Medicare Benefits Schedule - Item 90274

Professional attendance at a place other than consulting rooms by a general practitioner to provide treatment under an eating disorder treatment and management plan, lasting at least 40 minutes

The fee for item 90273, plus $30.30 divided by the number of patients seen, up to a maximum of six patients. For seven or more patients - the fee for item 90273 plus $2.40 per patient.
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(See para AN.36.2, AN.36.4 of explanatory notes to this Category)

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Eating Disorders Treatment and Management Plans Explanatory Notes (items 90250-90257, 92146-92153, 90260-90261, and 92162-92163)

This note provides information on Eating Disorders Treatment and Management Plan (EDTMP) items and should be read in conjunction with the Eating Disorders General Explanatory Notes

Eating Disorder Treatment and Management Plan (EDTMP) items overview

The EDTMP items define services for which Medicare benefits are payable where practitioners undertake the development of a treatment and management plan for patients with a diagnosis of anorexia nervosa, bulimia nervosa, binge-eating disorder and other specified feeding or eating disorder diagnoses who meet the eligibility criteria.

The EDTMP items trigger eligibility for items which provide delivery of eating disorders psychological treatment services (up to a total of 40 psychological services in a 12-month period) and dietetic services (up to a total of 20 in a 12-month period).

For any particular patient, an eating disorder treatment and management plan expires at the end of a 12-month period following provision of that service. Eating Disorders treatment services are not available to the patient if the EDTMP has expired.

Preparation of the EDTMP must include:

• discussing the patient’s medical and psychological health status with the patient and if appropriate their family/carer;
• identifying and discussing referral and treatment options with the patient and their family/carer where appropriate, including identification of appropriate support services;
• agreeing goals with the patient and their family/carer where appropriate - what should be achieved by the treatment - and any actions the patient will take;
• planning for the provision of appropriate patient and family/carer education;
• a plan for crisis intervention and/or for relapse prevention, if appropriate at this stage;
• making arrangements for required referrals, treatment, appropriate support services, review and follow-up;
• documenting the results of assessment, patient needs, goals and actions, referrals and required treatment/services, and review date in the patient's plan;
• discussing and organising the appropriate reviews throughout the patient’s treatment; and
• discussing the need for the patient to be reviewed to access a higher intensity of eating disorder psychological treatment services in a 12-month period.
   

Preparing a Medical practitioner in general practice Eating Disorder Treatment & Management Plan (items 90250-90257 and 92146-92153)

Who can provide the service

Items in subgroup 1 of Group A36 can be rendered by a medical practitioner in general practice. This includes:

• Medical practitioners who can render a general practitioner service in Group A1 of the MBS (see note AN.0.9 for the types of medical practitioners). These medical practitioners can render a ‘general practitioner’ service for items in subgroup 1 of Group A36.
• Medical practitioners who are not general practitioners, specialists or consultant physicians. These medical practitioners can render a ‘medical practitioner’ service for items in subgroup 1 of Group A36.

What is Involved - Assess and Plan

It is expected that the practitioner developing the EDTMP has either performed or reviewed the assessments and examinations required to make a judgement that the patient meets the eligibility criteria for accessing these items.

Items 90250-90257 and their equivalent telehealth items (92146-92153) provide services for development of the eating disorder treatment and management plan. Where a comprehensive physical examination is performed, either on the same occasion or different occasion, the appropriate item could be claimed provided the time taken performing the assessment is not included in the time for producing the plan, or time producing the EDTMP is not included in the time for assessment.

It is emphasised that it is best practice for the practitioner to perform a comprehensive physical assessment to facilitate ongoing patient management and monitoring of medical and nutritional status.

Patient Assessment

An assessment of a patient with an eating disorders includes:

• taking relevant history (biological, psychological, social, including family/carer support);
• eating disorder diagnostic assessment;
• medical review including physical examination and relevant tests;
• conducting an assessment of mental state, including identification of comorbid psychiatric conditions;
• an assessment of eating disorder behaviours;
• an assessment of associated risk and any medical co-morbidity, including as assessment on how this impacts on the patients functioning and activities of daily living;
• an assessment of family and/or carer support; and
• administering an outcome measurement tool, except where it is considered clinically inappropriate.

