Medicare Benefits Schedule - Item 326

Professional attendance by a consultant physician in the practice of the consultant physician's specialty of psychiatry following referral of the patient to the consultant physician by a referring practitioner-an attendance of more than 45 minutes, but not more than 75 minutes, in duration at hospital

Fee: $217.50 Benefit: 75% = $163.15 85% = $184.90

(See para AN.0.25, AN.0.32, AN.0.72 of explanatory notes to this Category)

Extended Medicare Safety Net Cap: $500.00

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

Items 137 or video 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, 107, 108, 110, 116, 119, 122, 128, 131, 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 (video and phone) items 91822 to 91831, 91833, 91836 to 91839, 91868 to 91878 to 91882 to 91884, 92437 or 92455 to 92457) 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, 107, 108, 110, 116, 119, 122, 128, 131, 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 (video and phone) 91822 to 91831, 91833, 91836 to 91839, 91868 to 91878 to 91882 to 91884, 92437 or 92455 to 92457.

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, dietitian, exercise physiologist, 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/video/phone) 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, 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 include:

o Recommendations using a biopsychosocial model

o Identifying major treatment goals and important milestones and objectives

o Recommendation/s 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, dietitian, exercise physiologist, 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 video 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: 104 105 107 108 110 116 119 122 128 131 137 296 297 299 300 302 304 306 308 310 312 314 316 318 319 320 324 326 328 330 332 334 336 338 341 342 343 344 345 346 347 349 82000 82005 82010 82015 82020 82025 82030 82035 91822 91823 91825 91826 91827 91828 91829 91830 91831 91833 91836 91837 91838 91839 91868 91869 91870 91871 91872 91873 91874 91875 91876 91877 91878 91879 91880 91881 91882 91883 91884 92141 92437 92455 92456 92457 93032 93033 93035 93036 93040 93041 93043 93044

Intention of these items:

Items 341, 343, 345, 347 and 349 and video equivalent items 91874 to 91878 and 91882 to 91884 are for the purpose of interviews with patient relatives or close associates to investigate the particular problem with which the patient presented or the interaction between the patient and the person interviewed. The items also provide for interviews concerned with the continuing management of the patient, focusing on clinically relevant problems rising in the management of the patient.

These items do not cover counselling of family or friends of the patient.

Referral requirements:

The patient who is the subject of the interview needs a referral to attend the psychiatrist in the first place, however the non-patient contacts who are interviewed do not require their own referral.

Claiming of Medicare benefits:

The payment of Medicare benefits under these items is limited to a total of 15 services in a calendar year. 

For Medicare benefit purposes, claims relating to services covered by items 341, 343, 345, 347, 349 and telehealth (video and phone) equivalent items 91874 to 91878 and 91882 to 91884 should be raised against the patient rather than against the person interviewed.

Same day attendance items:

Medicare benefits are payable on the same day for an interview under any of items 341, 343, 345, 347 and 349 or telehealth (video and phone) equivalent items 91874 to 91878 and 91882 to 91884 and for a consultation with a patient (under item 291, 293, 296, 297, 299, 300, 302, 304, 306, 308, 310, 312, 314, 316, 318, 319, 320, 322, 324, 326 or 328) provided that separate attendances are involved. This item can only be claimed if the interviewee attends without the patient. 

Related Items: 291 293 296 297 299 300 302 304 306 308 310 312 314 316 318 319 320 322 324 326 328 341 343 345 347 349 91874 91875 91876 91877 91878 91882 91883 91884

Intention of this service under item 289 and video equivalent item 92434

Items 289 or video equivalent item 92434 are intended for complex conditions, characterised by multi-domain cognitive and functional impairment. Patient eligibility is for neurodevelopmental disorders (NDD), which are assessed to be complex and mean that individuals require support across multiple domains.

The intention of this service is to provide access to treatment, through the development of a treatment and management plan by a psychiatrist, for individuals under 25 years of age, diagnosed with a complex NDD. The development of the treatment and management plan, follows a comprehensive medical assessment, and provides the opportunity to refer to eligible allied health practitioners for up to a total of 20 MBS treatment services per patient’s lifetime (items 82015, 82020, 82025, 82035, 93035, 93036, 93043 or 93044). This item is claimable once in a patient’s lifetime.

Eligibility:

In the context of item 289 (or 92434), the diagnosis of a complex NDD requires evidence of requiring support and showing impairment across two or more neurodevelopmental domains. Complexity is characterised by multi-domain cognitive and functional disabilities, delay or clinically significant impairment.

