Medicare Benefits Schedule - Item 82030

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Category 8 - MISCELLANEOUS SERVICES

82030

82030 - Additional Information

Item Start Date:
01-Jul-2011
Description Updated:
01-Mar-2024
Schedule Fee Updated:
01-Nov-2023

Group
M10 - Complex neurodevelopmental disorder and disability services
Subgroup
1 - Complex neurodevelopmental disorder and disability

Audiology, optometry, orthoptic or physiotherapy health service provided to a patient aged under 25 years by an eligible audiologist, optometrist, orthoptist or physiotherapist if:

(a)    the patient was referred by an eligible medical practitioner, or by an eligible allied health practitioner following referral by an eligible medical practitioner, to:

(i)   assist the eligible medical practitioner with diagnostic formulation where the patient has a suspected complex neurodevelopmental disorder or eligible disability; or

(ii)  contribute to the patient’s treatment and management plan developed by the referring eligible medical practitioner where a complex neurodevelopmental disorder (such as autism spectrum disorder) or eligible disability is confirmed; and

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

(c)    the service is at least 50 minutes duration

Up to 4 services to which this item or any of items 82000, 82005, 82010, 93032, 93033, 93040 or 93041 apply may be provided to the same patient on the same day

Fee: $96.80 Benefit: 85% = $82.30

(See para AN.0.25, MN.10.1, MN.10.3 of explanatory notes to this Category)

Extended Medicare Safety Net Cap: $290.40


Associated Notes

Category 1 - PROFESSIONAL ATTENDANCES

AN.0.25

Attendance services for eligible disabilities

Intention and eligibility of this service under item 137 and telehealth equivalent item 92141

Items 137 or telehealth equivalent item 92141 are intended for diagnosis and treatment for patients under 25 years of age with an eligible disability by a specialist or consultant physician.

Definition of Eligible Disabilities is found at AR.29.1.

Referral pathways:

Early identification of, and intervention for, individuals with eligible disabilities is important in promoting positive longer-term outcomes. Symptoms can cause clinically significant impairment in social, occupational or other important areas of functioning.

Where indications of eligible disability concerns have been identified and brought to the attention of the patient’s GP to initially assess these concerns and the GP considers there are persisting indications that require more specialised assessment, they are encouraged to refer to a specialist or consultant physician for a comprehensive assessment.

Diagnostic Assessment:

The assessment and diagnosis of an eligible disability should be evaluated in the context of both a physical and developmental assessment. The specialist or consultant physician may require a number of separate attendances (through usual time-tiered or subsequent attendance items 104, 105, 110, 116, 119, 296, 297, 299, 300, 302, 304, 306, 308, 310, 312, 314, 316, 318, 319, 320, 324, 326, 328, 330, 332, 334, 336, 338, 341, 342, 343, 344, 345, 346, 347 or 349 or telehealth items 91822 to 91831, 91833, 91836 to 91839, 91868 to 91878 to 91882 to 91884, 92437 or 92455 to 92460) to complete a comprehensive accurate assessment and formulate a diagnosis, exclude other disorders or assess for co-occurring conditions.

Multi-disciplinary assistance with assessment and/or contribution to the treatment and management plan:

Depending on a range of factors, not limited to the patient’s age and nature of suspected disabilities, the specialist or consultant physician may require a multi-disciplinary approach to complete a comprehensive accurate assessment and formulate a diagnosis. 

Where the specialist or consultant physician determines the patient requires additional assessments to formulate a diagnosis, through the assistance of an Allied Health practitioner, they are able to refer the patient to an eligible Allied Health practitioner from standard attendance items 104, 105, 110, 116, 119, 296, 297, 299, 300, 302, 304, 306, 308, 310, 312, 314, 316, 318, 319, 320, 324, 326, 328, 330, 332, 334, 336, 338, 341, 342, 343, 344, 345, 346, 347 or 349 or telehealth items 91822 to 91831, 91833, 91836 to 91839, 91868 to 91878 to 91882 to 91884, 92437 or 92455 to 92460.

Whilst MBS items provide for a total of 8 Allied Health assessment services per patient per lifetime, an eligible Allied Health practitioner can only provide up to 4 services before the need for a review (the type of review can be specified in the referral to the eligible Allied Health practitioner) by the referring specialist or consultant physician, who must agree to the need for any additional Allied Health services prior to the delivery of the remaining 4 Allied Health assessment services.

