Medicare Benefits Schedule - Item 109

Professional attendance by a specialist in the practice of the specialist's specialty of ophthalmology following referral of the patient to the specialist-an attendance (other than a second or subsequent attendance in a single course of treatment) at which a comprehensive eye examination, including pupil dilation, is performed on:

(a) a patient aged 9 years or younger; or

(b) a patient aged 14 years or younger with developmental delay;

(other than a service to which any of items 104, 106 and 10801 to 10816 applies)

Fee: $228.30 Benefit: 75% = $171.25 85% = $194.10

(See para MN.10.1 of explanatory notes to this Category)

Extended Medicare Safety Net Cap: $500.00

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These allied health items provide a benefit 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 benefit to be claimed for these services, a valid referral from an eligible medical practitioner (or subsequent interdisciplinary referral) is required. The general requirements for referrals under group M10 (subgroup 1) are detailed in Note AN.15.6 ‘Referral requirements for allied health services’. 

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 349 of the general medical services table or items 91827, 91828, 91829, 91830, 91831, 91837, 91838, 91839, 92437, 92455, 92456 or 92457 of the Telehealth Attendance Determination.

- consultant paediatrician using items 110 to 131 of the general medical services table or items 91824, 91825, 91826 or 91836 of the Telehealth Attendance 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 349 of the general medical services table or items 91822 to 91839, 92437, 92455, 92456 or 92457 of the Telehealth Attendance Determination.

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

* Note that more information on the telehealth (video and phone) 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. A Medicare claim must be submitted for the referring MBS service before a benefit 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: 3 4 23 24 36 37 44 47 104 105 106 107 108 109 110 111 115 116 117 119 120 122 123 124 125 126 127 128 129 131 296 297 299 300 301 302 303 304 306 308 310 312 314 316 318 319 320 322 324 326 328 330 332 334 336 338 341 342 343 344 345 346 347 349 82000 82005 82010 82030 91790 91800 91801 91802 91822 91823 91824 91825 91826 91827 91828 91829 91830 91831 91833 91836 91837 91838 91839 91890 91891 92437 92455 92456 92457 93032 93033 93040 93041 93044