Note AN.36.2 | Medicare Benefits Schedule

Category 1 - PROFESSIONAL ATTENDANCES

AN.36.2

Eating Disorders Treatment and Management Plans Explanatory Notes

Eating Disorders Treatment and Management Plans Explanatory Notes (items 90250-90257 and 90260-90261)

This note provides information on Eating Disorders Treatment and Management Plan (EDP) items and should be read in conjunction with the Eating Disorders General Explanatory Notes

Eating Disorder Treatment Plan (EDP) items overview

The EDP items define services for which Medicare rebates are payable where practitioners undertake the development of a treatment and management plan for patients with a diagnosis of anorexia nervosa and patients with other specified eating disorder diagnoses who meet the eligibility criteria.

The EDP items trigger eligibility for items which provide delivery of eating disorders psychological treatment (EDPT) services (up to a total of 40 psychological services in a 12 month period) and dietetic services (up to a total of 20 in a 12 Month period).

For any particular patient, an eating disorder treatment and management plan expires at the end of a 12 month period following provision of that service. Eating Disorders treatment services are not available to the patient if the EDP has expired.

Preparation of the EDP must include:

discussing the patient’s medical and psychological health status with the patient and if appropriate their family/carer;
identifying and discussing referral and treatment options with the patient and their family/carer where appropriate, including identification of appropriate support services;
agreeing goals with the patient and their family/carer where appropriate - what should be achieved by the treatment - and any actions the patient will take;
planning for the provision of appropriate patient and family/carer education;
a plan for crisis intervention and/or for relapse prevention, if appropriate at this stage;
making arrangements for required referrals, treatment, appropriate support services, review and follow-up;
documenting the results of assessment, patient needs, goals and actions, referrals and required treatment/services, and review date in the patient's plan;
Discussing and organising the appropriate reviews throughout the patient’s treatment; and
discussing the need for the patient to be reviewed to access a higher intensity of EDPT services in a 12 month period.

Preparing a Medical practitioner in general practice Eating Disorder Treatment & Management Plan (items 90250-90257)

Who can provide the service

Items in subgroup 1 of Group A36 can be rendered by a medical practitioner in general practice. This includes:

Medical practitioners who can render a general practitioner service in Group A1 of the MBS (see note AN.0.9 for the types of medical practitioners). These medical practitioners can render a ‘general practitioner’ service for items in subgroup 1 of Group A36.
Medical practitioners who are not general practitioners, specialists or consultant physicians. These medical practitioners can render a ‘medical practitioner’ service for items in subgroup 1 of Group A36.

What is Involved - Assess and Plan

It is expected that the practitioner developing the EDP has either performed or reviewed the assessments and examinations required to make a judgement that the patient meets the eligibility criteria for accessing these items.

Items 90250-90257 provide services for development of the eating disorder treatment and management plan. Where a comprehensive physical examination is performed, either on the same occasion or different occasion, the appropriate item could be claimed provided the time taken performing the assessment is not included in the time for producing the plan, or time producing the EDP is not included in the time for assessment.

It is emphasised that it is best practice for the practitioner to perform a comprehensive physical assessment to facilitate ongoing patient management and monitoring of medical and nutritional status.

Patient Assessment

An assessment of a patient with an eating disorders includes:

taking relevant history (biological, psychological, social, including family/carer support);
eating disorder diagnostic assessment;
medical review including physical examination and relevant tests;
conducting an assessment of mental state, including identification of comorbid psychiatric conditions;
an assessment of eating disorder behaviours;
an assessment of associated risk and any medical co-morbidity, including as assessment on how this impacts on the patients functioning and activities of daily living;
an assessment of family and/or carer support; and
administering an outcome measurement tool, except where it is considered clinically inappropriate.

Risk assessment for a patient with an eating disorder should include identification of:

medical instability and risk of hospitalisation;
level of psychological distress and suicide risk;
level of malnourishment;
identification of psychiatric comorbidity;
level of disability;
duration of illness;
response to earlier evidence-based eating disorders treatment;
level of family/carer support.

It should be noted that the patient's EDP should be treated as a living document for updating as required. In particular, the plan can be updated at any time to incorporate relevant information, such as feedback or advice from other health professionals on the diagnosis or treatment of the patient.

Preparing a Consultant Psychiatrist Eating Disorder Treatment & Management Plan (90260-90261)

Who can provide the service

Items in subgroup 2 of Group 36 can be rendered by consultant psychiatrists (items 90260 and 90261).

What is Involved – Assess and Plan

Items 90260-90261 provide access to specialist assessment and treatment planning. It is expected that items will be a single attendance. However, there may be particular circumstances where a patient has been referred by a GP for an assessment and management plan, but it is not possible for the consultant to determine in the initial consultation whether the patient is suitable for management under such a plan. In these cases, where clinically appropriate, other appropriate consultation items may be used. In those circumstances where the consultant undertakes a consultation (in accordance with the item requirements) prior to the consultation for providing the referring practitioner with an assessment and management plan. It is expected that such occurrences would be unusual for the purpose of diagnosis under item 90260.