Risk assessment for a patient with an eating disorder should include identification of:

• medical instability and risk of hospitalisation;
• level of psychological distress and suicide risk;
• level of malnourishment;
• identification of psychiatric comorbidity;
• level of disability;
• duration of illness;
• response to earlier evidence-based eating disorders treatment;
• level of family/carer support.

It should be noted that the patient's EDTMP should be treated as a living document for updating as required. In particular, the plan can be updated at any time to incorporate relevant information, such as feedback or advice from other health professionals on the diagnosis or treatment of the patient.

Preparing a Consultant Psychiatrist Eating Disorder Treatment & Management Plan (90260-90261 and 92162-92163)

Who can provide the service

Items in subgroup 2 of Group 36 can be rendered by consultant psychiatrists (items 90260 and 90261, and their respective telehealth items 92162 and 92163).

What is Involved – Assess and Plan

Items 90260-90261 and their equivalent telehealth items (92162 and 92163) provide access to specialist assessment and treatment planning. It is expected that items will be a single attendance. However, there may be particular circumstances where a patient has been referred by a GP for an assessment and management plan, but it is not possible for the consultant to determine in the initial consultation whether the patient is suitable for management under such a plan. In these cases, where clinically appropriate, other appropriate consultation items may be used. In those circumstances where the consultant undertakes a consultation (in accordance with the item requirements) prior to the consultation for providing the referring practitioner with an assessment and management plan. It is expected that such occurrences would be unusual for the purpose of diagnosis under item 90260.

Patient Assessment

In order to facilitate ongoing patient focussed management, an assessment of the patient must include:

• administering an outcome measurement tool during the assessment and review stages of treatment, where clinically appropriate. The choice of outcome tool to be used is at the clinical discretion of the practitioner;
• conducting a mental state examination;
• taking relevant history (biological, psychological, behavioural, nutritional, social);
• assessing associated risk and any co-morbidity; and
• making a psychiatric diagnosis for conditions meeting the eligibility criteria.

Risk assessment for a patient with an eating disorder should include identification of:

• medical instability and risk of hospitalisation;
• level of psychological distress and suicide risk;
• level of malnourishment;
• identification of psychiatric comorbidity;
• level of disability;
• duration of illness;
• response to earlier evidence-based eating disorders treatment;
• level of family/carer support.
   

Where a consultant psychiatrist provides an EDTMP service, the service must also include:

• administering an outcome measurement tool, where clinically appropriate. The choice of outcome tool to be used is at the clinical discretion of the practitioner. Practitioners using such tools should be familiar with their appropriate clinical use, and if not, should seek appropriate education and training; and
• conducting a mental state examination.

Consultation with the patient’s managing practitioner

A written copy of the EDTMP should be provided to the patient’s managing practitioner, within a maximum of two weeks of the assessment. It should be noted that two weeks is the outer limit and in more serious cases more prompt provision of the plan and verbal communication with the managing practitioner may be appropriate.

Additional Claiming Information (general conditions and limitations)

Patients seeking benefits for items 90250-90257 and 90260-90261 will not be eligible if the patient has had a claim within the last 12-months.

Items 90250-90257 cannot be claimed with Items 2713, 279, 735, 758, 235 and 244. Items 90261 cannot be claimed with Items 110, 116, 119, 132, 133.

Consultant psychiatrist and paediatrician EDTMP items 90260-90261 do not apply if the patient does not have a referral within the period of validity.

Before proceeding with the EDTMP the medical practitioner must ensure that:

(a) the steps involved in providing the service are explained to the patient and (if appropriate and with the patient's permission) to the patient's carer; and

(b) the patient's agreement to proceed is recorded.

