Medicare Benefits Schedule - Item 10964

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Category 8 - MISCELLANEOUS SERVICES

10964

10964 - Additional Information

Item Start Date:
01-Jul-2004
Description Updated:
01-Mar-2024
Schedule Fee Updated:
01-Nov-2023

Group
M3 - Allied Health Services
Subgroup
1 - Chronic disease management services

Chiropractic health service provided to a patient by an eligible chiropractor if:

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

(i) a chronic condition; and
(ii) complex care needs being managed by a medical practitioner (other than a specialist or consultant physician) under both a GP Management Plan and Team Care Arrangements or, if the patient is a resident of an aged care facility, the patient’s medical practitioner has contributed to a multidisciplinary care plan; and

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

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

to a maximum of 5 services (including any services to which this item or any other item in this Subgroup or item 93000 or 93013 in the Telehealth and Telephone Determination applies) in a calendar year

Fee: $68.55 Benefit: 85% = $58.30

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

Extended Medicare Safety Net Cap: $205.65


Associated Notes

Category 8 - MISCELLANEOUS SERVICES

MN.3.1

Individual Allied Health Services (Items 10950, 10951, 10952, 10953, 10954, 10956, 10958, 10960, 10962, 10964, 10966, 10968, 10970, 93000 and 93013) for Chronic Disease Management

Eligible patients

Medicare benefits are available for services provided by eligible allied health professionals to patients with chronic or terminal conditions and complex care needs who are being managed by a GP or prescribed medical practitioner using Chronic Disease Management (CDM) MBS items. The allied health services must be recommended in:

  • the GP Management Plan as part of the management of a chronic or terminal condition and Team Care Arrangements be undertaken, or
  • the multidisciplinary care plan if the patient is a resident of a residential aged care facility.

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 prescribed medical practitioner, and at least 2 other health or care providers.  

A prescribed medical practitioner is a medical practitioner other than a GP, specialist, or consultant physician.

Number of services per year

Medicare benefits are available for up to 5 services per eligible patient, per calendar year if clinically indicated and each service meets all the item requirements. The 5 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).

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.

Aboriginal or Torres Strait Islander patients

Aboriginal or Torres Strait Islander patients can claim additional allied health services under group M11. Refer to MN.11.1 for further information.

Referral requirements

To access these allied health services, patients must have the following MBS services in place:

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

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

Referral form

For Medicare benefits to be payable, the patient must be referred to an eligible allied health professional by their GP or prescribed 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 on the Department of Health and Aged Care website. GPs and prescribed medical practitioners are encouraged to attach relevant information to the referral form.

GPs and prescribed 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.

Providers should retain referrals for their services for 24 months from the date the service was rendered for Medicare auditing purposes.

Referrals for people of Aboriginal or Torres Strait Islander descent

Referrals for patients of Aboriginal or Torres Strait Islander descent can be made using the ‘Referral form for follow-up allied health services under Medicare for people of Aboriginal or Torres Strait Islander descent’ or a referral containing the same information as the form. The form issued by the department is available on the department’s website. This referral form is to be used for patients of Aboriginal or Torres Strait Islander descent for referral to allied health services under Group M11 (and equivalent telehealth items) where a GP Management Plan and Team Care Arrangements, or a multidisciplinary plan, or a health assessment has been undertaken (see MN.11.1 for more information).

Referral validity

If a patient has not used all their services under a referral in a calendar year, it is not necessary to obtain a new referral for the ‘unused’ services. The ‘unused’ services will roll over into the following calendar year and will count towards the total of 5 services for which the patient is eligible in that calendar year.

When patients have used all their referred services or require a referral for a different type of allied health service recommended under their GP Management Plan and Team Care Arrangement, they will need to obtain a new referral from their GP or prescribed medical practitioner. GPs and prescribed medical practitioners may choose to use this visit to undertake a review of the patient's GP Management Plan and Team Care Arrangements or multidisciplinary care plan or, where appropriate, to manage the process using a GP/ prescribed medical practitioner consultation item.

