Note AN.36.1 | Medicare Benefits Schedule

Category 1 - PROFESSIONAL ATTENDANCES

AN.36.1

Eating Disorders General Explanatory Notes

Eating Disorders General Explanatory Notes (items 90250-90257, 90260-90261, 90264-90267, 90271-90278; 92182, 92184, 92186 and 92188; 92194, 92196, 92198 and 92200)

This note provides a general overview of the full range of 1 November 2019 eating disorders items and supporting information more specifically on the Category 1 – Professional Attendances: Group A36 – Eating Disorders Services (90250-90257, 90260-90261, 90264-90267; 90271-90278, 92182, 92184, 92186 and 92188; 92194, 92196, 92198 and 92200).

It includes an overview of the items, model of care, patient eligibility, and links to other guidance and resources.

Overview

All 1 November 2019 Eating Disorders items:

The Eating Disorders items define services for which Medicare rebates are payable where service providers undertake assessment and management of patients with a diagnosis of anorexia nervosa and patients with other specified eating disorder diagnoses who meet the eligibility criteria (see – patient eligibility). It is expected that there will be a multidisciplinary approach to patient management through these items.

The items mean eligible patients are able to receive a Medicare rebate for development of an eating disorders treatment plan by a medical practitioner in general practice (Group A36, subgroup 1 and Group A40 subgroup 21), psychiatry or paediatrics (Group A36, subgroup 2 and Group A40, subgroup 23), psychiatry or paediatrics (Group A36, subgroup 2 and Group A40, subgroup 23). Patients with an eating disorders treatment and management plan (EDP) will be eligible for comprehensive treatment and management services for a 12 month period, including:

Up to 20 dietetic services under items 110954, 82350, 93074 and 93108.
Up to 40 eating disorder psychological treatment services (EDPT service).
Review and ongoing management services to ensure that the patient accesses the appropriate level of intervention (Group A36, subgroup 3).

An EDPT service includes mental health treatment services which are provided by an allied health professional or a medical practitioner in general practice with appropriate mental health training. These treatment services include:

Medicare mental health treatment services currently provided to patients under the ‘Better Access to Psychiatrists, Psychologists and General Practitioners through the MBS (‘Better Access’) initiative.
- This includes medical practitioner items 2721, 2723, 2725, 2727, 283, 285, 286, 287 and
- Their equivalent video and phone items 91818, 91819, 91820, 91844, 91821 and 91845
- This includes allied health items in Groups M6 and M7 of Category 8; and
Items for EDPT services provided by suitably trained medical practitioners in general practice (items 90271, 90278, 92182, 92184, 92186, 92188, 92194, 92198 and 92200)
new items for EDPT services provided by eligible clinical psychologists (items 82352, 82354, 82355, 82357-82359; 93076, 93079, 93110 and 93113), eligible psychologists (items 82360, 82362-82363, 82365-82367; 93084, 93087, 93118 and 93121), eligible occupational therapists (items 82368, 82370-82371, 82373-82375; 93092, 93095, 93126 and 93129) and eligible social workers (items 82376, 82378-82379, 82381-82383; 93100, 93103, 93134 and 93137)

For the purpose of the 40 EDPT count; eating disorder psychological treatment service includes a service under provided under the following items: 90271, 90272, 90273, 90274, 90275, 90276, 90277, 90278, 92182, 92184, 92186, 92188, 92194, 92196, 92198 and 92200, 2721, 2723, 2725, 2727, 283, 285, 286, 287, 91818, 91819, 91820 91821; 91842, 91843, 91844 and 91845 and items in Groups M6, M7 and M16 (excluding items 82350, 93074 and 93108)

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 EDP to continue accessing EDPT services.

Patient Eligibility

The Eating Disorder items are available to eligible patients in the community. These items do not apply to services provided to admitted (in-hospital) patients.

The referring practitioner is responsible for determining that a patient is eligible for an EDP and therefore EDPT and dietetic services.

‘Eligible patient’ defines the group of patients who can access the new eating disorder services. There are two cohorts of eligible patients.

Patients with a clinical diagnosis of anorexia nervosa; or
Patients who meet the eligibility criteria (below), and have a clinical diagnosis of any of the following conditions:
1. bulimia nervosa;
2. binge-eating disorder;
3. other specified feeding or eating disorder.