Neurodevelopmental domains include:

• Cognition
• Language
• Social-emotional development
• Motor skills
• Adaptive behaviour:  conceptual skills, practical skills, social skills or social communication skills

Referral pathways:

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

Where neurodevelopmental 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 either a consultant paediatrician or psychiatrist for a comprehensive assessment.

Diagnostic assessment:

The assessment and diagnosis of a complex NDD should be evaluated in the context of both a physical and developmental assessment. The psychiatrist may require a number of separate attendances (through usual time-tiered or subsequent attendance items 296 to 308, 310, 312, 314, 316, 318, 319 to 349, 91827 to 91831 or 91837 to 91839, 92437, 92455 to 92457) 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 consultant physician may require a multi-disciplinary approach to complete a comprehensive accurate assessment and formulate a diagnosis. 

Where the psychiatrist 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 provider from standard attendance items (296 to 308, 310, 312, 314, 316, 318, 319 to 349 or telehealth (video and phone) items 91827 to 91831, 91837 to 91839, 92437, 92455 to 92457).

Whilst Medicare rebates 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 professional) by the referring psychiatrist, 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 (82010, 93033, 93041)
• Audiologist, dietitian, exercise physiologist, optometrist, orthoptist, physiotherapist (MBS item 82030, 93033, 93041)

Requirements of the referral to allied health practitioners

The psychiatrist 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 four (4) allied health assessment services

Whilst an eligible allied health practitioner has provided 4 assessment services (through items 82000, 82005, 82010, 82030, 93032, 93040, 93033 or 93041) and considers additional assessment services are required, they must ensure the referring psychiatrist undertakes a review. If the type of review is not specified by the referring psychiatrist 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 psychiatrist.  Whilst they do not require the need for an attendance with the patient (face-to-face/video/phone) by the referring psychiatrist, they do require an agreement from the referring psychiatrist.  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 a psychiatrist makes a complex NDD diagnosis, the psychiatrist may require the contribution of an eligible allied health practitioner to assist with the development of the Treatment and Management plan (before billing item 289 or 92434).

MBS items 82000, 82005, 82010, 82030, 93032, 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 psychiatrist should be mindful of this when referring to eligible allied health practitioners.

Development of the Treatment and Management Plan

Once the psychiatrist has made a diagnosis of a complex NDD, to complete the item requirements of item 289 or 92434 they must develop a treatment and management plan which includes:

• Written documentation of the patient’s confirmed diagnosis of a complex NDD, 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:
  • the risk to the patient of a contributing co‑morbidity and
  • environmental, physical, social and emotional risk factors that may apply to the patient or to another individual.
• Treatment options which include:
  • Recommendations using a biopsychosocial model
  • Identifying major treatment goals and important milestones and objectives
  • Recommendation/s 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)
  • 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 289 or 92434 has been claimed) the psychiatrist 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, dietitian, exercise physiologist, 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 video items. Whilst the psychiatrist can refer to multiple eligible allied health practitioners concurrently, a separate referral letter must be provided to each allied health practitioner.

The referral should 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 (289 or 92434) have been processed through the Medicare claiming system.

On the completion of a “course of treatment” (specified by the referring psychiatrist, up to maximum of 10 services), the eligible allied health practitioner must provide a written report to the referring psychiatrist, which should include information on the treatment provided, recommendations for future management of the individual’s disorder and any advice to caregivers (such as parents, carers, school teachers). This written report will inform the referring psychiatrist’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.

Inconclusive assessment:

Where a patient does not meet the diagnostic threshold of a complex NDD and where ongoing medical management is required, patients can be managed through psychiatry attendance items 300-308, 310, 312, 314, 316, 318 or telehealth equivalent items 91827-91831 (video) or 91837-91839 (phone).

Examples include where:

• Neurodevelopment assessment is incomplete or inconclusive
• Neurodevelopmental impairment is present in fewer than two domains
• Neurodevelopmental impairment is present in two or more domains, but individuals do not require sufficient support to meet criteria
• Comprehensive, age-appropriate neurodevelopmental assessment is impossible or unavailable (e.g. in infants or young children- particularly those under 6 years of age)

These individuals may be considered “at risk of a complex NDD” and require follow-up and reassessment in the future.

Related Items: 289 296 297 299 300 301 302 303 304 306 308 310 312 314 316 318 319 320 322 324 326 328 330 332 334 336 338 341 342 343 344 345 346 347 349 82000 82005 82010 82015 82020 82025 82030 82035 91827 91828 91829 91830 91831 91837 91838 91839 92434 92437 92455 92456 92457 93032 93033 93035 93036 93040 93041 93043 93044