Medicare Benefits Schedule - Note AN.36.3

Eating Disorders Treatment and Management Plan Reviews (items 90264-90267)

This note provides information on Eating Disorders Treatment and Management Plan (EDP) review items and should be read in conjunction with the AN.36.1 Eating Disorders General Explanatory Notes and the AN.36.2 Eating Disorders Treatment and Management Plans Explanatory Notes

Eating Disorder Treatment Plan review (EDR) items overview

The EDR items define services for which Medicare rebates are payable where practitioners undertake to review the efficacy of the patient’s eating disorder treatment and management plan (EDP). This includes modifying the patient’s plan, where appropriate, to improve patient outcomes. The review services can be provided by medical practitioners working in general practice, psychiatry and paediatrics.

An EDR may be provided by the managing practitioner who prepared the patient's initial plan (or another practitioner in the same practice or in another practice where the patient has changed practices) and should include a systematic review of the patient's progress against the initial EDP (whether it was prepared by a GP, psychiatrist or paediatrician) and by completing the activities that must be included in a review (see below).

When to render an EDR review item

It is expected that the managing practitioner will be reviewing the patient on a regular, ongoing and as required basis. However, a patient must have a review of the EDP to assess the patient’s progress against the EDP or update the EDP, as the patient is approaching the end of each course of treatment before they can access the next course of treatment.

The eating disorder items incorporate a ‘stepped model’ for best practice care for eligible patients with eating disorders. Under the Eating Disorders Items Stepped Model of Care a course of treatment is defined as 10 eating disorder psychological treatment (EDPT) services. It is required that a patient must have a review after each course of treatment (see AN.36.1 Eating Disorders General Explanatory Notes). 

Reviewing an Eating Disorders Treatment Plan

The EDR must include:

• recording the patient's agreement for this service;
• referral to a psychiatrist or paediatrician for review under items 90266-90267, if this has not been initiated at an earlier stage;
• a review of the patient's progress against the goals outlined in the EDP, including discussion with the patient/and or their family/carer as to whether the EDPT services are meeting their needs;
• modification of the documented EDP if required;
• checking, reinforcing and expanding education;
• a plan for crisis intervention and/or for relapse prevention, if appropriate and if not previously provided; and
• reviewing reports back from the allied mental health professional on the patient’s response to treatment and documenting a recommendation on whether patient should continue with another course of EDPT services with that health professional or another health professional.
   

Where a consultant psychiatrist or paediatrician provides an EDR, the consultant physician must give the referring practitioner a copy of the diagnosis and the revised EDP within 2 weeks after the attendance. Where a consultant psychiatrist provides an EDR service, the review 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.

Note: It is expected there will be other consultations between the patient and the managing practitioner as part of ongoing patient and medical management, including the ordering and reviewing of the required testing for monitoring the patients’ medical and nutritional status. All other ongoing patient reviews should be claimed under the appropriate item.

Checking patient eligibility for services

Note: The 12 month period commences from the date of the EDP.

To provide an EDR service in items 90264-90267, the patient must have had an EDP 90250-90257 or 90260-90261 in the previous 12 months.

If the EDP service has not yet been claimed, Services Australia will not be aware of the patient's eligibility. In this case the practitioner should, with the patient's permission, contact the referring practitioner to ensure the relevant service has been provided to the patient.

Support:

If there is any doubt about whether a patient has had a claim for an eating disorder service, health professionals can access the Health Professionals Online System (HPOS). HPOS is a fast and secure way for health professionals and administrators to check if a patient is eligible for a Medicare benefit for a specific item on the date of the proposed service. However, this system will only return advice that the service/item is payable or not payable.

Patients can also access their own claiming history with a My Health Record or by establishing a Medicare online account through myGov or the Express Plus Medicare mobile app.

Alternatively, health professionals can call Services Australia on 132 150 to check this information, while patients can seek clarification by calling 132 011.

 Additional Claiming Information (general conditions and limitations)

Items 90264-90265 cannot be claimed with item 2713 and 279.

Consultant psychiatrist and paediatrician EDP items 90266-90267 do not apply if the patient does not have a referral within the period of validity.

Before proceeding with the EDR service 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 reviewed 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 revised EDP, or relevant parts of the plan, to other providers involved in the patient's treatment.

The medical practitioner EDR items cover the service of reviewing 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 or review 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 Better Access)

Items 90264-90265 for an EDR, performed by a medical practitioner working in general practice, should not be performed in association with a GP mental health consultation review service (item 2712 and 277).

Related Items: 90264 90265 90266 90267

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Professional attendance by a general practitioner to review an eating disorder treatment and management plan.

Fee: $78.95 Benefit: 100% = $78.95

(See para AN.36.1, AN.36.3 of explanatory notes to this Category)

Professional attendance by a medical practitioner (other than a general practitioner, specialist or consultant physician) to review an eating disorder treatment and management plan.

Fee: $63.15 Benefit: 100% = $63.15

(See para AN.36.1, AN.36.3 of explanatory notes to this Category)

Professional attendance at consulting rooms by a consultant physician in the practice of the physician’s specialty of psychiatry to review an eating disorder treatment and management plan, if:

(a) the patient is referred; and

(b) the attendance lasts at least 30 minutes

Fee: $316.15 Benefit: 85% = $268.75

(See para AN.36.1, AN.36.3, AN.40.1 of explanatory notes to this Category)

Professional attendance at consulting rooms by a consultant physician in the practice of the physician’s specialty of paediatrics to review an eating disorder treatment and management plan, if:

(a) the patient is referred; and

(b) the attendance lasts at least 20 minutes

Fee: $147.65 Benefit: 85% = $125.55

(See para AN.36.1, AN.36.3, AN.40.1 of explanatory notes to this Category)