It is not necessary to have a new GP Management Plan prepared each calendar year to access new referral/s for allied health services. Patients continue to be eligible for benefits for individual allied health services under M3 and telehealth equivalent services while they are being managed under the prerequisite GP Management Plan and Team Care Arrangements items if the need for eligible services continues to be recommended in their plan/s. However, regular reviews are encouraged.

Eligible Allied Health Professionals

To provide services under Medicare for patients with a chronic or terminal medical condition and complex care needs, eligible allied health professionals must meet the eligibility requirements as set out in the Health Insurance (Section 3C General Medical Services – Allied Health Services) Determination 2024.

The following allied health professionals are eligible to provide individual allied health services under these items:

  • Aboriginal and Torres Strait Islander health practitioners (10950)
  • Aboriginal health workers (10950)
  • audiologists (10952)
  • chiropractors (10964)
  • diabetes educators (10951)
  • dietitians (10954)
  • exercise physiologists (10953)
  • mental health service (10956) provided by allied health professionals including Aboriginal and Torres Strait Islander health practitioners, Aboriginal and Torres Strait Islander health workers, mental health nurses, occupational therapists, psychologists and social workers
  • occupational therapists (10958)
  • osteopaths (10966)
  • physiotherapists (10960)
  • podiatrists (10962)
  • psychologists (10968)
  • speech pathologists (10970)

Membership of Team Care Arrangements

The allied health professional providing the service may be a member of the TCA team convened by the GP or prescribed 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 prescribed medical practitioner and recommended in the patient's care plan/s.

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 prescribed 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 prescribed 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/s to the referring practitioner must be kept by the allied health professional who provided the service for 2 years from the date of the service.

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

Category 8 - MISCELLANEOUS SERVICES

MN.3.2

Multidisciplinary Case Conferencing for Chronic Disease Management (Items 10955, 10957, 10959)

These items provide MBS benefits for eligible allied health professionals to participate in a multidisciplinary case conference team in a community case conference with a patient’s GP or prescribed medical practitioner and other providers.

A prescribed medical practitioner is a medical practitioner other than a GP, specialist, or consultant physician. A multidisciplinary case conference means a process by which a multidisciplinary case conference team carries out all 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/prescribed medical practitioner in either the community or for a resident of a residential aged care facility.

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

  • 15–19 minutes (10955)
  • 20–39 minutes (10957)
  • 40 minutes or longer (10959)

Eligible Allied Health Professionals

For the purpose of these items, eligible health professionals must meet the eligibility requirements as set out in the Health Insurance (Section 3C General Medical Services – Allied Health Services) Determination 2024 and include the following:

  • Aboriginal health worker
  • Aboriginal and Torres Strait Islander health practitioner
  • audiologist
  • chiropractor
  • diabetes educator
  • dietitian
  • exercise physiologist
  • mental health worker which includes allied health professionals that meet the requirements of a mental health service which include Aboriginal and Torres Strait Islander health practitioners, Aboriginal and Torres Strait Islander health workers, mental health nurses, occupational therapists, psychologists and social workers
  • occupational therapist
  • osteopath
  • physiotherapist
  • podiatrist
  • psychologist
  • speech pathologist


Organisation of a case conference

The case conference must be organised by the GP/prescribed medical practitioner. The multidisciplinary case conference team must include a GP/prescribed 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 GP/prescribed 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 allied health professional 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:

  • asthma educators;
  • dental therapists;
  • dentists;
  • optometrists;
  • orthoptists;
  • orthotists or prosthetists;
  • pharmacists;
  • podiatrists;
  • registered nurses;
  • education providers;
  • “meals on wheels” providers;
  • personal care workers; and
  • probation officers.

In some instances, 2 allied health professionals 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 allied health professionals from the same profession have different specialisations that are clinically relevant to the same patient and cannot be provided by one of them alone. In this instance, both allied health professionals will be able to claim the items.

Participation in a case conference

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

The patient must agree to the allied health professional 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 GP/prescribed medical practitioner. The GP/prescribed medical practitioner should ensure that the patient has agreed and that their agreement has been recorded appropriately.

Allied health professionals 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 professional is not required to have a pre-existing relationship with the patient. However, the patient should agree to their participation 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 individual allied health services required and how they are allocated among professions 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 93000 93013


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