Medicare Benefits Schedule - Item 10958

OCCUPATIONAL THERAPY

Occupational therapy health service provided to a person by an eligible occupational therapist if:

(a)    the service is provided to a person who has:

1. a chronic condition; and
2. complex care needs being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under a shared care plan or under both a GP Management Plan and Team Care Arrangements or, if the person is a resident of an aged care facility, the person's medical practitioner has contributed to a multidisciplinary care plan; and

(b)    the service is recommended in the person's Team Care Arrangements, multidisciplinary care plan or shared care plan as part of the management of the person's chronic condition and complex care needs; and

(c)    the person is referred to the eligible occupational therapist by the medical practitioner using a referral form that has been issued by the Department or a referral form that contains all the components of the form issued by the Department; and

(d)    the person is not an admitted patient of a hospital; and

(e)    the service is provided to the person individually and in person; and

(f)    the service is of at least 20 minutes duration; and

(g)    after the service, the eligible occupational therapist gives a written report to the referring medical practitioner mentioned in paragraph (c):

    (i) if the service is the only service under the referral - in relation to that service; or

    (ii) if the service is the first or the last service under the referral - in relation to that service; or

    (iii) if neither subparagraph (i) nor (ii) applies but the service involves matters that the referring medical practitioner would reasonably expect to be informed of - in relation to those matters; and

(h)    for a service for which a private health insurance benefit is payable - the person who incurred the medical expenses for the service has elected to claim the Medicare benefit for the service, and not the private health insurance benefit;

- to a maximum of  five services (including any services to which items 10950 to 10970, 93000, 93013, 93501 to 93513 and 93524 to 93538 apply) in a calendar year

Fee: $68.20 Benefit: 85% = $58.00

(See para MN.3.1, MN.3.2, MN.3.3, MN.3.4, MN.3.5 of explanatory notes to this Category)

Extended Medicare Safety Net Cap: $204.60

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Eligible patients

Medicare benefits are available for certain services provided by eligible allied health professionals to people with chronic or terminal conditions and complex care needs who are being managed by a GP or medical practitioner using certain Chronic Disease Management (CDM) MBS items. The allied health services must be recommended in the patient's plan as part of the management of their chronic or terminal condition.

Chronic or terminal medical conditions and complex care needs

These items are for patients with one or more medical conditions that have been (or are likely to be) present for at least 6 months, or terminal condition(s). A patient is considered to have complex care needs if they require ongoing care from a multidisciplinary team consisting of their GP or medical practitioner, and at least 2 other health or care providers.

Prerequisite CDM services

Patients must have received the following MBS CDM services:

• GP Management Plan - GP item 721/92024 or medical practitioner item 229/92055; and
• Team Care Arrangements (TCA) - GP item 723/92025 or medical practitioner item 230/92056

Alternatively, for patients who are care recipients of an aged care facility, their GP or medical practitioner must have contributed to a multidisciplinary care plan prepared for them by the facility (MBS GP item 731/92027 or medical practitioner item 232/92058).

For more information on the CDM planning items, refer to the explanatory notes for these items.

Allied health membership of a TCA team

The allied health professional providing the service may be a member of the TCA team convened by the GP or medical practitioner to manage a patient's chronic condition and complex care needs. However, the service may also be provided by an allied health professional who is not a member of the TCA team, provided that the service has been identified as necessary by the patient's GP or medical practitioner and recommended in the patient's care plan/s.

Group services

In addition to individual services, patients who have type 2 diabetes may also access to Medicare rebates under items 81100, 81105, 81110, 81115, 81120, 81125, 93284, 93285 and 93286 for group allied health services (and assessments for these services). See the items and explanatory notes MN.9.1 – 9.6 for further information.

Related Items: 10950 10951 10952 10953 10954 10956 10958 10960 10962 10964 10966 10968 10970

Referral form

For Medicare benefits to be payable, the patient must be referred to an eligible allied health professional by their GP or medical practitioner using a referral form that has been issued by the Australian Government Department of Health and Aged Care or a form that contains all the components of this form.

The form issued by the department is available at www.health.gov.au (click on the link or search for allied health referral form on the department's website).

GPs and medical practitioners are encouraged to attach a copy of the relevant part of the patient's care plan to the referral form.

GPs and medical practitioners may use one referral form to refer patients for single or multiple services of the same service type (e.g. 5 chiropractic services). If referring a patient for single or multiple services of different service types (e.g. 2 dietetic services and 3 podiatry services), a separate referral form will be needed for each service type.

