Medicare Benefits Schedule - Note M6.2

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Category 8 - MISCELLANEOUS SERVICES

M6.2

Psychological Therapy Services Attracting Medicare Rebates

Eligible psychological therapy services

There are five MBS items for the provision of psychological therapy services to eligible patients by a clinical psychologist.  Clinical psychologists must meet the provider eligibility requirements set out below and be registered with the Department of Human Services.

 

In these notes, 'GP' means a medical practitioner, including a general practitioner, but not including a specialist or consultant physician.

 

Referrals and Referral Validity

Services provided under the Psychological Therapy items will not attract a Medicare rebate unless:

  • a referral has been made by a GP who is managing the patient under a GP Mental Health Treatment Plan (items 2700, 2701, 2715 or 2717);
  • a referral has been made by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) who is managing the patient under a referred psychiatrist assessment and management plan (item 291); or
  • a referral has been made by a psychiatrist or paediatrician from an eligible psychiatric or paediatric service (see Referral Requirements for further details regarding psychiatrist and paediatrician referrals). 

 

Number of services per year

Medicare rebates are available for up to ten allied mental health services in a calendar year.  The ten services may consist of: GP focussed psychological strategies services (items 2721 to 2727); and/or psychological therapy services (items 80000 to 80015); and/or focussed psychological strategies - allied mental health services (items 80100 to 80115; 80125 to 80140; 80150 to 80165).

 

In addition, the referring practitioner may consider that in exceptional circumstances the patient may require an additional six services above those already provided (to a maximum total of 16 individual services per patient from 1 March 2012 to 31 December 2012). 

 

Note: Patients will be able to receive an additional six individual allied mental health services under exceptional circumstances from 1 March 2012 to 31 December 2012.  From 1 January 2013 the number of individual allied mental health services for which a person can receive a Medicare rebate will be ten services per calendar year.

 

Exceptional circumstances are defined as a significant change in the patient's clinical condition or care circumstances which make it appropriate and necessary to increase the maximum number of services.

 

It is up to the referring practitioner (e.g GP) to determine that the patient meets these requirements. 

In these cases a new referral should be provided, and exceptional circumstances noted in that referral.  Invoices for services provided under exceptional circumstances must state that exceptional circumstances apply.

 

Referrals should be provided, as required, for an initial course of treatment (a maximum of six services but may be less depending on the referral and patient need) to a maximum of ten services per calendar year (up to 16 services from 1 March 2012 to 31 December 2012 where exceptional circumstances apply). For the purposes of these services, a course of treatment will consist of the number of services stated in the patient's referral (up to a maximum of six in any one referral).

 

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 (psychological therapy - clinical psychologist), 80120 (focussed psychological strategies - psychologist), 80145 (focussed psychological strategies - occupational therapist) and 80170 (focussed 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.

 

Services provided under the Access to Allied Psychological Services (ATAPS) should not be used in addition to the ten (up to 16 services from 1 March 2012 to 31 December 2012 where exceptional circumstances apply) psychological therapy services (items 80000 to 80020), focussed psychological services-allied mental health services (items 80100 to 80170 or GP focussed psychological strategies services (items 2721 to 2727) available under the Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule initiative per calendar year. Psychologists delivering services under the ATAPS program should refer to the ATAPS Operational Guidelines.

 

Service length and type

Services provided by eligible clinical psychologists under these items must be within the specified time period within the item descriptor.  The clinical psychologist must personally attend the patient.

 

It is expected that professional attendances at places other than consulting rooms would be provided where treatment in other environments is necessary to achieve therapeutic outcomes. 

 

In addition to psycho-education, it is recommended that cognitive-behaviour therapy be provided.  However, other evidence-based therapies ─ such as interpersonal therapy ─ may be used if considered clinically relevant.

 

Course of treatment and reporting back to the referring medical practitioner

Patients are eligible to receive up to ten individual services (up to 16 services from 1 March 2012 to 31 December 2012 where exceptional circumstances apply) and up to ten group sessions in a calendar year.

 

Within this maximum service allocation, the clinical psychologist can provide one or more courses of treatment.  For the purposes of these services, a course of treatment consists of the number of services stated in the patient's referral (up to a maximum of six in any one referral). This enables the referring medical practitioner to consider a report from the clinical psychologist on the services provided to the patient, and the need for further treatment.

 

On completion of the initial course of treatment, the clinical psychologist must provide a written report to the referring medical practitioner, which includes information on:

¿       assessments carried out on the patient;

¿       treatment provided; and

¿       recommendations on future management of the patient's disorder.

 

A written report must also be provided to the referring medical practitioner at the completion of any subsequent course(s) of treatment provided to the patient.

 

Out of pocket expenses and Medicare safety net

Charges in excess of the Medicare benefit for these items are the responsibility of the patient. However, if a service was provided out-of-hospital, any out-of-pocket costs will count towards the Medicare safety net for that patient. The out-of-pocket costs for mental health services which are not Medicare eligible do not count towards the Medicare safety net.

Eligible patients

Items 80000 to 80020 (inclusive) apply to people with an assessed mental disorder and where the patient is referred by a GP who is managing the patient under a GP Mental Health Treatment Plan (item 2700, 2701, 2715 or 2717), or under a referred psychiatrist assessment and management plan (item 291); or on referral from an eligible psychiatrist or paediatrician.

 

The conditions classified as mental disorders for the purposes of these services are informed by the World Health Organisation, 1996, Diagnostic and Management Guidelines for Mental Disorders in Primary Care: ICD-10 Chapter V Primary Care Version.  For the purposes of these items, dementia, delirium, tobacco use disorder and mental retardation are not regarded as a mental disorder.

 

Checking patient eligibility for psychological therapy services

Patients seeking Medicare rebates for psychological therapy services will need to have a referral from a GP, psychiatrist or paediatrician.  If there is any doubt about a patient's eligibility, the Department of Human Services will be able to confirm whether a GP Mental Health Treatment Plan; and/or a psychiatrist assessment and management plan is in place and claimed; or an eligible psychiatric or paediatric service has been claimed, as well as the number of allied mental health services already claimed by the patient during the calendar year. 

 

Clinical psychologists can call the Department of Human Services on 132 150 to check this information, while unsure patients can seek clarification by calling 132 011.

 

The patient will not be eligible if they have not been appropriately referred and a relevant Medicare service provided to them. If the referring service has not yet been claimed, the Department of Human Services will not be aware of the patient's eligibility.  In this case the clinical psychologist should, with the patient's permission, contact the referring practitioner to ensure the relevant service has been provided to the patient.

 

Publicly funded services

Psychological therapy items 80000 to 80020 do not apply for services that are provided by any other Commonwealth or State funded services or provided to an admitted patient of a hospital.  However, where an exemption under subsection 19(2) of the Health Insurance Act 1973 has been granted to an Aboriginal Community Controlled Health Service or State/Territory clinic, the items apply for services that are provided by eligible clinical psychologists salaried by, or contracted to, the service as long as all requirements of the items are met, including registration with the Department of Human Services.  These services must be direct billed (that is, the Medicare rebate is accepted as full payment for services).

 

Private health insurance

Patients need to decide if they will use Medicare or their private health insurance ancillary cover to pay for these services. Patients cannot use their private health insurance ancillary cover to 'top up' the Medicare rebate paid for the services.

 


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