Medicare Benefits Schedule - Item 293

Professional attendance of more than 30 minutes but not more than 45 minutes in duration at consulting rooms by a consultant physician in the practice of the consultant physician's specialty of psychiatry, if:

(a) the patient is being managed by a medical practitioner or a participating nurse practitioner in accordance with a management plan prepared by the consultant in accordance with item 291; and

(b) the attendance follows referral of the patient to the consultant for review of the management plan by the medical practitioner or a participating nurse practitioner managing the patient; and

(c) during the attendance, the consultant:

(i) uses an outcome tool (if clinically appropriate); and

(ii) carries out a mental state examination; and

(iii) makes a psychiatric diagnosis; and

(iv) reviews the management plan; and

(d) within 2 weeks after the attendance, the consultant:

(i) prepares a written diagnosis of the patient; and

(ii) revises the management plan; and

(iii) gives the referring practitioner a copy of the diagnosis and the revised management plan; and

(iv) if clinically appropriate, explains the diagnosis and the revised management plan, and gives a copy, to:

(A) the patient; and

(B) the patient's carer (if any), if the patient agrees; and

(e) in the preceding 12 months, a service to which item 291 applies has been provided; and

(f) in the preceding 12 months, a service to which this item applies has not been provided

Fee: $314.60 Benefit: 85% = $267.45

(See para AN.0.30, AN.40.1 of explanatory notes to this Category)

Extended Medicare Safety Net Cap: $500.00

• Previous - Item 291
• Next - Item 294

Referral for items 291, 293, 92435 and 92436 should be through the general practitioner or participating nurse practitioner for the management of patients with mental illness. In the event that a specialist of another discipline wishes to refer a patient for this item the referral should take place through the GP or participating nurse practitioner.

In order to facilitate ongoing patient focussed management, an outcome tool will be utilised during the assessment and review stage of treatment, where clinically appropriate. The choice of outcome tools to be used is at the clinical discretion of the practitioner, however the following outcome tools are recommended:

- Kessler Psychological Distress Scale (K10)

- Short Form Health Survey (SF12)

- Health of the Nation Outcome Scales (HoNOS)

Preparation of the management plan should be in consultation with the patient. If appropriate, a written copy of the management plan should be provided to the patient. A written copy of the management plan should be provided to the general 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 GP or participating nurse practitioner may be appropriate. A guide to the content of the report which should be provided to the GP or participating nurse practitioner under this item is included within this Schedule.

It is expected that item 291 or 92435 will be a single attendance. However, there may be particular circumstances where a patient has been referred by a GP or participating nurse practitioner for an assessment and management plan, but it is not possible for the consultant psychiatrist to determine in the initial consultation whether the patient is suitable for management under such a plan. In these cases, where clinically appropriate, items 296, 297, 299 or 92437 (for a new patient) or 300-308 (for continuing patients) may be used, and item 291 or 92435 may be used subsequently, in those circumstances where the consultant psychiatrist 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 not intended that items 296, 297, 299, 92437 or 300-308 will generally or routinely be used in conjunction with, or prior to, item 291 or 92435.

Items 293 and 92436 are available in instances where the GP or participating nurse practitioner initiates a review of the plan provided under item 291 or 92435, usually where the current plan is not achieving the anticipated outcome. It is expected that when a plan is reviewed, any modifications necessary will be made.

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) Referred Patient Assessment and Management Plan Guidelines

Note: This information is provided as a guide only and each case should be addressed according to a patient's individual needs. An electronic version of the Guidelines is available on the RANZCP website at www.ranzcp.org

REFERRED PATIENT ASSESSMENT AND MANAGEMENT PLAN

Preliminary

- The following content outline is indicative of what would usually be sent back to GPs or participating nurse practitioner.

- The Management plan should address the specific questions and issues raised by the GP or participating nurse practitioner

- In most cases the patient is usually well known by the GP or participating nurse practitioner

History and Examination

This should focus on the presenting symptoms and current difficulties, including precipitating and ongoing stresses; and only briefly mention any relevant aspects of the patient's family history, developmental history, personality features, past psychiatric history and past medical history.

It should contain a comprehensive relevant Mental Status Examination and any relevant pathology results if performed.

It should summarise any psychological tests that were performed as part of the assessment.

Diagnosis

A diagnosis should be made either using ICD 10 or DSM IV classification. In some cases the diagnosis may differ from that stated by the GP or participating nurse practitioner, and an explanation of why the diagnosis differs should be included.