The patient will need to present the referral form to the eligible allied health professional at the first consultation unless the GP or medical practitioner has previously provided it directly to the allied health professional.

Allied health professionals must retain the referral form for 2 years from the date the service was rendered (for Services Australia auditing purposes).

A copy of the referral form is not required to accompany Medicare claims, and allied health professionals do not need to attach a signed copy of the form to patients' itemised accounts/receipts or assignment of benefit forms.

Completed forms do not have to be sent to the Department of Health and Aged Care.

Referral validity

Medicare benefits are available for up to 5 allied health services per patient per calendar year if clinically indicated and each service meets all of the item requirements. Where a patient receives more than the limit of 5 services in a calendar year, the additional service/s will not attract a Medicare benefit and the MBS Safety Net arrangements will not apply to costs incurred by the patient for the service/s.

If a patient has not used all of their allied health services under a referral in a calendar year, it is not necessary to obtain a new referral for the "unused" services. However, any "unused" services received from 1 January in the following year under that referral will count as part of the total of 5 services for which the patient is eligible in that calendar year.

When patients have used all of their referred services or require a referral for a different type of allied health service recommended in their Chronic Disease Management (CDM) plan/s, they will need to obtain a new referral from their GP or medical practitioner. GPs and medical practitioners may choose to use this visit to undertake a review of the patient's CDM plan/s or, where appropriate, to manage the process using a GP/medical practitioner consultation item.

It is not necessary to have a new CDM plan/s prepared each calendar year in order to access a new referral/s for eligible allied health services. Patients continue to be eligible for rebates for allied health services while they are being managed under the prerequisite CDM items as long as the need for eligible services continues to be recommended in their plan. However, regular reviews are encouraged.

Related Items: 10950 10951 10952 10953 10954 10956 10958 10960 10962 10964 10966 10968 10970 93000 93013

Eligible allied health providers

The following allied health professionals are eligible to provide services under Medicare for patients with a chronic or terminal medical condition and complex care needs when they meet the provider eligibility requirements set out the next section and are registered with Services Australia.

• Aboriginal and Torres Strait Islander health practitioners
• Aboriginal health workers
• Audiologists
• Chiropractors
• Diabetes educators
• Dietitians
• Exercise physiologists
• Mental health workers
• Occupational therapists
• Osteopaths
• Physiotherapists
• Podiatrists
• Psychologists
• Speech pathologists

Number of services per year

Medicare benefits are available for up to 5 allied health services per eligible patient, per calendar year, if clinically indicated and each service meets all of the item requirements. The 5 allied health services can be made up of one type of service (e.g. 5 physiotherapy services) or a combination of different types of services (e.g. one dietetic and 4 podiatry services). Five Medicare rebated services per calendar year are the legal maximum per patient and exemptions to this are not possible.

Checking patient eligibility for allied health services

Patients seeking Medicare rebates for allied health services will need to have a valid referral form. If there is any doubt about a patient's eligibility, Services Australia can confirm the number of allied health services already claimed by the patient during the calendar year. The allied health professional or the patient can call Services Australia to check this information (132 150 for provider enquiries; 132 011 for public enquiries).

Service length and type

Individual allied health services under Medicare for patients with a chronic or terminal medical condition and complex care needs (items 10950–10970 and 93000 and 93013) must be of at least 20 minutes duration and provided to an individual patient, not to a group. For items 10950–10970 the allied health professional must personally attend the patient.

Reporting back to the Referring Practitioner

Where an allied health professional provides a single service to the patient under a referral, they must provide a written report back to the referring GP or medical practitioner after each service.

Where an allied health professional provides multiple services to the same patient under the one referral, they must provide a written report back to the referring GP or medical practitioner after the first and last service only, or more often if clinically necessary. Written reports should include:

• any investigations, tests, and/or assessments carried out on the patient;
• any treatment provided; and
• future management of the patient's condition or problem.

The report to the practitioner must be kept by the allied health provider for 2 years from the date of service.

Out-of-pocket expenses and Medicare Safety Net

Allied health professionals can determine their own fees for the professional service. Charges in excess of the Medicare benefit are the responsibility of the patient. However, out-of-pocket costs will count toward the Medicare Safety Net for that patient. Allied health services in excess of 5 in a calendar year will not attract a Medicare benefit and the Safety Net arrangements will not apply to costs incurred by the patient for such services.

