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 service is provided to the patient individually and in person; and

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

(d)    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

Fee: $100.20 Benefit: 85% = $85.20

(See para AN.0.25, MN.10.2, MN.10.3 of explanatory notes to this Category)

Extended Medicare Safety Net Cap: $300.60

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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 92460) 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 92460.

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, 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:

o Recommendations using a biopsychosocial model

o Identify major treatment goals and important milestones and objectives

o Recommendation 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, 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: 104 105 107 108 110 116 119 122 128 131 137 296 297 299 300 302 304 306 308 310 312 314 316 318 319 320 324 326 328 330 332 334 336 338 342 344 346 82000 82005 82010 82015 82020 82025 82030 82035 91822 91831 91833 91836 91839 92141 92437 92455 93032 93033 93035 93036 93040 93041 93043 93044

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 of the general medical services table or item 92434 of the Telehealth and Telephone Attendances Determination.

  Note. If a patient has previously been provided with a service mentioned in item 289, a consultant physician specialising in the practice of the consultant physician’s field of psychiatry may only refer the patient for a service to which any of 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 and Telephone Attendances Determination applies.

  - paediatrician using item 135 of the general medical services table or item 92140 of the Telehealth and Telephone Attendances Determination.

  Note. If a patient has previously been provided with a service mentioned in item 135 of the general medical services table or item 92140 of the Telehealth and Telephone Attendances Determination, a consultant physician specialising in the practice of the consultant physician’s field of paediatrics may only refer the patient for a service to which any of items 110 to 131 of the general medical services table or items 91824, 91825, 91826 or 91836 of the Telehealth and Telephone Attendances Determination applies.

  If a patient has previously been provided with a service mentioned in item 137 or 139 of the general medical services table or item 92141 or 92142 of the Telehealth and Telephone Attendances Determination, the medical practitioner cannot refer the patient for a service to which item 135 or 289 of the general medical services table or item 92140 or 92434 of the Telehealth and Telephone Attendances Determination applies.

• For an eligible disability referred by a:

  - specialist or consultant physician using item 137 of the general medical services table or item 92141 of the Telehealth and Telephone Attendances Determination.

  - GP using item 139 of the general medical services table or item 92142 of the Telehealth and Telephone Attendances Determination.

  Note. If a patient has previously been provided with a service mentioned in item 135 or 289 of the general medical services table or item 92140 or 92434 of the Telehealth and Telephone Attendances Determination, the medical practitioner cannot refer the patient for a service to which item 137 or 139 of the general medical services table or item 92141 or 92142 of the Telehealth and Telephone Attendances Determination applies.

* 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