Patient Assessment

In order to facilitate ongoing patient focussed management, an assessment of the patient must include:

administering an outcome measurement tool during the assessment and review stages of treatment, where clinically appropriate. The choice of outcome tool to be used is at the clinical discretion of the practitioner;
conducting a mental state examination;
taking relevant history (biological, psychological, behavioural, nutritional, social);
assessing associated risk and any co-morbidity; and
making a psychiatric diagnosis for conditions meeting the eligibility criteria.

Risk assessment for a patient with an eating disorder should include identification of:

medical instability and risk of hospitalisation;
level of psychological distress and suicide risk;
level of malnourishment;
identification of psychiatric comorbidity;
level of disability;
duration of illness;
response to earlier evidence-based eating disorders treatment;
level of family/carer support.

Where a consultant psychiatrist provides an EDP service, the service must also include:

administering an outcome measurement tool, where clinically appropriate. The choice of outcome tool to be used is at the clinical discretion of the practitioner. Practitioners using such tools should be familiar with their appropriate clinical use, and if not, should seek appropriate education and training; and
conducting a mental state examination.

Consultation with the patient’s managing practitioner

A written copy of the EDP should be provided to the patient’s managing 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 managing practitioner may be appropriate.

Additional Claiming Information (general conditions and limitations)

Patients seeking rebates for items 90250-90257 and 90260-90261 will not be eligible if the patient has had a claim within the last 12 months.

Items 90250-90257 cannot be claimed with Items 2713, 279, 735, 758, 235 and 244. Items 90261 cannot be claimed with Items 110, 116, 119, 132, 133.

Consultant psychiatrist and paediatrician EDP items 90260-90261 do not apply if the patient does not have a referral within the period of validity.

Before proceeding with the EDP the medical practitioner must ensure that:

(a) the steps involved in providing the service are explained to the patient and (if appropriate and with the patient's permission) to the patient's carer; and

(b) the patient's agreement to proceed is recorded.

The medical practitioner must offer the patient a copy of the EDP and add the document to the patient's records. This should include, subject to the patient's agreement, offering a copy to their carer, where appropriate. The medical practitioner may, with the permission of the patient, provide a copy of the EDP, or relevant parts of the plan, to other providers involved in the patient's treatment.

The medical practitioner EDP cover the service of developing an EDP. A separate consultation item can be performed with the EDP if the patient is treated for an unrelated condition to their eating disorder. Where a separate consultation is performed, it should be annotated separately on the patient’s account that a separate consultation was clinically required/indicated.

All consultations conducted as part of the EDP must be rendered by the medical practitioner and include a personal attendance with the patient. A specialist mental health nurse, other allied health practitioner, Aboriginal and Torres Strait Islander health practitioner or Aboriginal Health Worker with appropriate mental health qualifications and training may provide general assistance to the medical practitioner in provision of this care.

Additional Claiming Information (interaction with Chronic Disease Management and Better Access)

It is preferable that wherever possible patients have only one plan for primary care management of their disorder. As a general principle the creation of multiple plans should be avoided, unless the patient clearly requires an additional plan for the management of a separate medical condition.

The Chronic Disease Management (CDM) care plan items (items 721, 723, 729, 731 and 732) continue to be available for patients with chronic medical conditions, including patients with complex needs.

Where a patient has a separate chronic medical condition, it may be appropriate to manage the patient's medical condition through a CDM Plan, and to manage their eating disorder through an EDP. In this case, both items can be used. Where the patient receives dietetic services under the CDM arrangements (item 10954), these services will count towards the patients maximum of 20 dietetic services in a 12 month period.

Where a patient has other psychiatric comorbidities, these conditions should be managed under the EDP. Once a patient has a claim for an EDP, the patient should not be able to have a claim for the development or review of a Mental Health Treatment plan by a GP (items 2700, 2701, 2715 and 2717) or medical practitioner in general practice (items 272, 276, 281 and 282) within 12 months of their EDP unless there are exceptional circumstances.

For the purpose of the 40 EDPT count; eating disorder psychological treatment service includes a service under provided under the following items: 90271, 90272, 90273, 90274, 90275, 90276, 90277, 90278, 2721, 2723, 2725, 2727, 283, 285, 286, 287, 371, 372 and items in Groups M6, M7 and M16 (excluding item 82350).

Related Items: 90250 90251 90252 90253 90254 90255 90256 90257 90260 90261

Category 1 - PROFESSIONAL ATTENDANCES

90250

Professional attendance by a general practitioner to prepare an eating disorder treatment and management plan, lasting at least 20 minutes but less than 40 minutes.

Fee: $78.95 Benefit: 100% = $78.95