The eligibility criteria, for a patient, is:

a person who has been assessed as having an Eating Disorder Examination Questionnaire score of 3 or more; and
the condition is characterised by rapid weight loss, or frequent binge eating or inappropriate compensatory behaviour as manifested by 3 or more occurrences per week; and
a person who has at least two of the following indicators:
1. clinically underweight with a body weight less than 85% of expected weight where weight loss is directly attributable to the eating disorder;
2. current or high risk of medical complications due to eating disorder behaviours and symptoms;
3. serious comorbid medical or psychological conditions significantly impacting on medical or psychological health status with impacts on function;
4. the person has been admitted to a hospital for an eating disorder in the previous 12 months;
5. inadequate treatment response to evidence based eating disorder treatment over the past six months despite active and consistent participation.

Practitioners should have regard to the relevant diagnostic criteria set out in the Diagnostic and Statistical Manual of the American Psychiatric Association – Fifth Edition (DSM-5)

Practitioners can access the Eating Disorder Examination Questionnaire at https://www.credo-oxford.com/pdfs/EDE_17.0D.pdf

The Eating Disorders Items Stepped Model of Care

The eating disorder items incorporate a ‘stepped model’ for best practice care for eligible patients with eating disorders that comprise:

assessment and treatment planning
provision of and/or referral for appropriate evidence based eating disorder specific treatment services by allied mental health professionals and provision of services by dietitians
review and ongoing management items to ensure that the patient accesses the appropriate level of intervention.

The Stepped Model

‘STEP 1’ – PLANNING (trigger Eating Disorders pathway) 90250-90257; 92146 to 92153 and 90260 or 90261

An eligible patient receives an EDP developed by a medical practitioner in general practice (items 90250-90257), psychiatry (items 90260) or paediatrics (items 90261).

‘STEP 2’ – COMMENCE INITIAL COURSE OF TREATMENT (psychological & dietetic services)

Once an eligible patient has an EDP in place, the 12 month period commences, and the patient is eligible for an initial course of treatment up to 20 dietetic services and 10 eating disorder psychological treatment (EDPT) services. A patient will be eligible for an additional 30 EDPT services in the 12 month period, subject to reviews from medical practitioners to determine appropriate intensity of treatment.

‘STEP 3' – CONTINUE ON INITIAL COURSE OF TREATMENT 90264-90267 (managing practitioner review and progress up to 20 EDPT services)

It is expected that the managing practitioner will be reviewing the patient on a regular, ongoing and as required basis. However, a patient must have a review of the EDP (90264-90267; 92170, 92171, 92175 and 92177), to assess the patient’s progress against the EDP or update the EDP, before they can access more than 10 EDPT services. This is known as the ‘first review’. The first review should be provided by the patient’s managing practitioner, where possible.

‘STEP 4’ FORMAL SPECIALIST AND PRACTITIONER REVIEW 90266 and 90267 (continue beyond 20 EDPT services)

A patient must have two additional reviews before they can access more than 20 EDPT services. One review (the ‘second review’) must be performed by a medical practitioner in general practice (who is expected to be the managing practitioner), and the other (the ‘third review’) must be performed by a paediatrician (90267 or 92173) or psychiatrist (90266 or 92172). Should both recommend the patient requires more intensive treatment, the patient would be able to access an additional 10 EDPT services in the 12 month period. These reviews are required to determine that the patient has not responded to treatment at the lower intensity levels.

The patient’s managing practitioner should be provided with a copy of the specialist review.

The specialist review by the psychiatrist or paediatrician can occur at any point before 20 EDPT services. The practitioner should refer the patient for specialist review as early in the treatment process as appropriate. If the practitioner is of the opinion that the patient should receive more than 20 EDPT services, the referral should occur at the first practitioner review (after the first course of treatment) if it has not been initiated earlier.

Practitioners should be aware that the specialist review can be provided via video (92172 and 92173). Where appropriate, provision has been made for practitioner participation on the patient-end of the video consultation.

It is expected that the managing practitioner will be reviewing the patient on a regular, ongoing and as required basis. However, a patient must have a review of the EDP (90264-90267), to assess the patient’s progress against the EDP or update the EDP, before they can access the next course of treatment.

‘STEP 5’ ACCESS TO MAXIMUM INTENSITY OF TREATMENT 90266-90267 (continue beyond 30 EDPT services)

To access more than 30 EDPT treatment services in the 12 month period, patients are required to have an additional review (the ‘fourth review’) to ensure the highest intensity of treatment is appropriate. Subject to this review, a patient could access the maximum of 40 EDPT treatment services in a 12 month period. The fourth review should be provided by the patient’s managing practitioner, where possible.

