedule fee is $330.20 or more.

Should a component of the consultation be unrelated to the booked T8 procedure and it is considered by the medical practitioner that it would be a clinical risk to defer this consultation then item 115 could be claimable.

It would not be appropriate to claim item 115 if a patient attends for the booked operation, and prior to surgery an examination is conducted relevant to performing that procedure; together with a discussion of the outcomes and aftercare. If the consultation extends beyond this; including the development of a management plan involving a broader diagnosis, prognosis, associated treatments and follow-up; then it could be appropriate to claim item 115.

In claiming item 115, the specialist or consultant physician must be satisfied that it would be a clinical risk to defer the consultation for the patient at this time.

Where item 115 is claimed, the records for the consultation should clearly identify why the consultation is considered necessary for the patient including the clinical risk to defer the consultation.

Related Items: 105 115 116 119 386 2806 2814 3010 3014 6009 6011 6013 6015 6019 6052 16404 91823 91825 91826 91833 91836 92610 92611 92612 92613

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Professional attendance by a specialist in the practice of the specialist's specialty following referral of the patient to the specialist-an attendance after the first in a single course of treatment, if that attendance is at consulting rooms or hospital, other than a service to which item 16404 applies

Fee: $48.05 Benefit: 75% = $36.05 85% = $40.85

(See para AN.0.7, AN.0.25, AN.0.70, AN.2.1, AN.3.1, AN.40.1, TN.1.4 of explanatory notes to this Category)

Professional attendance at consulting rooms or in hospital on a day by a medical practitioner (the attending practitioner) who is a specialist or consultant physician in the practice of the attending practitioner’s specialty after referral of the patient to the attending practitioner by a referring practitioner—an attendance after the initial attendance in a single course of treatment, if:

(a) the attending practitioner performs a scheduled operation on the patient on the same day; and

(b) the operation is a service to which an item in Group T8 applies; and

(c) the amount specified in the item in Group T8 as the fee for a service to which that item applies is $330.20 or more; and

(d) the attendance is unrelated to the scheduled operation; and

(e) it is considered a clinical risk to defer the attendance to a later day

For any particular patient, once only on the same day

Fee: $48.05 Benefit: 75% = $36.05 85% = $40.85

(See para AN.3.1 of explanatory notes to this Category)

Professional attendance at consulting rooms or hospital by a specialist, or consultant physician, in the practice of the specialist's or consultant physician's specialty of palliative medicine following referral of the patient to the specialist or consultant physician by a referring practitioner-each attendance (other than a service to which item 3014 applies) after the first in a single course of treatment

Fee: $84.35 Benefit: 75% = $63.30 85% = $71.70

(See para AN.0.58, AN.0.70, AN.3.1 of explanatory notes to this Category)

Professional attendance at consulting rooms or hospital by a specialist, or consultant physician, in the practice of the specialist's or consultant physician's specialty of palliative medicine following referral of the patient to the specialist or consultant physician by a referring practitioner-each minor attendance after the first attendance in a single course of treatment

Fee: $48.05 Benefit: 75% = $36.05 85% = $40.85

(See para AN.0.58, AN.0.70, AN.3.1 of explanatory notes to this Category)

Professional attendance by an addiction medicine specialist in the practice of the addiction medicine specialist's specialty following referral of the patient to the addiction medicine specialist by a referring practitioner, if the attendance is a patient assessment:

(a) before or after a comprehensive assessment under item 6018 in a single course of treatment; or

(b) that follows an initial assessment under item 6023 in a single course of treatment; or

(c) that follows a review under item 6024 in a single course of treatment

Fee: $84.35 Benefit: 75% = $63.30 85% = $71.70

(See para AN.0.70, AN.3.1 of explanatory notes to this Category)

Phone attendance for a person by a specialist in the practice of the specialist’s specialty if:

(a)           the attendance follows referral of the patient to the specialist; and

(b)           the attendance was of more than 5 minutes in duration. 

Where the attendance is after the first attendance as part of a single course of treatment.

