Medicare Benefits Schedule - Item 82025

Occupational therapy health service provided to a patient aged under 25 years for the treatment of a diagnosed complex neurodevelopmental disorder (such as autism spectrum disorder) or eligible disability by an eligible occupational therapist, if:

(a) the patient has a treatment and management plan in place and has been referred by an eligible medical practitioner for a course of treatment consistent with that treatment and management plan; and

(b) the patient is not an admitted patient; and

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

(d) the service is at least 30 minutes duration; and

(e) on the completion of the course of treatment, the eligible occupational therapist gives a written report to the referring eligible medical practitioner on assessments (if performed), treatment provided and recommendations on future management of the patient’s condition

Up to 4 services to which this item or any of items 82015, 82020, 82035, 93035, 93036, 93043 or 93044 apply may be provided to the same patient on the same day

Further information on the requirements for this item are available in the explanatory notes to this Category

Fee: $96.80 Benefit: 85% = $82.30

(See para MN.10.2, MN.10.3 of explanatory notes to this Category)

Extended Medicare Safety Net Cap: $290.40

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These allied health items are available for patients that have been diagnosed with a complex Neurodevelopmental Disorder (such as Autism Spectrum Disorder) or an eligible disability. It is expected that eligible allied health practitioners will deliver treatment under these items that is consistent with the complex Neurodevelopmental Disorder or eligible disability treatment and management plan prepared by the referring eligible medical practitioner and is in keeping with commonly established interventions as practised by their profession and appropriate for the age and particular needs of the patient being treated.

It is anticipated that professional attendances at places other than consulting rooms will be provided where treatment in other environments is necessary to achieve therapeutic outcomes.

Number of services

• A maximum of 20 services can be claimed per patient per lifetime, including services consisting of any combination of 82015, 82020, 82025, 82035, 93035, 93036, 93043 or 93044.
• A course of treatment means up to 10 treatment services.
• Up to 4 of these services may be provided to the same patient on the same day.
• It is the responsibility of the referring eligible medical practitioner to allocate these services in keeping with the patient’s individual treatment needs and to refer the patient to the appropriate allied health professional(s) accordingly.

Referral Requirements

For a Medicare rebate to be paid, the eligible allied health practitioner providing the service must be in receipt of a current referral provided by an eligible medical practitioner. A separate referral from an eligible medical practitioner is required for each eligible allied health practitioner. The referral is only valid if the referring provider uses any of the following MBS items*:

• For a complex Neurodevelopmental Disorder referred by a:

- consultant psychiatrist (using item 289 or 92434)

- paediatrician (using item 135 or 92140)

• For an eligible disability referred by a:

- specialist or consultant physician (using item 137 or 92141)

- GP (using item 139 or 92142)

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

The referral may be a letter or note to an eligible allied health practitioner, signed and dated by the referring eligible medical practitioner. Referring eligible medical practitioners are not required to use a specific form to refer patients for these services. A Medicare claim must be submitted for the referring service before a rebate for the subsequent referred allied health service can be paid.

The referred service consists of the number of allied health services stated on the patient’s referral. This enables the referring practitioner to consider a report from the allied health practitioners about the services provided to the patient, and the need for further treatment.

Within the maximum service allocation of 20 services for the treatment items, the eligible allied health practitioner/s can provide one or more courses of treatment. A new referral is required for each new course of treatment (up to 10 services). The amount of services in each course of treatment is determined by the referring eligible medical practitioner. The referring eligible medical practitioner should review the written report provided by the eligible allied health practitioner after completion of a course of treatment and prior to referring for a subsequent course of treatment.

Eligible allied health practitioners should retain the referral for 24 months from the date the service was rendered for Medicare auditing purposes.

Reporting requirements

On completion of a course of treatment (and any subsequent courses of treatment), the eligible allied health practitioner must provide a written report to the referring eligible medical practitioner which includes information on:

• treatment provided;
• recommendations on future management of the patient’s disorder or disability; and
• if applicable, any advice provided to third parties (for example: parents, schools, places of employment).

The writing of the report is not counted towards the service time under the item.

Related Items: 82015 82020 82025 82035 93035 93036 93043 93044

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