Medicare Benefits Schedule - Note AN.0.38

Publication date: 1 July 2024 

SUMMARY

Time-tiered health assessment items may be used to undertake a health assessment for people aged 45-49 years (inclusive) who are at risk of developing chronic disease.

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 ITEMS

The specific requirements of the Type 2 Diabetes Risk Evaluation are set out in clause 2.15.5 of the Health Insurance (General Medical Service Table) Regulations 2021 (the Regulations).

The Regulations specify GPs (see GN.4.13) and prescribed medical practitioners (PMP, see AN.7.1) can provide this health assessment to patients, where in the clinical judgement of the attending medical practitioner, a specific risk factor for chronic disease has been identified.

Specific risk factors the medical practitioner can consider when providing this health assessment include, but are not limited to:

• lifestyle risk factors (such as smoking, physical inactivity, poor nutrition or alcohol misuse)
• biomedical risk factors (such as high cholesterol, high blood pressure, impaired glucose metabolism or excess weight)
• a family history of a chronic disease.

The regulation states the health assessment must include:

• information collection, including taking a patient's history and performing examinations and investigations, as required
• making an overall assessment of the patient
  initiating interventions or referrals, as appropriate, and
  giving health advice and information to the patient.

The Regulations state that a chronic disease is one that “has been, or is likely to be, present for at least 6 months, including, but not limited to: asthma, cancer, cardiovascular illness, diabetes mellitus, a mental health condition, arthritis or a musculoskeletal condition.” It is important to note that this definition of a chronic disease is specific to this health assessment cohort. It does not apply more broadly across the MBS.

ELIGIBLE PATIENTS

Eligible patients for a health assessment for people who are at risk of developing a chronic disease are:

• aged between 45-49 years (inclusive), and
• are at risk of developing a chronic disease, in the clinical judgement of the attending medical practitioner based on the identification of a specific risk factor.

A health assessment for a patient at risk of developing a chronic disease cannot be claimed more than once per eligible patient.

ELIGIBLE PRACTITIONERS

A health assessment for patients at risk of developing a chronic disease can be undertaken by a general practitioner (see GN.4.13) or a prescribed medical practitioner (see AN.7.1).

CO-CLAIMING RESTRICTIONS

Clause 2.15.14 of the Regulations specifies a separate consultation must not be performed in conjunction with a health assessment for patients at risk of developing a chronic disease, unless clinically necessary.

To co-claim the health assessment item for patients at risk of developing a chronic disease 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 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

• Previous - Note AN.0.37
• Next - Note AN.0.39

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)