Medicare Benefits Schedule - Note AN.7.20

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Category 1 - PROFESSIONAL ATTENDANCES

AN.7.20

Medical Practitioner Completion of the Annual Diabetes Cycle of Care for Patients with Established Diabetes Mellitus (Items 259 to 264)

Eligibility

Items 259 to 264 are available to medical practitioners providing services in eligible areas.

Eligible area means an area that is a Modified Monash 2 area, Modified Monash 3 area, Modified Monash 4 area, Modified Monash 5 area, Modified Monash 6 area or Modified Monash 7 area.

Medical practitioners providing services in a Modified Monash 1 area should use the items in Group A19, Subgroup 2.

A locator map to identify a medical practice's Modified Monash Model Area location is available at the DoctorConnect website at http://www.doctorconnect.gov.au/internet/otd/publishing.nsf/Content/locator

Guidance Notes

Item numbers 259, 260, 261, 262, 263 and 264 should be used in place of the usual attendance item when a consultation completes the minimum requirements of the annual Diabetes Cycle of Care for a patient with established diabetes mellitus.

The annual Diabetes Cycle of Care must be completed over a period of 11 months and up to 13 months, and at a minimum must include: 

Assess diabetes control by measuring HbA1c At least once every year
Ensure that a comprehensive eye examination is carried out* At least once every two years
Measure weight and height and calculate BMI** At least twice every cycle of care
Measure blood pressure At least twice every cycle of care
Examine feet*** At least twice every cycle of care
Measure total cholesterol, triglycerides and HDL cholesterol At least once every year
Test for microalbuminuria At least once every year
Test for estimated Glomerular Filtration Rate (eGFR) At least once every year
Provide self-care education Patient education regarding diabetes management
Review diet Reinforce information about appropriate dietary choices
Review levels of physical activity Reinforce information about appropriate levels of physical activity
Check smoking status Encourage cessation of smoking (if relevant)
Review of Medication Medication review

*Not required if the patient is blind or does not have both eyes.

**Initial visit: measure height and weight and calculate BMI as part of the initial assessment.

   Subsequent visits: measure weight.

***Not required if the patient does not have both feet.

These requirements are generally based on the current guidelines produced by Diabetes Australia and the Royal Australian College of General Practitioners (Diabetes Management in General Practice). Medical practitioners using these items should familiarise themselves with these guidelines and with subsequent editions of these guidelines as they become available.

Use of these items certifies that the minimum requirements of the Diabetes Cycle of Care have been completed for a patient with established diabetes mellitus in accordance with the guidelines above.

These items should only be used once per cycle per patient: A7 Subgroup 8, A18 Subgroup 2 or A19 Subgroup 2. For example, if item 259 is claimed for a patient then no other diabetes item in groups A18 or A19 can be used for this patient in the same cycle.

The requirements for claiming these items are the minimum needed to provide good care for a patient with diabetes.  Additional levels of care will be needed by insulin-dependent patients and those with abnormal review findings, complications and/or co-morbidities.

In addition to attracting a Medicare rebate, recording a completion of a Diabetes Cycle of Care through the use of these items will initiate a Diabetes Service Incentive Payment (SIP) through the Practice Incentives Program (PIP).

All visits should be billed under the normal attendance items with the exception of the visit that completes all of the minimum requirements of the Diabetes Cycle of Care.

A PIP Diabetes SIP is available for completing the minimum requirements of the Diabetes Cycle of Care for individual patients as specified above. The Diabetes SIP is only paid once every 11-13 month period per patient. The SIP will be paid to the medical practitioner who provided the service if the service was provided in a medical practice participating in the PIP Diabetes Incentive. A further PIP Diabetes Incentive payment is paid to medical practices which reach target levels of care for their patients with diabetes mellitus.  More detailed information on the PIP Diabetes Incentive is available from the Department of Human Services PIP enquiry line on 1800 222 032 or  the Department of Human Services website.

Related Items: 259 260 261 262 263 264


Related Items

Category 1 - PROFESSIONAL ATTENDANCES

259

259 - Additional Information

Item Start Date:
01-Jul-2018
Description Start Date:
01-Jul-2018
Schedule Fee Start Date:
01-Jul-2019

Professional attendance at consulting rooms of more than 5 minutes, but not more than 25 minutes in duration by a medical practitioner in an eligible area, that completes the minimum requirements for a cycle of care of a patient with established diabetes mellitus

Fee: $30.10 Benefit: 100% = $30.10

(See para AN.7.1, AN.7.20 of explanatory notes to this Category)

Category 1 - PROFESSIONAL ATTENDANCES

260

260 - Additional Information

Item Start Date:
01-Jul-2018
Description Start Date:
01-Jul-2018
Schedule Fee Start Date:
01-Jul-2019

Professional attendance at a place other than consulting rooms of more than 5 minutes, but not more than 25 minutes in duration by a medical practitioner in an eligible area, that completes the minimum requirements for a cycle of care of a patient with established diabetes mellitus

The fee for item 259, plus $21.10 divided by the number of patients seen, up to a maximum of six patients. For seven or more patients - the fee for item 259 plus $1.65 per patient.
Ready Reckoner

(See para AN.7.1, AN.7.20 of explanatory notes to this Category)

Category 1 - PROFESSIONAL ATTENDANCES

261

261 - Additional Information

Item Start Date:
01-Jul-2018
Description Start Date:
01-Jul-2018
Schedule Fee Start Date:
01-Jul-2019

Professional attendance at consulting rooms of more than 25 minutes, but not more than 45 minutes in duration by a medical practitioner in an eligible area, that completes the requirements for a cycle of care of a patient with established diabetes mellitus

Fee: $58.30 Benefit: 100% = $58.30

(See para AN.7.1, AN.7.20 of explanatory notes to this Category)

Category 1 - PROFESSIONAL ATTENDANCES

262

262 - Additional Information

Item Start Date:
01-Jul-2018
Description Start Date:
01-Jul-2018
Schedule Fee Start Date:
01-Jul-2019

Professional attendance at a place other than consulting rooms of more than 25 minutes but not more than 45 minutes, in duration by a medical practitioner in an eligible area, that completes the minimum requirements for a cycle of care of a patient with established diabetes mellitus

The fee for item 261, plus $21.10 divided by the number of patients seen, up to a maximum of six patients. For seven or more patients - the fee for item 261 plus $1.65 per patient.
Ready Reckoner

(See para AN.7.1, AN.7.20 of explanatory notes to this Category)

Category 1 - PROFESSIONAL ATTENDANCES

263

263 - Additional Information

Item Start Date:
01-Jul-2018
Description Start Date:
01-Jul-2018
Schedule Fee Start Date:
01-Jul-2019

Professional attendance at consulting rooms of more than 45 minutes in duration by a medical practitioner in an eligible area, that completes the minimum requirements for a cycle of care of a patient with established diabetes mellitus

Fee: $85.80 Benefit: 100% = $85.80

(See para AN.7.1, AN.7.20 of explanatory notes to this Category)

Category 1 - PROFESSIONAL ATTENDANCES

264

264 - Additional Information

Item Start Date:
01-Jul-2018
Description Start Date:
01-Jul-2018
Schedule Fee Start Date:
01-Jul-2019

Professional attendance at a place other than consulting rooms of more than 45 minutes in duration by a medical practitioner in an eligible area, that completes the minimum requirements for a cycle of care of a patient with established diabetes mellitus

The fee for item 263, plus $21.10 divided by the number of patients seen, up to a maximum of six patients. For seven or more patients - the fee for item 263 plus $1.65 per patient.
Ready Reckoner

(See para AN.7.1, AN.7.20 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