Medicare Benefits Schedule - Item 81100

DIABETES EDUCATION SERVICE - ASSESSMENT FOR GROUP SERVICES

Diabetes education health service provided to a person by an eligible diabetes educator for the purposes of ASSESSING a person's suitability for group services for the management of type 2 diabetes, including taking a comprehensive patient history, identifying an appropriate group services program based on the patient's needs, and preparing the person for the group services, if:

(a)    the service is provided to a person who has type 2 diabetes; and

(b)  the person is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under a shared care plan or a GP Management Plan or, if the person is a resident of an aged care facility, their medical practitioner has contributed to a multidisciplinary care plan; and  

(c)    the person is referred to an eligible diabetes educator by the medical practitioner using a referral form that has been issued by the Department of Health, or a referral form that contains all the components of the form issued by the Department; and

(d)    the person is not an admitted patient of a hospital; and

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

(f)    the service is of at least 45 minutes duration; and

(g)    after the service, the eligible diabetes educator gives a written report to the referring medical practitioner mentioned in paragraph (c); and

(h)    in the case of a service in respect of which a private health insurance benefit is payable - the person who incurred the medical expenses in respect of the service has elected to claim the Medicare benefit in respect of the service, and not the private health insurance benefit.

Benefits are payable once only in a calendar year for this or any other Assessment for Group Services item (including services to which items 81100, 81110, 81120, 93284, 93286, 93606, 93607 and 93608 apply).

Fee: $87.50 Benefit: 85% = $74.40

(See para MN.9.1, MN.9.2, MN.9.3, MN.9.4, MN.9.6 of explanatory notes to this Category)

Extended Medicare Safety Net Cap: $262.50

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MBS items (81100, 81105, 81110, 81115, 81120 and 81125) are available for group allied health services for patients with type 2 diabetes. These items apply to services provided by eligible diabetes educators, exercise physiologists and dietitians, on referral from a GP or medical practitioner.

Services available under these items are in addition to the 5 individual allied health services available to patients each calendar year (refer to items 10950, 10951, 10952, 10953, 10954, 10956, 10958, 10960, 10962, 10964, 10966, 10968, 10970, 93000 and 93013).

To be eligible for these services, the patient must have in place one of the following:

• a GP Management Plan (GPMP) (GP item 721 or medical practitioner item 229); OR
• for a resident of a residential aged care facility, the GP or medical practitioner must have contributed to a multidisciplinary care plan, or contributed to a review of a multidisciplinary care plan prepared for them by the facility (GP item 731 or medical practitioner item 232). [Note: Generally, residents of an aged care facility rely on the facility for assistance to manage their type 2 diabetes. Therefore, the resident may not need to be referred for group allied health services under these items, as the self-management approach offered in group services may not be appropriate.].

Unlike the individual allied health services, there is no additional requirement for a Team Care Arrangement (GP item 723 or medical practitioner item 230) in order for the patient to be referred for group allied health services.

Once the patient has been referred by their GP or medical practitioner, a diabetes educator, exercise physiologist or dietitian will conduct an individual assessment (under items 81100, 81110, 81120, 93284 or 93286). A maximum of one assessment service is available per calendar year. After assessment, the patient may receive up to 8 group services per calendar year from an eligible diabetes educator, exercise physiologist and/or dietitian (under items 81105, 81115, 81125 or 93285). A collaborative approach, where diabetes educators, exercise physiologists and dietitians work together to develop group service programs in their local area, is encouraged.

Related Items: 81100 81105 81110 81115 81120 81125

Patients must be referred by their GP or medical practitioner to an eligible allied health professional (diabetes educator, exercise physiologist or dietitian) who will undertake an individual assessment (under item 81100, 81110, 81120, 93284 or 93286) of the patient's suitability for a group services program.

Related Items: 81100 81110 81120 93284 93286

Items 81100, 81105, 81110, 81115, 81120, 81125, 93284, 93285 and 93286 only apply to services provided by eligible diabetes educators, exercise physiologists and dietitians who are registered with Services Australia. If providers are already registered with Services Australia to use items 10951, 10953, 10954, they do not need to register separately for these items. Eligibility criteria are as follows: 

Diabetes educator: must be a 'credentialed diabetes educator' as credentialed by the Australian Diabetes Educators Association. 