Publicly funded services

Items 10950 –10970, 93000 and 93013 do not apply to services provided by any Commonwealth or state funded services or services 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 government health clinic, these items can be claimed for services provided by eligible allied health professionals salaried by, or contracted to, the service or health clinic. All requirements of the relevant item must be met, including registration of the allied health professional with Services Australia. Medicare services provided under a subsection 19(2) exemption must be bulk billed (i.e. the Medicare rebate is accepted as full payment from the patient for services).

Private health insurance

Patients need to decide if they will use Medicare or their private health insurance general treatment cover (also known as ancillary or extras cover) to pay for these services. Patients cannot use their private health insurance general treatment cover to 'top up' the Medicare rebate paid for the services.

Related Items: 10950 10951 10952 10953 10954 10956 10958 10960 10962 10964 10966 10968 10970 93000 93013

The individual allied health items can only be claimed for services provided by eligible allied health professionals who are registered with Services Australia. To be eligible to register with Services Australia to provide these services, allied health professionals must meet the specific eligibility requirements detailed below. 

Aboriginal and Torres Strait Islander health practitioners must be registered with the Aboriginal and Torres Strait Islander Health Practice Board of Australia. Aboriginal and Torres Strait Islander health practitioners may use any of the titles authorised by the Aboriginal and Torres Strait Islander Health Practice Board: Aboriginal health practitioners; Aboriginal and Torres Strait Islander health practitioners; or Torres Strait Islander health practitioners. 

Aboriginal health workers in a state or territory other than the Northern Territory must have been awarded either:

• a Certificate III in Aboriginal and/or Torres Strait Islander Primary Health Care (or an equivalent or higher qualification) by a registered training organisation; or
• a Certificate III in Aboriginal and Torres Strait Islander Health (or an equivalent or higher qualification) by a registered training organisation before 1 July 2012. 

Note: Where individuals consider their qualification to be equivalent to or higher than the qualifications listed above, they will need to contact a registered training organisation in their state or territory to have the qualification assessed as such before they can register with Services Australia. In the Northern Territory, a practitioner must be registered with the Aboriginal and Torres Strait Islander Health Practice Board of Australia. 

Audiologists must be either a 'Full Member' of the Audiological Society of Australia Inc (ASA), who holds a 'Certificate of Clinical Practice' issued by the ASA; or an 'Ordinary Member - Audiologist' or 'Fellow Audiologist' of the Australian College of Audiology. 

Chiropractors must be registered as a person who may provide that kind of service under the applicable law in force in the State or Territory in which the service is provided.

Diabetes educators must be a Credentialled Diabetes Educator as credentialled by the Australian Diabetes Educators Association. 

Dietitians must be an 'Accredited Practising Dietitian' as recognised by the Dietitians Association of Australia.

Exercise physiologists must be an 'Accredited Exercise Physiologist' as accredited by Exercise and Sports Science Australia. 

Mental health workers can include services provided by the following:

• Aboriginal and Torres Strait Islander health practitioners;
• Aboriginal health workers;
• mental health nurses;
• occupational therapists;
• psychologists; and
• social workers.

Note. Psychologists, occupational therapists, Aboriginal and Torres Strait Islander health practitioners and Aboriginal health workers are eligible in separate categories for these items. 

Mental health nurses must be a credentialled mental health nurse, as certified by the Australian College of Mental Health Nurses.

Social workers must be a 'Member' of the Australian Association of Social Workers (AASW) and be certified by AASW as meeting the standards for mental health set out in the document published by AASW titled 'Practice Standards for Mental Health Social Workers' as in force on 8 November 2008. 

Occupational therapists must be registered as a person who may provide that kind of service under the applicable law in force in the State or Territory in which the service is provided.

Osteopaths must be registered as a person who may provide that kind of service under the applicable law in force in the State or Territory in which the service is provided.

Physiotherapists must be registered as a person who may provide that kind of service under the applicable law in force in the State or Territory in which the service is provided.

Podiatrists must be registered as a person who may provide that kind of service under the applicable law in force in the State or Territory in which the service is provided.

Psychologists must be registered as a person who may provide that kind of service under the applicable law in force in the State or Territory in which the service is provided.

Speech pathologists must be a 'Practising Member' of Speech Pathology Australia. 

Registering with Services Australia

Provider registration forms may be obtained from the Services Australia website or by contacting Services Australia on 132 150. 

Changes to provider details

Allied health providers must notify Services Australia in writing of all changes to mailing details to ensure that they continue to receive information about Medicare rebates for allied health services.