Psychiatric formulation

A brief integrated psychiatric formulation focussing on the biological, psychological and physical factors. Any precipitant and maintaining factors should be identified including relevant personality factors. Protective factors should also be noted. Issues of risk to the patient or others should be highlighted.

Management plan

1. Education - Include a list of any handout material available to help people understand the nature of the problem. This includes recommending the relevant RANZCP consumer and carer clinical practice guidelines. 

2. Medication recommendations - Give recommendations for immediate management including the alternatives or options. This should include doses, expected response times, adverse effects and interactions, and a warning of any contra-indicated therapies. 

3. Psychotherapy - Recommendations should be given on the most appropriate mode of psychotherapy required, such as supportive psychotherapy, cognitive and behavioural psychotherapy, family or relationship therapy or intensive explorative psychotherapy. This should include recommendations on who should provide this therapy.

4. Social measures - Identify issues which may have triggered or are contributing to the maintenance of the problem in the family, workplace or other social environment which need to be addressed, including suggestions for addressing them. 

5. Other non medication measures - This may include other options such as life style changes including exercise and diet, any rehabilitation recommendations, discussion of any complementary medicines, reading recommendations, relationship with other support services or agencies etc.

6. Indications for re-referral - It is anticipated that the majority of patients will be able to be managed effectively by the GP or participating nurse practitioner using the plan. If there are particular concerns about the possible need for further review, these should be noted.

7. Longer term management - Provide a longer term management plan listing alternative measures that might be taken in the future if the clinical situation changes. This might be articulated as a relapse signature and relapse drill, and should include drug doses and other indicated interventions, expected response times, adverse effects and interactions.

Initial Consultation for a NEW PATIENT (item 296 in rooms, item 297 at hospital, item 299 for home visits, or item 92437 for telehealth)

The rationale for items 296, 297, 299 and 92437 is to improve access to psychiatric services by encouraging an increase in the number of new patients seen by each psychiatrist, while acknowledging that ongoing care of patients with severe mental illness is integral to the role of the psychiatrist. Referral for items 296, 297, 299 and 92437 may be from a participating nurse practitioner, medical practitioner practising in general practice, a specialist or another consultant physician.

It is intended that either item 296, 297, 299 and 92437 will apply once only for each new patient on the first occasion that the patient is seen by a consultant psychiatrist, unless the patient is referred by a medical practitioner practising in general practice or participating nurse practitioner for an assessment and management plan, in which case the consultant psychiatrist, if they agree that the patient is suitable for management in a general practice setting, will use item 291 or 92435 where an assessment and management plan is provided to the referring practitioner. 

There may be particular circumstances where a patient has been referred by a GP or participating nurse practitioner to a consultant psychiatrist for an assessment and management plan, but it is not possible for the consultant psychiatrist to determine in the initial consultation whether the patient is suitable for management under such a plan. In these cases, where clinically appropriate, item 296, 297, 299 or 92437 (for a new patient) or 300-308 (for continuing patients) may be used and item 291 or 92435 may be used subsequently, in those circumstances where the consultant psychiatrist undertakes a consultation (in accordance with the item requirements) and provides the referring practitioner with an assessment and management plan. It is not generally intended that item 296, 297, 299 or 92437 will be used in conjunction with, or prior to, item 291 or 92435.

Use of items 296, 297, 299 or 92437 by one consultant psychiatrist does not preclude them being used by another consultant psychiatrist for the same patient. The use of items 296, 297, 299 or 92437 are identical except for the location of where the service is rendered. That is item 296 is only available for consultations rendered in consulting rooms, item 297 is only available for consultations rendered at a hospital, item 299 is only available for consultations rendered at a place other than consulting rooms or a hospital (such as in a patient’s home) and item 92437 is only available for video consultations.

Items 300 - 308 are available for consultations in consulting rooms other than those provided under items 296, 291 and 293. Similarly, time tiered items remain available for hospital, and home visits. These would cover a new course of treatment for patients who have already been seen by the consultant psychiatrist in the preceding 24 months as well as subsequent consultations for all patients.