Fee: $48.05 Benefit: 85% = $40.85

(See para AN.0.7, AN.0.25, AN.0.70, AN.3.1, AN.40.1 of explanatory notes to this Category)

Professional attendance by a specialist in the practice of neurosurgery following referral of the patient to the specialist-a minor attendance after the first in a single course of treatment at consulting rooms or hospital

Fee: $48.05 Benefit: 75% = $36.05 85% = $40.85

(See para AN.0.64, AN.0.70, AN.3.1, AN.40.1 of explanatory notes to this Category)

Professional attendance by a specialist in the practice of neurosurgery following referral of the patient to the specialist-an attendance after the first in a single course of treatment, involving an extensive and comprehensive examination, arranging any necessary investigations in relation to one or more complex problems and of more than 15 minutes in duration but not more than 30 minutes in duration at consulting rooms or hospital

Fee: $95.60 Benefit: 75% = $71.70 85% = $81.30

(See para AN.0.64, AN.0.70, AN.3.1, AN.40.1 of explanatory notes to this Category)

Professional attendance by a specialist in the practice of neurosurgery following referral of the patient to the specialist-an attendance after the first in a single course of treatment, involving a detailed and comprehensive examination, arranging any necessary investigations in relation to one or more complex problems and of more than 30 minutes in duration but not more than 45 minutes in duration at consulting rooms or hospital

Fee: $132.40 Benefit: 75% = $99.30 85% = $112.55

(See para AN.0.64, AN.0.70, AN.3.1, AN.40.1 of explanatory notes to this Category)

Professional attendance by a specialist in the practice of neurosurgery following referral of the patient to the specialist-an attendance after the first in a single course of treatment, involving an exhaustive and comprehensive examination, arranging any necessary investigations in relation to one or more complex problems and of more than 45 minutes in duration at consulting rooms or hospital

Fee: $168.60 Benefit: 75% = $126.45 85% = $143.35

(See para AN.0.64, AN.0.70, AN.3.1, AN.40.1 of explanatory notes to this Category)

Professional attendance at consulting rooms or hospital by a consultant occupational physician in the practice of the consultant occupational physician's specialty of occupational medicine following referral of the patient to the consultant occupational physician by a referring practitioner-each attendance after the first in a single course of treatment

Fee: $48.05 Benefit: 75% = $36.05 85% = $40.85

(See para AN.0.33, AN.0.70, AN.3.1 of explanatory notes to this Category)

Telehealth attendance for a person by a consultant physician in the practice of the consultant physician’s specialty (other than psychiatry) if:

(a)           the attendance follows referral of the patient to the specialist; and

(b)           the attendance was of more than 5 minutes in duration.

 Where the attendance is not a minor attendance after the first as part of a single course of treatment.

Fee: $84.35 Benefit: 85% = $71.70

(See para AN.0.7, AN.0.70, AN.3.1, AN.40.1 of explanatory notes to this Category)

Telehealth attendance for a person by a consultant physician in the practice of the consultant physician’s specialty (other than psychiatry) if:

(a)           the attendance follows referral of the patient to the specialist; and

(b)           the attendance was of more than 5 minutes in duration. 

Where the attendance is a minor attendance after the first as part of a single course of treatment.

Fee: $48.05 Benefit: 85% = $40.85

(See para AN.0.7, AN.0.70, AN.3.1, AN.40.1 of explanatory notes to this Category)

Phone attendance for a person by a consultant physician in the practice of the consultant physician’s specialty (other than psychiatry) if:

(a)           the attendance follows referral of the patient to the specialist; and

(b)           the attendance was of more than 5 minutes in duration.

Where the attendance is a minor attendance after the first as part of a single course of treatment.