An Integrated Team Approach

A patient’s family and/or carers should be involved in the treatment planning and discussions where appropriate. The family can be involved in care options throughout the diagnosis and assessment, and are usually the support unit that help to bridge the gap between initial diagnosis and eating disorder specific treatment.

The National Standards for the safe treatment of eating disorders specify a multi-disciplinary treatment approach that provides coordinated psychological, physical, behavioural, nutritional and functional care to address all aspects of eating disorders. People with eating disorders require integrated inter-professional treatment that is able to work within a framework of shared goals, care plans and client and family information. Frequent communication is required between treatment providers to prevent deterioration in physical and mental health (RANZCP Clinical Guidelines: Hay et al., 2014). Consider regular case conferencing to ensure that the contributing team members are able to work within a shared care plan and with client and carers to achieve best outcomes.

Clinical guidelines and other resources

It is expected that the consultants providing services under these items should have the appropriate skills, knowledge and experience to provide eating disorders treatment. However, there are a number of resources which may be of assistance to practitioners in supporting and developing EDP and EDPT plans, these include:

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders
The Royal Australian and New Zealand College of Psychiatrists (RANZCP) Referred Patient Assessment and Management Plan Guidelines
ANZAED eating disorder treatment principles and general clinical practice and training standards:

Heruc, G., Hurst, K., Casey, A. et al. ANZAED eating disorder treatment principles and general clinical practice and training standards. J Eat Disord 8, 63 (2020).

ANZAED practice and training standards for dietitians providing eating disorder treatment:

Heruc, G., Hart, S., Stiles, G. et al. ANZAED practice and training standards for dietitians providing eating disorder treatment. J Eat Disord 8, 77 (2020).

ANZAED practice and training standards for mental health professionals providing eating disorder treatment:

Hurst, K., Heruc, G., Thornton, C. et al. ANZAED practice and training standards for mental health professionals providing eating disorder treatment. J Eat Disord 8, 58 (2020).

Note: This information is provided as a guide only and each case should be addressed according to a patient's individual needs. An electronic version of the Guidelines is available on the RANZCP website at www.ranzcp.org

National Eating Disorders Collaboration Eating Disorders: a professional resources for general practitioners available at www.nedc.com.au

Eating Disorders Training

It is expected that practitioners who are providing services under these items have appropriate training, skills and experience in treatment of patients with eating disorders and meet the national workforce core competencies for the safe and effective identification of and response to eating disorders more information available at National Eating Disorders Collaboration

Training Services

Practitioners should contact their professional organisation to identify education and training which may assist to practitioners to gain the skills and knowledge to provide services under these items.

The following organisations provide training which may assist practitioners to meet the workforce competency standards:

The Australia and New Zealand Academy of eating disorders (ANZAED) - National
InsideOut Institute - National
The Victorian Centre of Excellence in Eating Disorders (CEED) - VIC
Queensland Eating Disorder Service (QuEDS) - QLD
Statewide Eating Disorder Service (SEDS) - SA
WA Eating Disorders Outreach & Consultation Service (WAEDOCS) – WA

This list is not exhaustive but has been included to provide examples on the types of training available which may assist practitioners to upskill in this area.

Category 1 - PROFESSIONAL ATTENDANCES

90250 ^Fee

Professional attendance by a general practitioner to prepare an eating disorder treatment and management plan, lasting at least 20 minutes but less than 40 minutes.

Fee: $83.65 Benefit: 100% = $83.65

(See para AN.36.1, AN.36.2 of explanatory notes to this Category)

Category 1 - PROFESSIONAL ATTENDANCES

90251 ^Fee

Professional attendance by a general practitioner to prepare an eating disorder treatment and management plan, lasting at least 40 minutes

Fee: $123.15 Benefit: 100% = $123.15

(See para AN.36.1, AN.36.2 of explanatory notes to this Category)

Category 1 - PROFESSIONAL ATTENDANCES

90252 ^Fee

Professional attendance by a general practitioner to prepare an eating disorder treatment and management plan, lasting at least 20 minutes but less than 40 minutes, if the practitioner has successfully completed mental health skills training.

Fee: $106.20 Benefit: 100% = $106.20

(See para AN.36.1, AN.36.2 of explanatory notes to this Category)

Category 1 - PROFESSIONAL ATTENDANCES

90253 ^Fee

Professional attendance by a general practitioner to prepare an eating disorder treatment and management plan, lasting at least 40 minutes, if the practitioner has successfully completed mental health skills training.