Eligible Allied Health assessment practitioners include:

  • Psychologist (MBS item 82000, 93032, 93040)
  • Speech Pathologist (MBS item 82005, 93033, 93041)
  • Occupational Therapist (MBS item 82010, 93033, 93041)
  • Audiologist, Optometrist, Orthoptist, Physiotherapist (MBS item 82030, 93033, 93041)

Requirements of the referral to Allied Health practitioners

The specialist or consultant physician can refer to multiple eligible Allied Health practitioners concurrently, but a separate referral letter must be provided to each Allied Health practitioner. The referral should specify the intent of the assessment and if appropriate, specify the number of services to be provided. Where the number of sessions is not specified, each Allied Health practitioner can provide up to 4 assessment services without the need for review or agreement to provide further assessment services. 

Review requirements following delivery of 4 Allied Health assessment services

Where an eligible Allied Health practitioner has provided 4 assessment services (through items 82000, 82005, 82010, 82030, 93032, 93033, 93040 or 93041) and considers additional assessment services are required, they must ensure the referring specialist or consultant physician undertakes a review. If the type of review is not specified by the referring specialist or consultant physician an acceptable means of review includes: a case conference, phone call, written correspondence, secure online messaging exchange or attendance of the patient with the referring psychiatrist.

Inter-disciplinary Allied Health referral

Eligible Allied Health practitioners are also able to make inter-disciplinary referrals to other eligible Allied Health practitioners as clinically necessary to assist with the formulation of the diagnosis or contribute to the treatment and management plan. Inter-disciplinary referrals must be undertaken in consultation and agreement with the referring specialist or consultant physician.  Whilst they do not require the need for an attendance with the patient (face-to-face or telehealth) by the referring specialist or consultant physician, they do require an agreement from the referring specialist or consultant physician. This can be undertaken (but is not limited to) an exchange by phone, written communication or secure online messaging.

Contribution to the treatment and management plan through Allied Health referral

In addition to referring to Allied Health practitioners for assistance with formulating a diagnosis, once the specialist or consultant physician makes a diagnosis, the specialist or consultant physician may require the contribution of an eligible Allied Health practitioner to assist with the development of the treatment and management plan (before billing item 137 or 92141).

MBS items 82000, 82005, 82010, 82030, 93032[BJ1] , 93033, 93040 or 93041 provide a dual function for this purpose. It is important to note that the service limit of a total of 8 services per patient per lifetime apply regardless of whether the items are used for assistance with diagnosis or contribution to the treatment and management plan, and the referring specialist or consultant physician should be mindful of this when referring to eligible Allied Health practitioners.

Development of the treatment and management plan

Once the specialist or consultant physician has made a diagnosis of an eligible disability, to complete the item requirements of item 137 or 92141 they must develop a treatment and management plan which includes:

  • Written documentation of the patient’s confirmed diagnosis of an eligible disability, including any findings of assessments performed (which assisted with the formulation of the diagnosis or contributed to the treatment and management plan)
  • A risk assessment which means assessment of:

o the risk to the patient of a contributing co‑morbidity and

o environmental, physical, social and emotional risk factors that may apply to the patient or to another individual.

  • Treatment options which:

o Recommendations using a biopsychosocial model

o Identify major treatment goals and important milestones and objectives

o Recommendation and referral for treatment services provided by eligible Allied Health practitioners (where relevant) and who should provide this, specifying number of treatments recommended (to a maximum of 20 treatment services)

o  Indications for review or episodes requiring escalation of treatment strategies

  • Documenting the treatment and management plan and providing a copy to the referring medical practitioner and relevant Allied Health practitioner/s.

Referral for Allied Health treatment services

Once a treatment and management plan is in place (after item 137 or 92141 has been claimed) the specialist or consultant physician can refer the individual to eligible Allied Health practitioners for the provision of treatment services. Treatment services address the functional impairments identified through the comprehensive medical assessment which are outlined in the treatment and management plan. Treatment services focus on interventions to address developmental delays/disabilities or impairments.

Eligible Allied Health treatment practitioners include:

  • Psychologist (MBS items 82015, 93035, 93043)
  • Speech Pathologist (MBS items 82020, 93036, 93044)
  • Occupational Therapist (MBS items 82025, 93036, 93044)
  • Audiologist, Optometrist, Orthoptist, Physiotherapist (MBS items 82035, 93036, 93044)

A total of 20 Allied Health treatment services per patient per lifetime are available through the MBS, which may consist of any combination of items 82015, 82020, 82025 or 82035 or equivalent telehealth items. Whilst the specialist or consultant physician can refer to multiple eligible Allied Health practitioners concurrently, a separate referral letter must be provided to each Allied Health practitioner.

