GP referrals for respiratory function and sleep studies

Last updated 6 July 2023

Changes from 1 November 2018

The Government announced changes to the Medicare Benefits Schedule (MBS) items for thoracic medicine (respiratory and sleep studies) in the 2018-19 Budget. The revised structure of the items was based on recommendations from the MBS Review Taskforce. A number of these changes affect general practice and these are outlined below.

These changes will take effect on 1 November 2018.

Changes to spirometry

Changes to office-based spirometry (items 11505 and 11506) will require GPs to change their billing practices, as two items have been introduced – one for diagnosis and one for monitoring.

Item 11505 for diagnosis can be billed each occasion at which three or more spirometry recordings are made and is applicable for a patient once per year. Item 11506 for monitoring can be billed each occasion at which spirometry recordings are made.

More information on these changes is available at MBS Online.

Item number

Descriptor

Rebate

11505

Measurement of spirometry, that:

  1. involves a permanently recorded tracing, performed before and after inhalation of a bronchodilator; and
  2. is performed to confirm diagnosis of:
    1. asthma; or
    2. chronic obstructive pulmonary disease (COPD); or
    3. another cause of airflow limitation;

each occasion at which 3 or more recordings are made

Applicable only once in any 12 month period

$41.10

11506

Measurement of spirometry, that:

  1. involves a permanently recorded tracing, performed before and after inhalation of a bronchodilator; and
  2. is performed to:
    1. confirm diagnosis of chronic obstructive pulmonary disease (COPD); or
    2. assess acute exacerbations of asthma; or
    3. monitor asthma and COPD; or
    4. assess other causes of obstructive lung disease or the presence of restrictive lung disease;

each occasion at which recordings are made

$20.55

 

Diagnostic services for sleep disorders

GPs will be able to directly refer eligible patients for diagnostic home-based (unattended) or laboratory-based sleep studies for obstructive sleep apnoea only when an approved assessment tool has been used. Further investigation of suspected sleep disorders can be ordered by referring eligible patients to qualified adult sleep medicine practitioners and consultant respiratory physicians.

GPs need to use approved assessment tools and meet the below criteria in order to directly refer patients for a diagnostic home or laboratory-based sleep study to confirm a diagnosis of sleep apnoea.

Either one of:

  • STOP-BANG score ≥ 4
  • OSA-50 score ≥ 5
  • Berlin Questionnaire – high risk

Plus:

  • Epworth Sleepiness Scale score ≥ 8

Preparing a referral

There is no requirement for referrals to be made out to a certain specialist or consultant physician. There is also nothing to preclude a referral being addressed to a non-named specialist such as a business, as long as the referral includes the following information:

  • relevant clinical information about the patient’s condition for investigation, opinion, treatment and/or management
  • the date of the referral, and
  • the signature of the referring practitioner

Where a referral has been specifically addressed to a named specialist who is unable to provide the service, the specialist has the option of referring the patient to another specialist.

More information

More information on these changes is available at MBS Online.

Item number

Descriptor

Rebate

12203

Overnight diagnostic assessment of sleep, for a period of at least 8 hours duration, for a patient aged 18 years or more, to confirm diagnosis of a sleep disorder, if:

  1. either:
    1. the patient has been referred by a medical practitioner to a qualified sleep medicine practitioner or a consultant respiratory physician who has determined that the patient has a high probability for symptomatic, moderate to severe obstructive sleep apnoea based on a STOP-Bang score of 4 or more, an OSA50 score of 5 or more or a high risk score on the Berlin Questionnaire, and an Epworth Sleepiness Scale score of 8 or more; or
    2. following professional attendance on the patient (either face-to-face or by video conference) by a qualified sleep medicine practitioner or a consultant respiratory physician, the qualified sleep medicine practitioner or consultant respiratory physician determines that assessment is necessary to confirm the diagnosis of a sleep disorder; and
  2. the overnight diagnostic assessment is performed to investigate:
    1. suspected obstructive sleep apnoea syndrome where the patient is assessed as not suitable for an unattended sleep study; or
    2. suspected central sleep apnoea syndrome; or
    3. suspected sleep hypoventilation syndrome; or
    4. suspected sleep-related breathing disorders in association with non-respiratory co-morbid conditions including heart failure, significant cardiac arrhythmias, neurological disease, acromegaly or hypothyroidism; or
    5. unexplained hypersomnolence which is not attributed to inadequate sleep hygiene or environmental factors; or
    6. suspected parasomnia or seizure disorder where clinical diagnosis cannot be established on clinical features alone (including associated atypical features, vigilance behaviours or failure to respond to conventional therapy); or
    7. suspected sleep related movement disorder, where the diagnosis of restless legs syndrome is not evident on clinical assessment; and
  3. a sleep technician is in continuous attendance under the supervision of a qualified sleep medicine practitioner; and
  4. there is continuous monitoring and recording, performed in accordance with current professional guidelines, of the following measures:
    1. airflow;
    2. continuous EMG;
    3. anterior tibial EMG;
    4. continuous ECG;
    5. continuous EEG;
    6. EOG;
    7. oxygen saturation;
    8. respiratory movement (chest and abdomen);
    9. position; and
  5. polygraphic records are:
    1. analysed (for assessment of sleep stage, arousals, respiratory events, cardiac abnormalities and limb movements) with manual scoring, or manual correction of computerised scoring in epochs of not more than 1 minute; and
    2. stored for interpretation and preparation of report; and
  6. interpretation and preparation of a permanent report is provided by a qualified sleep medicine practitioner with personal direct review of raw data from the original recording of polygraphic data from the patient; and
  7. the overnight diagnostic assessment is not provided to the patient on the same occasion that a service mentioned in any of items 11000 to 11005, 11503, 11700 to 11709, 11713 or 12250 is provided to the patient