Fee: $156.45 Benefit: 100% = $156.45

(See para AN.36.1, AN.36.2 of explanatory notes to this Category)

Category 1 - PROFESSIONAL ATTENDANCES

90254 ^Fee

Professional attendance by a medical practitioner (other than a general practitioner, specialist or consultant physician) to prepare an eating disorder treatment and management plant, lasting at least 20 minutes but less than 40 minutes.

Fee: $66.90 Benefit: 100% = $66.90

(See para AN.36.1, AN.36.2 of explanatory notes to this Category)

Category 1 - PROFESSIONAL ATTENDANCES

90255 ^Fee

Professional attendance by a medical practitioner (other than a general practitioner, specialist or consultant physician) to prepare an eating disorder treatment and management plan, lasting at least 40 minutes.

Fee: $98.50 Benefit: 100% = $98.50

(See para AN.36.1, AN.36.2 of explanatory notes to this Category)

Category 1 - PROFESSIONAL ATTENDANCES

90256 ^Fee

Professional attendance by a medical practitioner (other than a general practitioner, specialist or consultant physician) to prepare an eating disorder treatment and management plan, lasting at least 20 minutes but less than 40 minutes, if the practitioner has successfully completed mental health skills training.

Fee: $84.95 Benefit: 100% = $84.95

(See para AN.36.1, AN.36.2 of explanatory notes to this Category)

Category 1 - PROFESSIONAL ATTENDANCES

90257 ^Fee

Professional attendance by a medical practitioner (other than a general practitioner, specialist or consultant physician) to prepare an eating disorder treatment and management plan, lasting at least 40 minutes, if the practitioner has successfully completed mental health skills training.

Fee: $125.20 Benefit: 100% = $125.20

(See para AN.36.1, AN.36.2 of explanatory notes to this Category)

Category 1 - PROFESSIONAL ATTENDANCES

90260 ^Fee

Professional attendance at consulting rooms by a consultant physician in the practice of the physician’s specialty of psychiatry to prepare an eating disorder treatment and management plan, if:

(a) the patient is referred; and

(b) the attendance lasts at least 45 minutes

Fee: $535.95 Benefit: 85% = $455.60

(See para AN.36.1, AN.36.2, AN.40.1 of explanatory notes to this Category)

Category 1 - PROFESSIONAL ATTENDANCES

90261 ^Fee

Professional attendance at consulting rooms by a consultant physician in the practice of the physician’s specialty of paediatrics to prepare an eating disorder treatment and management plan, if:

(a) the patient is referred; and

(b) the attendance lasts at least 45 minutes

Fee: $312.45 Benefit: 85% = $265.60

(See para AN.36.1, AN.36.2, AN.40.1 of explanatory notes to this Category)

Category 1 - PROFESSIONAL ATTENDANCES

90264 ^Fee

Professional attendance by a general practitioner to review an eating disorder treatment and management plan.

Fee: $83.65 Benefit: 100% = $83.65

(See para AN.36.1, AN.36.3 of explanatory notes to this Category)

Category 1 - PROFESSIONAL ATTENDANCES

90265 ^Fee

Professional attendance by a medical practitioner (other than a general practitioner, specialist or consultant physician) to review an eating disorder treatment and management plan.

Fee: $66.90 Benefit: 100% = $66.90

(See para AN.36.1, AN.36.3 of explanatory notes to this Category)

Category 1 - PROFESSIONAL ATTENDANCES

90266 ^Fee

Professional attendance at consulting rooms by a consultant physician in the practice of the physician’s specialty of psychiatry to review an eating disorder treatment and management plan, if:

(a) the patient is referred; and

(b) the attendance lasts at least 30 minutes

Fee: $335.05 Benefit: 85% = $284.80

(See para AN.36.1, AN.36.3, AN.40.1 of explanatory notes to this Category)

Category 1 - PROFESSIONAL ATTENDANCES

90267 ^Fee

Professional attendance at consulting rooms by a consultant physician in the practice of the physician’s specialty of paediatrics to review an eating disorder treatment and management plan, if:

(a) the patient is referred; and

(b) the attendance lasts at least 20 minutes

Fee: $156.45 Benefit: 85% = $133.00

(See para AN.36.1, AN.36.3, AN.40.1 of explanatory notes to this Category)

Category 1 - PROFESSIONAL ATTENDANCES

90271 ^Fee

Professional attendance at consulting rooms by a general practitioner to provide treatment under an eating disorder treatment and management plan, lasting at least 30 minutes but less than 40 minutes.

Fee: $108.20 Benefit: 100% = $108.20