Exercise physiologist: must be an 'accredited exercise physiologist' as accredited by Exercise and Sports Science Australia. 

Dietitian: must be an 'accredited practising dietitian' as recognised by the Dietitians Association of Australia. 

Services Australia registration forms may be obtained from Services Australia on 132 150 or on the Services Australia website.

Related Items: 81100 81105 81110 81115 81120 81125 93284 93285 93286

An assessment service is provided by a diabetes educator (item 81100), an exercise physiologist (item 81110) or a dietitian (items 81120, 93284 and 93286), on referral from a GP or medical practitioner. 

The purpose of this service is to undertake an individual assessment and determine the patient's suitability for a group services program. It involves taking a comprehensive patient history and identification of individual goals. This may also provide an opportunity to identify any patient who is likely to be unsuitable for group services.

Number of services per year

Patients are eligible for a maximum of one assessment for group services (either item 81100, 81110, 81120, 93284 or 93286) per calendar year. If more than one assessment service is provided in a calendar year, the subsequent service/s will not attract a Medicare rebate and the MBS Safety Net arrangements will not apply to costs incurred by the patient for the service/s. 

If there is any doubt about a patient's eligibility for these items, the allied health professional should contact Services Australia to confirm the number of assessment services already claimed by the patient in the calendar year. Allied health professionals can call Services Australia on 132 150 to check this information. 

Referral form

The GP or medical practitioner must refer the patient using the Referral form for group allied health services under Medicare for patients with type 2 diabetes or a form that contains all the components of this form. This includes:

• identifying that the patient has type 2 diabetes and either:
  • has prepared a new GP Management Plan (MBS item 721) OR
  • has reviewed an existing GP Management Plan (MBS item 732) OR
  • for a resident of an aged care facility, the GP or medical practitioner has contributed to or reviewed a multidisciplinary care plan prepared by the facility (MBS item 731) [Note: Generally, residents of an aged care facility rely on the facility for assistance to manage their type 2 diabetes. Therefore, residents may not need to be referred for allied health group services as the self-management approach may not be appropriate.]
• GP or medical practitioner details including provider number, name, address, signature and date of referral
• Patient details including name and address
• Allied Health Practitioner (or practice) the patient is referred to for assessment and the address 

The allied health professional undertaking the assessment service will need to complete Part B of this form providing information on:

• Name of provider/s
• Name of program
• Number of sessions in the program
• Venue (if known)
• Name of allied health professional undertaking the assessment

The patient will then need to present this form/information to the provider/s of group services.

Length of service

This service must be of at least 45 minutes duration and provided to an individual patient. For items 81100, 81110 and 81120, the allied health professional must personally attend the patient. 

Reporting requirements

On completion of the assessment service, the allied health professional must provide a written report back to the referring GP outlining the assessment undertaken, whether the patient is suitable for group services and, if so, the nature of the group services to be delivered.

Related Items: 81100 81110 81120 93284 93286

Retention of Referral Form for Services Australia Audit Purposes

It is recommended that Allied health professionals retain a copy of the referral form for 2 years from the date the service was rendered (for Services Australia auditing purposes). 

Publicly funded services

Items 81100, 81105, 81110, 81115, 81120, 81125, 93284, 93285 and 93286 do not apply for services that are provided by any other Commonwealth or state-funded services or provided to an admitted patient of a hospital. However, where an exemption under subsection 19(2) of the Health Insurance Act 1973 has been granted to an Aboriginal Community Controlled Health Service or a state/territory government health clinic, these items can be claimed for services provided by eligible allied health professionals salaried by, or contracted to, service or health clinic. All requirements of the relevant item must be met, including registration of the allied health professional with Services Australia. These services must also be bulk billed. 

Private health insurance

Patients need to decide if they will use Medicare or their private health insurance general treatment cover (also known as ancillary or extras cover) to pay for these services. Patients cannot use their private health insurance general cover to 'top up' the Medicare rebate paid. 

Out-of-pocket expenses and Medicare Safety Net

Allied health professionals are free to determine their own fees for the professional service. Charges in excess of the Medicare benefit for the allied health items are the responsibility of the patient. However, such out-of-pocket costs will count toward the Medicare Safety Net for that patient.

Related Items: 81100 81105 81110 81115 81120 81125 93284 93285 93286