Medicare Benefits Schedule - Note AN.7.18

Publication date: 1 January 2025

SUMMARY

Medication management reviews are collaborative services through which a GP (see GN.4.13) or prescribed medical practitioner (see AN.7.1) works with a pharmacist to review the patient’s medications. The service is intended to support the quality use of medicines and identify patients  who may be at risk of medication misadventure.

Residential medication management reviews (RMMRs) are available to care recipients in a residential aged care facility (home).

Patients living in the community may be eligible for a domiciliary medication management review (see AN.0.52).

While the GP’s or prescribed medical practitioner’s work in the RMMR is supported through the MBS, the pharmacist’s participation is funded through other programs.

USE OF THE ITEMS

The Health Insurance (General Medical Services Table) Regulations 2021 (the Regulations) state that a RMMR is “a collaborative service provided by a general practitioner (for item 903), or a prescribed medical practitioner (for item 249), and a pharmacist to review the medication management needs of a care recipient in a residential aged care facility”. A residential aged care facility is defined with reference to the Aged Care Act 1997; the definition includes facilities formerly known as nursing homes and hostels (see GN.14.38).

The Regulations state:

1. “a medical practitioner’s involvement in a RMMR includes all of the following:

• discussing the proposed review with the resident and seeking the resident’s consent to the review;
• collaborating with the reviewing pharmacist about the pharmacist’s involvement in the review;
• providing input from the resident’s most recent comprehensive medical assessment or, if such an assessment has not been undertaken, providing relevant clinical information for the review and for the resident’s records;
• [(subject to point 2 below)] participating in a post‑review discussion if required (either face‑to‑face or by telephone) with the pharmacist to discuss the outcomes of the review including:
  • the findings of the review; and
  • medication management strategies; and
  • means to ensure that the strategies are implemented and reviewed, including any issues for implementation and follow‑up; and
• developing or revising the resident’s medication management plan after discussion with the reviewing pharmacist, and finalising the plan after discussion with the resident;
• offering a copy of the medication management plan to the resident (or the resident’s carer or representative if appropriate);
• providing copies of the plan for the resident’s records and for the nursing staff of the residential aged care facility; and
• discussing the plan with nursing staff if necessary.

2. A post‑review discussion is not required if:

• there are no recommended changes to the resident’s medication management arising out of the review; or
• any changes are minor in nature and do not require immediate discussion; or
• the pharmacist and medical practitioner agree that issues arising out of the review should be considered in a case conference.”

Do I need to see the resident as part of the RMMR?

Yes. The Regulations state that RMMRs are a “service provided in the course of personal attendance by a single [general practitioner/prescribed medical practitioner] on a single patient”. This means that the medical practitioner must see the patient as part of the RMMR service. However, it is acknowledged that third parties, such a nurses or carers of people with communication difficulties, may need to communicate with the health professional at times during the consultation.

How often can an RMMR be provided to a patient?

Patients can have an RMMR (either item 249 or item 903) every 12 months if it is clinically appropriate. Exceptional circumstances apply if there is a significant change in the patient’s medical condition or medication management plan requiring a new RMMR in which case a service can be provided sooner than 12 months.

Services Australia needs to be advised that exceptional circumstances apply to pay a benefit sooner than is generally allowable. To facilitate this the patient's invoice, Medicare voucher or the digital claim should indicate that exceptional circumstances are in play, no further explanation is required to support payment. However, the GP or prescribed medical practitioner should document the reasons for the exceptional circumstances in their records.

RMMRs can be provided following admission of a new resident of residential aged care if appropriate. There is no time restriction applicable between their first RMMR and any previous domiciliary medication management reviews (items 245 and 900).

This is a complex service. When can I bill the MBS?

An MBS claim can only be submitted once all the requirements of the RMMR have been completed (i.e. at the end of the RMMR).

Can I claim another service for the same patient on the same day as the RMMR?

In general, yes. However, there are some limitations including:

• both services must be clinically relevant and distinct services
• the other item must not have restrictions on same day claiming with an RMMR.

My patient had a domiciliary medication management review 6 months ago. Their condition has deteriorated significantly and they are now in residential aged care. How soon can they have a RMMR?

If it is clinically appropriate, the patient can have a RMMR once they are admitted to residential aged care. There is no time restriction between the provision of a domiciliary medication management review and a RMMR. It is recommended that the GP or prescribed medical practitioner document the reasons why the RMMR was clinically appropriate.

There is a pharmacist engaged through the Aged Care On-Site Pharmacist (ACOP) Measure at the facility. Is the resident still eligible for a RMMR?

Yes. Participation in the ACOP affects the source of payment for the pharmacist’s time, not the resident’s eligibility for a RMMR service. A key role of an ACOP is to review residents’ medications regularly and resolve any issues identified promptly. This is expected to reduce (but may not eliminate) the need for RMMRs.

ELIGIBLE PATIENTS

Care recipients of a residential aged care facility.

ELIGIBLE PRACTITIONERS

Item 903 can be claimed by General Practitioners (see GN.4.13).

Item 249 can be claimed by Prescribed Medical Practitioners (see AN.7.1).

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 item can be found on the Federal Register of Legislation at www.legislation.gov.au. Items 249 and 903 are set out in Health Insurance (General Medical Services Table) Regulations 2021.

Related Items: 249 903

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Participation by a prescribed medical practitioner in a residential medication management review (RMMR) for a patient who is a permanent resident of a residential aged care facility—other than an RMMR for a resident in relation to whom, in the preceding 12 months, this item or item 903 has applied, unless there has been a significant change in the resident’s medical condition or medication management plan requiring a new RMMR

Fee: $96.60 Benefit: 100% = $96.60

(See para AN.7.1, AN.7.18 of explanatory notes to this Category)

Participation by a general practitioner (not including a specialist or consultant physician) in a residential medication management review (RMMR) for a patient who is a care recipient in a residential aged care facility—other than an RMMR for a resident in relation to whom, in the preceding 12 months, this item or item 249 has applied, unless there has been a significant change in the resident’s medical condition or medication management plan requiring a new RMMR.

Fee: $120.80 Benefit: 100% = $120.80

(See para AN.7.18 of explanatory notes to this Category)