Applicable only once in any 12 month period

$588.00

12204

Overnight assessment of positive airway pressure, for a period of at least 8 hours duration, for a patient aged 18 years or more, if:

  1. the necessity for an intervention sleep study is determined by a qualified sleep medicine practitioner or consultant respiratory physician where a diagnosis of a sleep-related breathing disorder has been made; and
  2. the patient has not undergone positive airway pressure therapy in the previous 6 months; and
  3. following professional attendance on the patient by a qualified sleep medicine practitioner or a consultant respiratory physician (either face-to-face or by video conference), the qualified sleep medicine practitioner or consultant respiratory physician establishes that the sleep-related breathing disorder is responsible for the patient’s symptoms; and
  4. a sleep technician is in continuous attendance under the supervision of a qualified sleep medicine practitioner; and
  5. there is continuous monitoring and recording, performed in accordance with current professional guidelines, of the following measures:
    1. airflow;
    2. continuous EMG;
    3. anterior tibial EMG;
    4. continuous ECG;
    5. continuous EEG;
    6. EOG;
    7. oxygen saturation;
    8. respiratory movement;
    9. position; and
  6. polygraphic records are:
    1. analysed (for assessment of sleep stage, arousals, respiratory events, cardiac abnormalities and limb movements) with manual scoring, or manual correction of computerised scoring in epochs of not more than 1 minute; and
    2. stored for interpretation and preparation of a report; and
  7. interpretation and preparation of a permanent report is provided by a qualified sleep medicine practitioner with personal direct review of raw data from the original recording of polygraphic data from the patient; and
  8. the overnight assessment is not provided to the patient on the same occasion that a service mentioned in any of items 11000 to 11005, 11503, 11700 to 11709, 11713 or 12250 is provided to the patient

Applicable only once in any 12 month period

$588.00

12205

Follow-up study for a patient aged 18 years or more with a sleep-related breathing disorder, following professional attendance on the patient by a qualified sleep medicine practitioner or consultant respiratory physician, if:

  1. either:
    1. there has been a recurrence of symptoms not explained by known or identifiable factors such as inadequate usage of treatment, sleep duration or significant recent illness; or
    2. there has been a significant change in weight or changes in co-morbid conditions that could affect sleep-related breathing disorders and other means of assessing treatment efficacy (including review of data stored by a therapy device used by the patient) are unavailable, or have been equivocal; and
  2. a sleep technician is in continuous attendance under the supervision of a qualified sleep medicine practitioner; and
  3. there is continuous monitoring and recording, performed in accordance with current professional guidelines, of the following measures:
    1. airflow;
    2. continuous EMG;
    3. anterior tibial EMG;
    4. continuous ECG;
    5. continuous EEG;
    6. EOG;
    7. oxygen saturation;
    8. respiratory movement (chest and abdomen);
    9. position; and
  4. polygraphic records are:
    1. analysed (for assessment of sleep stage, arousals, respiratory events, cardiac abnormalities and limb movements) with manual scoring, or manual correction of computerised scoring in epochs of not more than 1 minute; and
    2. stored for interpretation and preparation of report; and
  5. interpretation and preparation of a permanent report is provided by a qualified sleep medicine practitioner with personal direct review of raw data from the original recording of polygraphic data from the patient; and
  6. the follow-up study is not provided to the patient on the same occasion that a service mentioned in any of items 11000 to 11005, 11503, 11700 to 11709, 11713 or 12250 is provided to the patient

Applicable only once in any 12 month period

$588.00

12250

Overnight investigation of sleep for a period of at least 8 hours of a patient aged 18 years or more to confirm diagnosis of obstructive sleep apnoea, if:

  1. either:
    1. the patient has been referred by a medical practitioner to a qualified sleep medicine practitioner or a consultant respiratory physician who has determined that the patient has a high probability for symptomatic, moderate to severe obstructive sleep apnoea based on a STOP-Bang score of 4 or more, an OSA50 score of 5 or more or a high risk score on the Berlin Questionnaire, and an Epworth Sleepiness Scale score of 8 or more; or
    2. following professional attendance on the patient (either face-to-face or by video conference) by a qualified sleep medicine practitioner or a consultant respiratory physician, the qualified sleep medicine practitioner or consultant respiratory physician determines that investigation is necessary to confirm the diagnosis of obstructive sleep apnoea; and
  2. during a period of sleep, there is continuous monitoring and recording, performed in accordance with current professional guidelines, of the following measures:
    1. airflow;
    2. continuous EMG;
    3. continuous ECG;
    4. continuous EEG;
    5. EOG;
    6. oxygen saturation;
    7. respiratory effort; and
  3. the investigation is performed under the supervision of a qualified sleep medicine practitioner; and
  4. either:
    1. the equipment is applied to the patient by a sleep technician; or
    2. if this is not possible—the reason it is not possible for the sleep technician to apply the equipment to the patient is documented and the patient is given instructions on how to apply the equipment by a sleep technician supported by written instructions; and
  5. polygraphic records are:
    1. analysed (for assessment of sleep stage, arousals, respiratory events and cardiac abnormalities) with manual scoring, or manual correction of computerised scoring in epochs of not more than 1 minute; and
    2. stored for interpretation and preparation of report; and
  6. interpretation and preparation of a permanent report is provided by a qualified sleep medicine practitioner with personal direct review of raw data from the original recording of polygraphic data from the patient; and
  7. the investigation is not provided to the patient on the same occasion that a service mentioned in any of items 11000 to 11005, 11503, 11700 to 11709, 11713 and 12203 is provided to the patient

Applicable only once in any 12 month period

$335.30

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