Referral to Allied Mental Health Professionals (for new and continuing patients)

To increase the clinical treatment options available to psychiatrists and paediatricians for which a Medicare benefit is payable, patients with an assessed mental disorder (dementia, delirium, tobacco use disorder and mental retardation are not regarded as mental disorders for the purposes of these items) may be referred to mental health professional for a total of ten individual allied mental health services in a calendar year. The ten services may consist of: GP focussed psychological strategies services (items 2721, 2723, 2725, 2727; 91818, 91819, 91842 and 91843) or non-specialist medical practitioner items (283, 285, 286, 287, 91820, 91821, 91844 and 91845); psychological therapy services items 80000, 80005, 80010, 80015, 91166, 91167, 91181 and 91182) - provided by eligible clinical psychologists; and/or focussed psychological strategies - allied mental health services (items 80100, 80105, 80110, 80115, 80125, 80130, 80135, 80140; 80150, 80155, 80160, 80165; 91169, 91170,; 91172, 91173, 91175, 91176, 91183, 91184, 91185, 91186, 91187 and 91188) - provided by eligible psychologists, occupational therapists and social workers.

Referrals from psychiatrists and paediatricians to an allied mental health professional must be made from eligible Medicare services. For specialist psychiatrists and paediatricians these services include any of the specialist attendance items 104 through 109. For consultant physician psychiatrists the relevant eligible Medicare services cover any of the consultant psychiatrist items 293 to 299, 92436 and 92437; while for consultant physician paediatricians the eligible services are consultant physician attendance items 110 through 133.

Within the maximum service allocation of ten services, the allied mental health professional can provide one or more courses of treatment. 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). These services 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.

While such referrals are likely to occur for new patients seen under items 296, 297, 299 or 92437, they are also available for patients at any point in treatment (from items 293 to 299, 92436 and 92437), as clinically required, under the same arrangements and limitations as outlined above. The referral may be in the form of a letter or note to an eligible allied health professional signed and dated by the referring practitioner. 

Patients will also be eligible to claim up to ten services within a calendar year for group therapy services involving 4-10 patients to which items 80020, 80021, 80022, 80023, 80024 and 80025 (psychological therapy - clinical psychologist), 80120, 80121, 80122, 80123, 80127 and 80128 (focussed psychological strategies - psychologist), 80145, 80146, 80147, 80148, 80152, 80153 (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.

Related Items: 291 293 296 297 299 91166 91167 91169 91170 91172 91173 91175 91176 92435 92436 92437

From 1 January 2022, a number of telehealth items were permanently added to the MBS.

The intent of these ongoing telehealth items is to allow practitioners to provide MBS attendances remotely (by videoconference or telephone) where it is safe and clinically appropriate to do so in accordance with relevant professional standards.  

Providing telehealth services by videoconference is the preferred substitution for a face-to-face consultation. However, providers can provide a consultation via telephone where it is clinically relevant (and the service is covered by a relevant telephone item).

A list of the ongoing telehealth items and the equivalent face‑to‑face items can be found at Table 1.

Table 1 – Ongoing telehealth items and equivalent face to face services (out of hospital patients)

Further information on the telehealth changes can be found at www.mbsonline.gov.au by searching under the Facts Sheets tab – July 2022.

Eligible providers

All MBS items for referred attendances require a valid referral. However, if the specialist, consultant physician, consultant psychiatrist, paediatrician or geriatrician has previously seen the patient under a referral that is still valid, there is no need to obtain a specific referral for the purposes of claiming the video and telephone items.

Restrictions

All MBS telehealth and telephone attendance items are stand-alone items and are to be billed instead of a face‑to-face MBS item.

Billing Requirements

Bulk billing of specialist (and Allied Health) telehealth services is at the discretion of the provider, so long as informed financial consent is obtained prior to the provision of the service.

Further information on the assignment of benefit for bulk billed MBS telehealth services can be found in the ‘Provider Frequently Asked Questions’ at www.mbsonline.gov.au.

Relevant definitions and requirements

Specialist telehealth services (91822, 91823 and 91833) can be billed by all specialities that can currently bill items 104 and 105 or equivalent MBS items. This also includes sports and exercise medicine and occupational and environmental health medicine specialists.

Consultant physician telehealth services (91824, 91825, 91826 and 91836) can be billed by all specialities that can currently bill items 110, 116 and 119 or equivalent MBS items. This also includes pain and palliative medicine, sexual health medicine and addiction medicine.

Consultant physician telehealth services to prepare and review a management plan (92422 and 92423) can be billed by all physicians that can currently bill items 132 and 133 or equivalent MBS items. This also includes sexual health medicine, addiction medicine and paediatricians.

