Medicare Benefits Schedule - Note AN.0.37

Publication date: 1 July 2024

SUMMARY

Time-tiered health assessment items may be used to undertake a Type 2 Diabetes Risk Evaluation for Medicare eligible patients aged 40-49 years (inclusive) with a high risk of developing type 2 diabetes.

Note: The requirements below must be met in addition to common principles for time-tiered health assessment items, contained in AN.0.36.

USE OF THE ITEMS

The specific requirements of the Type 2 Diabetes Risk Evaluation are set out in clause 2.15.4 of the Health Insurance (General Medical Services Table) Regulations 2021 (the Regulations).

The Regulations require that a Type 2 Diabetes Risk Evaluation must include:

• a review of the risk factors underlying a patient’s high-risk score as identified by the Australian Type 2 Diabetes Risk Assessment Tool, and
• initiating interventions, if appropriate, to address risk factors or to exclude diabetes.

 The Regulations also state that the evaluation must include:

• assessing the patient’s high-risk score as determined by the Australian Type 2 Diabetes Risk Assessment Tool
• updating the patient’s history and performing physical examinations and clinical investigations
• making an overall assessment of the patient’s risk factors and the results of examinations and investigations
• initiating interventions, if appropriate, including referrals and follow‑up services relating to the management of any risk factors identified, and
• giving the patient advice and information, including strategies to achieve lifestyle and behaviour changes if appropriate.

For the purposes of a Type 2 Diabetes Risk Evaluation, risk factors include:

• lifestyle risk factors (e.g. smoking, physical inactivity or poor nutrition)
• biomedical risk factors (e.g. high blood pressure, impaired glucose metabolism or excess weight), and
• a family history of a chronic disease.

ELIGIBLE PATIENTS

Patients eligible for a Type 2 Diabetes Risk Evaluation are:

• aged between 40-49 years (inclusive), and
• have a high risk of developing type 2 diabetes as determined by the Australian Type 2 Diabetes Risk Assessment Tool.

The Australian Type 2 Diabetes Risk Assessment Tool must have been completed by the patient no more than 3 months prior to the Type 2 Diabetes Risk Evaluation.

A Type 2 Diabetes Risk Evaluation cannot be claimed more than once every 3 years by an eligible patient.

ELIGIBLE PRACTITIONERS

Type 2 Diabetes Risk Evaluations can be undertaken by a general practitioner (see GN.4.13) or a prescribed medical practitioner (see AN.7.1).

CO-CLAIMING RESTRICTIONS 

A separate consultation must not be performed in conjunction with a Type 2 Diabetes Risk Evaluation, unless clinically necessary.

To co-claim a Type 2 Diabetes Risk Evaluation item and another item, both items must be clinically necessary and distinct services.

RECORD KEEPING AND REPORTING REQUIREMENTS

The department undertakes regular post payment auditing to ensure that MBS items are claimed appropriately. Practitioners should ensure they keep adequate and contemporaneous records. For information on what constitutes adequate and contemporaneous records see GN.15.39.

Clause 4.3 of the Health Insurance Act 1973 specifies that, where an item specifies the creation of a document (however described) and where a document is created, the document must be retained for the period of 2 years.

RELEVANT LEGISLATION

Details about the legislative requirements of the MBS items can be found on the Federal Register of Legislation at www.legislation.gov.au. Health assessment items are set out in the following regulatory instrument:

• Health Insurance (General Medical Services Table) Regulations 2021.