The referral must specify the goals of the treatment and if appropriate, specify the number of services to be provided. It is the responsibility of the referring psychiatrist to allocate the number of treatment services (up to a maximum of 10 services per course of treatment) in keeping with the individual’s treatment and management plan.

It is important to note, that a benefit will not be paid for the MBS Allied Health treatment services unless the pre-requisite items (137 or 92141) have been processed through the Medicare claiming system.

On the completion of a “course of treatment” (specified by the referring specialist or consultant physician, up to maximum of 10 services), the eligible Allied Health practitioner must provide a written report to the referring specialist or consultant physician, which must include information on the treatment provided, recommendations for future management of the individual’s disorder and any advice to caregivers (such as parents, carers, schoolteachers). This written report will inform the referring specialist or consultant physician’s decision to refer for further treatment services. Where subsequent courses of treatment after the initial 10 services are required (up to a maximum of 20 services per patient per lifetime) a new referral is required.

Related Items: 104 105 110 116 119 137 296 297 299 300 302 304 306 308 310 312 314 316 318 319 320 324 326 328 330 332 334 336 338 342 344 346 82000 82005 82010 82015 82020 82025 82030 82035 91822 91831 91833 91836 91839 92141 92437 92455 93032 93033 93035 93036 93040 93041 93043 93044

Category 8 - MISCELLANEOUS SERVICES

MN.10.1

Assessment to assist with Diagnostic Formulation and Contribution to a Treatment and Management Plan by Eligible Allied Health Practitioner(s) for Complex Neurodevelopmental Disorder (such as Autism Spectrum Disorder) or Eligible Disability Services

These allied health items provide rebates for:

  • the assessment of patients for the purpose of assisting the referring eligible medical practitioner with the diagnosis (including a differential diagnosis) of a complex Neurodevelopmental Disorder (such as Autism Spectrum Disorder) or an eligible disability; or
  • to contribute to a treatment and management plan that is being developed by the referring eligible medical practitioner.

The list of eligible disabilities can be found at MN.10.3.

Number of services

  • A maximum of 8 services can be claimed per patient per lifetime, including services consisting of any combination of 82000, 82005, 82010, 82030, 93032, 93033, 93040 or 93041.
  • A course of assessment means up to 4 services.
  • Up to 4 of these services may be provided to the same patient on the same day.
  • Where a patient requires more than 4 services from the same eligible allied health provider, review and agreement is required by the referring medical practitioner before further Medicare eligible services can be claimed. 

Provision of assessment services and need for review and agreement by the referring eligible medical practitioner

  • An eligible allied health practitioner can provide up to 4 assessment services without the need for review and agreement by the referring eligible medical practitioner.
  • If an eligible allied health professional has provided 4 assessment services to a patient and proposes to provide more assessment services to that patient, review and agreement from the referring eligible medical practitioner must be obtained prior.
  • The referring eligible medical practitioner may specify the type of review that should be undertaken as part of the original referral. If it is not specified, an acceptable means of review includes: a case conference, phone call, written correspondence, secure online messaging exchange, or attendance with the referring eligible medical practitioner. 
  • The review and agreement by the referring eligible medical practitioner should be recorded by the eligible allied health practitioner in the patient notes.

Referral requirements

For an MBS rebate to be claimed for these services, a valid referral from an eligible medical practitioner (or subsequent interdisciplinary referral) is required. The eligible medical practitioner referral is only valid if the referring eligible medical practitioner used any of the following MBS items* for the suspected diagnosis of:

  • complex Neurodevelopmental Disorders referred by a:

- consultant psychiatrist using items 296 to 308, 310, 312, 314, 316, 318 or 319 to 352 of the general medical services table or items 91827, 91828, 91829, 91830, 91831, 91837, 91838, 91839, 92437, 92455, 92456, 92457, 92458, 92459 or 92460 of the COVID 19 Determination.

- consultant paediatrician using items 110 to 131 of the general medical services table or items 91824, 91825, 91826 or 91836 of the COVID 19 Determination.

  • eligible disability referred by a:

- specialist or consultant physician using items 104 to 131, 296 to 308, 310, 312, 314, 316, 318 or 319 to 352 of the general medical services table or items 91822 to 91839, 92437, 92455, 92456, 92457, 92458, 92459 or 92460 of the COVID 19 Determination.

- GP using items 3 to 47 of the general medical services table or item 91790, 91800, 91801, 91802, 91890, 91891 or 91894 of the COVID 19 Determination.

* Note that more information on the telehealth items that can be claimed for these services can be found in Note AN.40.1.