The medical practitioner must offer the patient a copy of the EDTMP and add the document to the patient's records. This should include, subject to the patient's agreement, offering a copy to their carer, where appropriate. The medical practitioner may, with the permission of the patient, provide a copy of the EDTMP, or relevant parts of the plan, to other providers involved in the patient's treatment.

The medical practitioner EDTMP cover the service of developing an EDTMP. A separate consultation item can be performed with the EDTMP if the patient is treated for an unrelated condition to their eating disorder. Where a separate consultation is performed, it should be annotated separately on the patient’s account that a separate consultation was clinically required/indicated.

All consultations conducted as part of the EDTMP must be rendered by the medical practitioner and include a personal attendance with the patient. A specialist mental health nurse, other allied health practitioner, Aboriginal and Torres Strait Islander health practitioner or Aboriginal and Torres Strait Islander health worker with appropriate mental health qualifications and training may provide general assistance to the medical practitioner in provision of this care.

Additional Claiming Information (interaction with Chronic Condition Management and Better Access)

It is preferable that wherever possible patients have only one plan for primary care management of their disorder. As a general principle the creation of multiple plans should be avoided, unless the patient clearly requires an additional plan for the management of a separate medical condition.

The Chronic Condition Management (CCM) items (items 231, 232, 392, 393, 729, 731, 965, 967, 92026, 92027, 92029, 92030, 92057, 92058, 92060 and 92061) continue to be available for patients with chronic medical conditions, including patients with complex needs. 

Where a patient has a separate chronic medical condition, it may be appropriate to manage the patient's medical condition through a CCM Plan, and to manage their eating disorder through an EDTMP. In this case, both items can be used. Where the patient receives dietetic services under the CCM arrangements (item 10954), these services will count towards the patients maximum of 20 dietetic services in a 12-month period. 

Where a patient has other psychiatric comorbidities, these conditions should be managed under the EDTMP. Once a patient has a claim for an EDTMP, the patient should not be able to have a claim for the development or review of a Mental Health Treatment plan by a GP (items 2700, 2701, 2715 and 2717) or medical practitioner in general practice (items 272, 276, 281 and 282) within 12-months of their EDTMP unless there are exceptional circumstances.

For the purpose of the 40 eating disorder psychological treatment count; eating disorder psychological treatment service includes a service provided under the following items: 90271-90278, 92182, 92184, 92186, 92188, 92194, 92196, 92198, 92200, 2721, 2723, 2725, 2727, 283, 285, 286, 287 and items in Groups M6, M7 and M16 (excluding item 82350). 

Related Items: 110 116 119 132 133 231 232 235 244 272 276 281 282 283 285 286 287 392 393 729 731 735 758 965 967 2700 2701 2715 2717 2721 2723 2725 2727 82350 90250 90251 90252 90253 90254 90255 90256 90257 90260 90261 90271 90272 90273 90274 90275 90276 90277 90278 92026 92027 92029 92030 92057 92058 92060 92061 92146 92147 92148 92149 92150 92151 92152 92153 92162 92163 92182 92184 92186 92188 92194 92196 92198 92200

Eating Disorders Psychological Treatment (EDPT) services (90271-78; 92182, 92184, 92186, 92188; 92194, 92196, 92198 and 92200)

This note provides information on the Category 1 – Professional Attendances: Group A36 – Subgroup 4 (90271-90278) should be read in conjunction the AN.36.1 Eating Disorders General Explanatory Notes

Eating Disorder Psychological Treatment (EDPT) Services Overview

Provision of EDPT services by a suitably trained medical practitioner in general practice (90271-90278;92182, 92184, 92186, 92188; 92194, 92196, 92198 and 92200) is for patients with anorexia nervosa and other patients with complex presentations of diagnosed eating disorders who meet the eligibility requirements and would benefit from a structured approach to the management of their treatment needs in the community setting.

Patients seeking benefits for EDPT services must have had an EDTMP 90250-90257, 92146-92153, 90260 or 90261; 92162 or 92163 in the previous 12 months.

