Medicare Benefits Schedule - Note AN.0.41

Publication date: 1 July 2024

SUMMARY

Time-tiered health assessment items may be used to undertake a health assessment for a person with an intellectual disability.

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 a health assessment for a person with an intellectual disability are set out in clause 2.15.8 of the Health Insurance (General Medical Services Table) Regulations 2021 (the Regulations).

The Regulations specify that a Health assessment for a person with an intellectual disability is an assessment of:

• the patient’s physical, psychological and social function, and
• whether any medical intervention and preventive health care is required.

They also state that the health assessment must include the following matters, to the extent that they are relevant to the patient:

• checking dental health (including dentition)
• conducting an aural examination (including arranging a formal audiometry if an audiometry has not been conducted within the last 5 years)
• assessing ocular health (arrange review by an ophthalmologist or optometrist if a comprehensive eye examination has not been conducted within the last 5 years)
• assessing nutritional status (including weight and height measurements) and a review of growth and development
• assessing bowel and bladder function (particularly for incontinence or chronic constipation)
• assessing medications including:
  • ­non-prescription medicines taken by the patient, prescriptions from other doctors, medications prescribed but not taken, interactions, side effects and review of indications
  • advice to carers on the common side effects and interactions, and
  • ­consideration of the need for a formal medication review
• checking immunisation status (including influenza, tetanus, hepatitis A and B, measles, mumps, rubella and pneumococcal vaccinations)
• checking exercise opportunities (with the aim of moderate exercise for at least 30 minutes each day)
• checking whether the support provided for activities of daily living adequately and appropriately meets the patient’s needs, and considering formal review if required
• considering the need for breast examination, mammography, papanicolaou smears, testicular examination, lipid measurement and prostate assessment as for the general population
• checking for dysphagia and gastroesophageal disease (especially for patients with cerebral palsy) and arranging for investigation or treatment as required
• assessing risk factors for osteoporosis (including diet, exercise, Vitamin D deficiency, hormonal status, family history, medication and fracture history) and arranging for investigation or treatment as required
• for a patient diagnosed with epilepsy—reviewing seizure control (including anticonvulsant drugs) and considering referral to a neurologist at appropriate intervals
• screening for thyroid disease at least every 2 years (or yearly for patients with Down syndrome)
• for a patient without a definitive aetiological diagnosis—considering referral to a genetic clinic every 5 years
• assessing or reviewing treatment for comorbid mental health issues
• considering timing of puberty and management of sexual development, sexual activity and reproductive health, and
• considering whether there are any signs of physical, psychological or sexual abuse.

Note: The Regulations do not preclude a medical practitioner’s consideration of the patient’s broader immunisation status, such as for immunisations listed under the National Immunisation Program schedule or for COVID-19.

Practitioners may also wish to utilise publicly available guidelines such as the Royal Australian College of General Practitioner’s Guidelines for preventative activities in general practice as a guideline to conduct patient assessments to current clinical standards.

Eligible health practitioners may wish to consider the use of relevant assessment tools in the delivery of this service, such as the Adult Comprehensive Health Assessment Program (CHAP). However, it remains the responsibility of the treating practitioner to ensure all requirements of the items are met.

ELIGIBLE PATIENTS

Patients are eligible for this assessment if they are a person living with an intellectual disability.

A health assessment for a person with an intellectual disability cannot be claimed more than once every 12 months by an eligible patient.

ELIGIBLE PRACTITIONERS

Health assessment for a person with an intellectual disability can be undertaken by a general practitioner (see GN.4.13) or a prescribed medical practitioner (see AN.7.1).

CO-CLAIMING RESTRICTIONS

To co-claim a health assessment for a person with an intellectual disability item and another item, both items must be clinically necessary and distinct services.

RECORD KEEPING AND REPORTING REQUIREMENTS

A health assessment for a person with an intellectual disability must include:

• keeping a record of the health assessment;
• offering the patient a written report on the health assessment;
• offering the patient’s carer (if any, and if the general practitioner or the prescribed medical practitioner considers it appropriate, and the patient agrees) a copy of the report or extracts of the report; and
• offering relevant disability professionals (if the general practitioner or the prescribed medical practitioner considers it appropriate and the patient or, if appropriate, the patient’s carer, agrees) a copy of the report or extracts of the report.

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 it 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.0.40
• Next - Note AN.0.42

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)