Fee: $48.05 Benefit: 85% = $40.85

(See para AN.0.7, AN.0.25, AN.0.70, AN.3.1, AN.40.1 of explanatory notes to this Category)

Professional attendance by a sexual health medicine specialist in the practice of the sexual health medicine specialist's specialty following referral of the patient to the sexual health medicine specialist by a referring practitioner, if the attendance is a patient assessment:

(a) before or after a comprehensive assessment under item 6051 in a single course of treatment; or

(b) that follows an initial assessment under item 6057 in a single course of treatment; or

(c) that follows a review under item 6058 in a single course of treatment

Fee: $84.35 Benefit: 75% = $63.30 85% = $71.70

(See para AN.0.70, AN.3.1 of explanatory notes to this Category)

Professional attendance at consulting rooms or hospital, by a consultant physician in the practice of the consultant physician's specialty (other than psychiatry) following referral of the patient to the consultant physician by a referring practitioner-each attendance (other than a service to which item 119 applies) after the first in a single course of treatment

Fee: $84.35 Benefit: 75% = $63.30 85% = $71.70

(See para AN.0.7, AN.0.25, AN.0.70, AN.3.1, AN.40.1 of explanatory notes to this Category)

Professional attendance at consulting rooms or hospital, by a consultant physician in the practice of the consultant physician's specialty (other than psychiatry) following referral of the patient to the consultant physician by a referring practitioner-each minor attendance after the first in a single course of treatment

Fee: $48.05 Benefit: 75% = $36.05 85% = $40.85

(See para AN.0.7, AN.0.21, AN.0.25, AN.0.70, AN.3.1, AN.40.1 of explanatory notes to this Category)

Professional attendance at consulting rooms or a hospital by a specialist in the practice of the specialist’s specialty of obstetrics after referral of the patient to the specialist—an attendance after the initial attendance in a single course of treatment

Fee: $47.35 Benefit: 75% = $35.55 85% = $40.25

(See para AN.0.70, AN.3.1, TN.4.2 of explanatory notes to this Category)

Telehealth attendance by a specialist in the practice of neurosurgery following referral of the patient to the specialist (other than a second or subsequent attendance in a single course of treatment).

Fee: $144.75 Benefit: 85% = $123.05

(See para AN.3.1 of explanatory notes to this Category)

Telehealth attendance by a specialist in the practice of neurosurgery following referral of the patient to the specialist—a minor attendance after the first in a single course of treatment.

Fee: $48.05 Benefit: 85% = $40.85

(See para AN.0.70, AN.3.1 of explanatory notes to this Category)

Telehealth attendance by a specialist in the practice of neurosurgery following referral of the patient to the specialist—an attendance after the first in a single course of treatment, involving arranging any necessary investigations in relation to one or more complex problems and of more than 15 minutes in duration but not more than 30 minutes in duration.

Fee: $95.60 Benefit: 85% = $81.30

(See para AN.0.70, AN.3.1 of explanatory notes to this Category)

Telehealth attendance by a specialist in the practice of neurosurgery following referral of the patient to the specialist—an attendance after the first in a single course of treatment, involving arranging any necessary investigations in relation to one or more complex problems and of more than 30 minutes in duration but not more than 45 minutes in duration.

Fee: $132.40 Benefit: 85% = $112.55

(See para AN.0.70, AN.3.1 of explanatory notes to this Category)

Telehealth attendance for a person by a specialist in the practice of the specialist’s specialty if:

(a)           the attendance follows referral of the patient to the specialist; and

(b)           the attendance was of more than 5 minutes in duration.

 Where the attendance is after the first attendance as part of a single course of treatment.

Fee: $48.05 Benefit: 85% = $40.85

(See para AN.0.7, AN.0.70, AN.3.1, AN.40.1 of explanatory notes to this Category)

Professional attendance at consulting rooms or hospital by a specialist, or consultant physician, in the practice of the specialist's or consultant physician's specialty of pain medicine following referral of the patient to the specialist or consultant physician by a referring practitioner-each attendance (other than a service to which item 2814 applies) after the first in a single course of treatment

Fee: $84.35 Benefit: 75% = $63.30 85% = $71.70

(See para AN.0.58, AN.0.70, AN.3.1 of explanatory notes to this Category)

Professional attendance at consulting rooms or hospital by a specialist, or consultant physician, in the practice of the specialist's or consultant physician's specialty of pain medicine following referral of the patient to the specialist or consultant physician by a referring practitioner-each minor attendance after the first attendance in a single course of treatment

Fee: $48.05 Benefit: 75% = $36.05 85% = $40.85

(See para AN.0.58, AN.0.70, AN.3.1 of explanatory notes to this Category)