Related Items: 224 225 226 227 701 703 705 707

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Professional attendance by a general practitioner  to perform a brief health assessment, lasting not more than 30 minutes and including:

(a) collection of relevant information, including taking a patient history; and

(b) a basic physical examination; and

(c) initiating interventions and referrals as indicated; and

(d) providing the patient with preventive health care advice and information

Fee: $67.60 Benefit: 100% = $67.60

(See para AN.0.36, AN.0.37, AN.0.38, AN.0.39, AN.0.40, AN.0.41, AN.0.42, AN.0.69 of explanatory notes to this Category)

Professional attendance by a general practitioner to perform a standard health assessment, lasting more than 30 minutes but less than 45 minutes, including:

(a) detailed information collection, including taking a patient history; and

(b) an extensive physical examination; and

(c) initiating interventions and referrals as indicated; and

(d) providing a preventive health care strategy for the patient

Fee: $157.10 Benefit: 100% = $157.10

(See para AN.0.36, AN.0.37, AN.0.38, AN.0.39, AN.0.40, AN.0.41, AN.0.42, AN.0.69 of explanatory notes to this Category)

Professional attendance by a general practitioner  to perform a long health assessment, lasting at least 45 minutes but less than 60 minutes, including:

(a) comprehensive information collection, including taking a patient history; and

(b) an extensive examination of the patient's medical condition and physical function; and

(c) initiating interventions and referrals as indicated; and

(d) providing a basic preventive health care management plan for the patient

Fee: $216.80 Benefit: 100% = $216.80

(See para AN.0.36, AN.0.37, AN.0.38, AN.0.39, AN.0.40, AN.0.41, AN.0.42, AN.0.69 of explanatory notes to this Category)

Professional attendance by a general practitioner to perform a prolonged health assessment (lasting at least 60 minutes) including:

(a) comprehensive information collection, including taking a patient history; and

(b) an extensive examination of the patient's medical condition, and physical, psychological and social function; and

(c) initiating interventions or referrals as indicated; and

(d) providing a comprehensive preventive health care management plan for the patient

Fee: $306.25 Benefit: 100% = $306.25

(See para AN.0.36, AN.0.37, AN.0.38, AN.0.39, AN.0.40, AN.0.41, AN.0.42, AN.0.69 of explanatory notes to this Category)

Professional attendance by a prescribed medical practitioner to perform a brief health assessment, lasting not more than 30 minutes and including:
(a) collection of relevant information, including taking a patient history; and
(b) a basic physical examination; and
(c) initiating interventions and referrals as indicated; and
(d) providing the patient with preventive health care advice and information

Fee: $54.10 Benefit: 100% = $54.10

(See para AN.0.36, AN.0.37, AN.0.38, AN.0.39, AN.0.40, AN.0.41, AN.0.42, AN.0.69 of explanatory notes to this Category)

Professional attendance by a prescribed medical practitioner to perform a standard health assessment, lasting more than 30 minutes but less than 45 minutes, including:
(a) detailed information collection, including taking a patient history; and
(b) an extensive physical examination; and
(c) initiating interventions and referrals as indicated; and
(d) providing a preventive health care strategy for the patient

Fee: $125.70 Benefit: 100% = $125.70

(See para AN.0.36, AN.0.37, AN.0.38, AN.0.39, AN.0.40, AN.0.41, AN.0.42, AN.0.69 of explanatory notes to this Category)

Professional attendance by a prescribed medical practitioner to perform a long health assessment, lasting at least 45 minutes but less than 60 minutes, including:
(a) comprehensive information collection, including taking a patient history; and
(b) an extensive examination of the patient’s medical condition and physical function; and
(c) initiating interventions and referrals as indicated; and
(d) providing a basic preventive health care management plan for the patient

Fee: $173.40 Benefit: 100% = $173.40

(See para AN.0.36, AN.0.37, AN.0.38, AN.0.39, AN.0.40, AN.0.41, AN.0.42, AN.0.69 of explanatory notes to this Category)

Professional attendance by a prescribed medical practitioner to perform a prolonged health assessment, lasting at least 60 minutes, including:
(a) comprehensive information collection, including taking a patient history; and
(b) an extensive examination of the patient’s medical condition, and physical, psychological and social function; and
(c) initiating interventions and referrals as indicated; and
(d) providing a comprehensive preventive health care management plan for the patient

Fee: $245.00 Benefit: 100% = $245.00

(See para AN.0.36, AN.0.37, AN.0.38, AN.0.39, AN.0.40, AN.0.41, AN.0.42, AN.0.69 of explanatory notes to this Category)