Related Items: 10950 10951 10952 10953 10954 10956 10958 10960 10962 10964 10966 10968 10970 93000 93013

The allied health items provide MBS rebates for eligible allied health practitioners to participate in a multidisciplinary case conference team in a community case conference with a patient’s medical practitioner and other providers.

A multidisciplinary case conference means a process by which a multidisciplinary case conference team carries out all of the following activities:

• discussing a patient’s history;
• identifying the patient’s multidisciplinary care needs;
• identifying outcomes to be achieved by members of the multidisciplinary case conference team giving care and service to the patient;
• identifying tasks that need to be undertaken to achieve these outcomes, and allocating those tasks to members of the multidisciplinary case conference team;
• assessing whether previously identified outcomes (if any) have been achieved.

 These items apply to non-hospital admitted patients for:

• chronic disease management under the care of a GP/medical practitioner in either community or for a care recipient in a residential aged care facility.

 Eligible allied health practitioners may claim reimbursement for participating in case conferences through the following time-tiered items:

• 15–20 minutes (10955)
• 20–40 minutes (10957)
• At least 40 minutes (10959)

Eligible allied health practitioners

For the purposes of these items, eligible allied health practitioner means an eligible:

• Aboriginal health worker;
• Aboriginal and Torres Strait Islander health practitioner;
• diabetes educator;
• audiologist;
• dietitian;
• mental health worker;
• occupational therapist;
• exercise physiologist;
• physiotherapist;
• podiatrist;
• chiropractor;
• osteopath;
• psychologist; or
• speech pathologist.

Eligible patients

These items only apply to patients who, are not an admitted patient of a hospital and have at least one medical condition that has been (or is likely to be) present for at least six months; or is terminal.

Frequency limitations

These items cannot be claimed if the service has been performed in the last 3 months, unless in exceptional circumstances. An exceptional circumstance means there has been a significant change in the patient’s clinical condition or care circumstances that necessitate the performance of the service.

 Organisation of a case conference

The case conference must be organised by the medical practitioner. The multidisciplinary case conference team must include a medical practitioner and at least 2 other members providing different kinds of care to the patient. The multidisciplinary case conference team requirements include:

• each member must provide a different kind of care or service to the patient; and
• each member must not be an unpaid carer of the patient; and
• one member may be another medical practitioner.

The patient and family members or carers can attend the case conference but will not count towards the minimum team member requirements. 

The eligible allied health practitioner does not need all participants to be MBS-eligible to be able to claim payment for their participation. Members can include allied health professionals, home and community service providers and care organisers, including the following:

• Aboriginal and Torres Strait Islander health practitioners;
• asthma educators;
• audiologists;
• dental therapists;
• dentists;
• diabetes educators;
• dieticians;
• mental health workers;
• occupational therapists;
• optometrists;
• orthoptists;
• orthotists or prosthetists;
• pharmacists;
• physiotherapists;
• podiatrists;
• psychologists;
• registered nurses;
• social workers;
• speech pathologists;
• education providers;
• “meals on wheels” providers;
• personal care workers;
• probation officers.

In some instances, 2 eligible allied health practitioners from the same profession may participate in the same case conference, where both provide different aspects of care to the patient. For instance, the 2 providers from the same profession have different specialisations that are clinically relevant to the same patient and cannot be provided by one of the providers alone. In this instance, both providers will be able to claim the items.

Participation in a case conference

A referral is not required for eligible allied health practitioners to access the allied health case conferencing items for chronic disease management. However, the allied health practitioner must be invited to participate in the case conference by the patient’s treating medical practitioner.

The patient must agree to the allied health practitioner participating in the case conference and be informed that Medicare will be accessed to fund the service. The patient may agree through discussion with their medical practitioner. The allied health practitioner should ensure that the patient has agreed and that their agreement has been recorded appropriately.

Allied health practitioners claiming a case conferencing item should record the day, start and end times, the names of all participants and all matters discussed in the patient’s medical record.

The allied health practitioner is not required to have a pre-existing relationship with the patient. However, the patient should agree to the allied health practitioner participating in the case conference and be informed that Medicare will be accessed to fund the service.

The case conference may lead to an agreed care plan between all participating providers, including the number of allied health practitioner services required and how they are allocated among eligible allied health practitioners within a patient’s entitlement.

The case conferencing items can be accessed in person, via videoconference or telephone, using the same item number. There is no requirement that all participants use the same communication method.

Related Items: 10950 10951 10952 10953 10954 10956 10958 10960 10962 10964 10966 10968 10970