A separate referral from the eligible medical practitioner is required for each eligible allied health practitioner providing the service. The referral may be a letter, departmental form or note to an eligible allied health practitioner, signed and dated by the referring eligible medical practitioner. A Medicare claim must be submitted for the referring MBS service before a rebate for the subsequent referred allied health service can be paid.

Allied health practitioners should retain referrals for 24 months from the date the service was rendered for Medicare auditing purposes.

Interdisciplinary referrals

If an eligible allied health practitioner seeks to make an interdisciplinary referral of the patient to another eligible allied health professional, this must be undertaken in consultation and agreement with, but without the need for a physical attendance by, the original referring eligible medical practitioner (such as but not limited to, a phone call, written correspondence or secure online messaging exchange). This consultation and agreement should be documented in the patient notes by the eligible allied health practitioner and included in the interdisciplinary referral. The referral may be a letter or note to an eligible allied health practitioner, signed and dated by the referring eligible allied health practitioner. There is no specific form to refer patients for these services. The referral should include a copy of the original referral by the eligible medical practitioner.

Interdisciplinary referrals will only be valid where the referring eligible medical practitioner’s referral (whose original referral initiated the assessment and assisting with a diagnosis service/contribution to a treatment and management plan) remains valid.

Reporting requirements for assessment services

After completion of the final assessment service by an eligible allied health practitioner, a written report must be provided to the referring eligible medical practitioner that outlines the assessment findings. Preparation of the report is not counted towards the service time under the item.

The written report must include information on:

  • the assessment/s provided;
  • the results of the assessment/s that may assist with diagnostic formulation or development of a treatment and management plan by the referring eligible medical practitioner; and
  • if applicable, advice on further assessments that could be undertaken by other eligible allied health practitioners to assist with the referring medical practitioners’ diagnostic formulation or development of a treatment and management plan by the referring eligible medical practitioner.

Related Items: 82000 82005 82010 82030 93032 93033 93035 93036 93040 93041 93043 93044

Category 8 - MISCELLANEOUS SERVICES

MN.10.3

Eligibility for Allied Health Assessment and Treatment Services for Complex Neurodevelopmental Disorder (such as Autism Spectrum Disorder) and Eligible Disability Services

Eligible patients

These items provide Medicare rebates for allied health services provided to patients under 25 years old with a suspected or diagnosed complex Neurodevelopmental Disorder (such as Autism Spectrum Disorder) or one or more of the eligible disabilities.

Eligible Disabilities

'Eligible disabilities' for the purpose of these services means any of the following conditions:

(a) Sight impairment that results in vision of less than or equal to 6/18 vision or equivalent field loss in the better eye, with correction.

(b) Hearing impairment that results in:

  • a hearing loss of 40 decibels or greater in the better ear, across 4 frequencies; or
  • permanent conductive hearing loss and auditory neuropathy

(c) Deafblindness

(d) Cerebral palsy

(e) Down syndrome

(f) Fragile X syndrome

(g) Prader-Willi syndrome

(h) Williams syndrome

(i) Angelman syndrome

(j) Kabuki syndrome

(k) Smith-Magenis syndrome

(l) CHARGE syndrome

(m) Cri du Chat syndrome

(n) Cornelia de Lange syndrome

(o) Microcephaly if a child has:

  • a head circumference less than the third percentile for age and sex; and
  • a functional level at or below 2 standard deviations below the mean for age on a standard developmental test, or an IQ score of less than 70 on a standardised test of intelligence*

(p) Rett's disorder

(q) Fetal Alcohol Spectrum Disorder (FASD)

(r) Lesch-Nyhan syndrome 

(s) 22q deletion Syndrome

*"standard developmental test" refers to tests such as the Bayley Scales of Infant Development or the Griffiths Mental Development Scales; "standardised test of intelligence" means the Wechsler Intelligence Scale for Children (WISC) or the Wechsler Preschool and Primary Scale of Intelligence (WPPSI). It is up to the clinical judgement of the practitioner to determine which tests are appropriate to be used.

Eligible allied health practitioners

The allied health assessment and treatment services can be provided by eligible audiologists, occupational therapists, optometrists, orthoptists, physiotherapists, psychologists and speech pathologists.

To provide services under these items eligible allied health practitioners must meet the eligibility requirements as set out in the Health Insurance (Allied Health Services) Determination 2014.

It is expected that eligible providers will 'self-select' for the complex Neurodevelopmental Disorder and eligible disability items (i.e. possess the skills and experience appropriate for provision of these services and be oriented to work with patients with complex Neurodevelopmental Disorders or eligible disabilities).

Related Items: 82000 82005 82010 82015 82020 82025 82030 82035 93032 93033 93035 93036 93040 93041 93043 93044


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