The specialist and consultant physician service for diagnosis and treatment for patients with an eligible disability (92141) can be billed by specialists and consultant physicians that are able to item 137.

Single course of treatment

The same conditions for a single course of treatment apply across all modalities (i.e. face‑to-face, video or telephone). Once an initial consultation is billed, all subsequent services related to the same condition are considered to be part of a single course of treatment. For example, if a patient has seen a specialist in a face‑to‑face consultation (where item 104 has been billed), item 91823 (video) or 91833 (telephone) should be billed if the patient sees the specialist remotely for the same condition.

Anaesthetist services

The Anaesthetist telehealth service (92701) can be billed by practitioners that can currently bill item 17615.

Service limits

At present, the service limits that apply to standard psychiatry services do not currently apply to the video and telephone attendance items for psychiatry (except for item 92460). Patients who have received more than 50 attendances under existing items are eligible to receive services under the video and telephone psychiatry items as long as they meet the item descriptor requirements.

In addition, patients who have received more than 50 attendances under item 319 are eligible to receive services under the video and telephone psychiatry items as long as they meet the item descriptor requirements.

The Department of Health and Aged Care will work with the Royal Australian and New Zealand College of Psychiatrists (RANZCP) and the Medicare Review Advisory Committee (MRAC) to review the current service limits, and ensure a consistent approach across all of the psychiatry attendance items, including services provided by face‑to‑face, video and telephone.

Interview item (92460)

Item 92460 provides for an interview with a person other than the patient. A maximum of 4 services in a calendar year can be billed under item 92460, or the equivalent face‑to‑face item (item 352), in the continuing management of a patient. That is, a consultant psychiatrist can bill for a service under item 92460 once more in the calendar year if a patient has received three MBS services under items 352 or 92460 in the same calendar year.

Management Plan items (92435 and 92436)

The MBS remote attendance preparation and review of GP management plan items have the same diagnosis, assessment and record-keeping requirements as the existing face-to-face items (291 and 293). Refer to MBS Explanatory Note AN.0.30 for further information.

Group psychotherapy items (92455, 92456 and 92457)

The MBS remote attendance group psychotherapy items have the same requirements as the existing face-to-face  items (342, 344 and 346). It is the responsibility of the practitioner rendering the service to maintain privacy and confidentiality for all participants throughout the service. Practitioners should refer to the relevant professional practice standards and guidelines for technology-based consultations.

Technical Requirements

The services can be provided by telehealth and by phone. It is the responsibility of the practitioner rendering the service to maintain privacy and confidentiality for all participants throughout the service. 

Telehealth attendance means a professional attendance by video conference where the medical practitioner:

1. has the capacity to provide the full service through this means safely and in accordance with relevant professional standards; and
2. is satisfied that it is clinically appropriate to provide the service to the patient; and
3. maintains a visual and audio link with the patient; and
4. is satisfied that the software and hardware used to deliver the service meets the applicable laws for security and privacy.

Note – only the time where a visual and audio link is maintained between the patient and the provider can be counted in meeting the relevant item descriptor.

No specific equipment is required to provide Medicare-compliant telehealth services. Practitioners must ensure that their chosen telecommunications solution meets their clinical requirements and satisfies privacy laws. Information on how to select a web conferencing solution is available at: www.cyber.gov.au

Phone attendance means a professional attendance by telephone where the health practitioner:

1. has the capacity to provide the full service through this means safely and in accordance with professional standards; and
2. is satisfied that it is clinically appropriate to provide the service to the patient; and
3. maintains an audio link with the patient.

There are no longer geographic restrictions on the MBS video or telephone services provided by specialists, consultant physicians, consultant psychiatrists, paediatricians, geriatricians and anaesthetists.

Recording Clinical Notes (for specialist, consultant physician, consultant psychiatrist, neurosurgery, public health medicine, geriatrician, paediatrician and anaesthetist)

In relation to the time taken in recording appropriate details of the service, only clinical details recorded at the time of the attendance count towards the time of consultation.  It does not include information added later, such as reports of investigations, or when either the visual or audio link between the patient and the practitioner is lost. 

Clinicians should record the date, time and duration of the consultation, and retain these records.

Related Items: 104 105 110 116 119 132 133 135 137 141 143 289 291 293 296 300 302 304 306 308 342 344 346 348 350 352 410 411 412 413 6007 6009 6011 6013 6015 90260 90261 90266 90267 91822 91823 91824 91825 91826 91833 91836 92422 92423