An ‘eating disorder psychological treatment (EDPT) services’ is defined in the AN.36.1 Eating Disorders General Explanatory Note. For any particular patient, an eating disorder treatment and management plan expires at the end of a 12-month period following provision of that service. After that period, a patient will require a new EDTMP to continue accessing EDPT services.

Rendering an EDPT service item

Who can provide the service

Items in subgroup 4 of Group A36 can be rendered by a medical practitioner in general practice with the required mental training. This includes:

• Medical practitioners who can render a general practitioner service in Group A1 of the MBS (see note AN.0.9 for the types of medical practitioners). These medical practitioners can render a ‘general practitioner’ service for items in subgroup 1 of Group A36. These doctors must have the mental health training requirements as specified below.
• Medical practitioners who are not general practitioners, specialists or consultant physicians. These medical practitioners can render a ‘medical practitioner’ service for items in subgroup 1 of Group A36. These doctors must have the mental health training requirements as specified below.

Mental health training

Medical practitioner in general practice who meets the training and skills requirements as determined by the General Practice Mental Health Standards Collaboration, and are entered on the Register as being eligible to render a focussed psychological strategy service, can render an eating disorders psychological treatment service.

Note: The General Practice Mental Health Standards Collaboration operates under the auspices of the Royal Australian College of General Practitioners.

What is Involved in EDPT services

The eating disorder items incorporate a ‘stepped model’ for best practice care for eligible patients with eating disorders. Under the Eating Disorders Items Stepped Model of Care a course of treatment is defined as 10 eating disorder psychological treatment (EDPT) services. It is required that a patient must have a review (an EDR item in subgroup 3 of A36) after each course of treatment (see AN.36.1 Eating Disorders General Explanatory Notes). 

After each course of treatment, the relevant practitioners should provide the medical practitioner who is managing the patient’s EDTMP (where appropriate) with a written report.

A range of acceptable treatments has been approved for use by practitioners in this context. It is expected that professionals will have the relevant education and training to deliver these services. The approved treatments are:

• Family Based Treatment for Eating Disorders (EDs) (including whole family, Parent Based Therapy, parent only or separated therapy)
• Adolescent Focused Therapy for EDs
• Cognitive Behavioural Therapy (CBT) for EDs (CBT-ED)
• CBT-Anorexia Nervosa (AN) (CBT-AN)
• CBT for Bulimia Nervosa (BN) and Binge-eating Disorder (BED) (CBT-BN and CBT-BED)
• Specialist Supportive Clinical Management (SSCM) for EDs
• Maudsley Model of Anorexia Treatment in Adults (MANTRA)
• Interpersonal Therapy (IPT) for BN, BED
• Dialectical Behavioural Therapy (DBT) for BN, BED
• Focal psychodynamic therapy for EDs
   

Checking patient eligibility for services

Note: The 12-month period commences from the date of the EDTMP.

Patients seeking benefits for EDPT services 90271-90278; 92182, 92184, 92186, 92188; 92194, 92196, 92198, 92200 must have had an EDTMP 90250-90257; 92146-92153; 90260, 90261; 92162 or 92163 in the previous 12 months.

If the EDTMP has not yet been claimed, the Services Australia will not be aware of the patient's eligibility. In this case the practitioner should, with the patient's permission, contact the practitioner who developed the plan to ensure the relevant service has been provided to the patient.

Support:

If there is any doubt about a patient’s eligibility, Services Australia will be able to confirm whether a patient has had a claim for an eating disorder service, as well as the number of services already claimed by the patient. Additionally, providers can also access the Health Professionals Online System (HPOS) to view a patient’s history.

Allied health professionals can call Services Australia on 132 150 to check this information, while unsure patients can seek clarification by calling 132 011 or view their care plan history in their Medicare online account through myGov to help track services that have been claimed.

Additional Claiming Information (general conditions and limitations)

Other than Consultation Room (items 90272, 90274, 90276, 90278)

It is expected that this service would be provided only for patients who are unable to attend the practice. 

 

 

Related Items: 90271 90272 90273 90274 90275 90276 90277 90278