Medicare frequently asked questions

Disclaimer

As per the RACGP Statement on Medicare interpretation and compliance: As with all specialist medical colleges, the RACGP has no legal authority to interpret MBS rules and regulations. There is no guarantee that Medicare will consider the use of an MBS item number appropriate, even if the RACGP does. It is the responsibility of the treating practitioner to ensure that any service billed to Medicare meets the item descriptor in the MBS and any eligibility requirements in full. You should maintain appropriate patient notes to demonstrate how you meet the descriptor of any Medicare service billed. Any further enquiries relating exclusively to interpretation of the MBS can be emailed to askmbs@health.gov.au.

After-hours care

If a consultation spills over into an after-hours period, which item should we bill?

Attendances using urgent after-hours items (585, 594, 599) must be booked during the same unbroken urgent after-hours period.

For non-urgent services, when an attendance takes place over an in-hours and an after-hours period (in either order) the period in which the greater portion of the attendance took place determines the type of item to claim, for the total duration of the attendance.

Ahpra / complaints handling

What do we do with patients who engage in threats and intimidation, including reporting to the Australian Health Practitioner Regulation Agency (Ahpra), because I am trying to explain the rules of Medicare in a polite way?

Providers should continue to explain Medicare requirements clearly, calmly and professionally, and ensure the discussion is documented in the patient record where relevant. Medicare compliance obligations remain the responsibility of the provider, including billing only where the service is clinically relevant, the full item requirements are met, and adequate records are kept. If a patient threatens a complaint or attempts to pressure a provider into billing incorrectly, the provider should not claim an item unless they are satisfied the Medicare Benefits Schedule (MBS) requirements have been met.

AskMBS

How do we get legally binding advice? There are lots of item numbers and rules. It’s not a simple, straightforward system.

Due to the varying nature of clinical practice and an abundance of factors such as patient demographics, as well as the unique circumstances of each individual consultation, it is not possible to issue legally binding advice in relation to each MBS item number.

Responses from the Department of Health, Disability and Ageing’s (DoHDA) AskMBS email service are specific to the particular question asked and the relevant policy or legislation applying at the time the question is asked. Changes in policy or legislation may result in responses to the same issue varying over time.

DoHDA welcomes the opportunity to review instances of possible inconsistent advice by forwarding it to askmbs@health.gov.au for internal quality assurance purposes, and so that corrections or clarifications can be issued where required.

AskMBS aims to respond to enquiries as soon as possible. You can also check this collection of AskMBS advisories to see if your issue is addressed there. AskMBS responses do not constitute legal advice, however they remain a useful tool to help you better understand Medicare billing rules and whether it is appropriate to claim certain items. If you have concerns about relying on advice received from AskMBS, you should contact your medical defence organisation (MDO).

Billing multiple MBS items

Can you bill a telehealth item in the morning and a face-to-face item for review in the afternoon for the same issue?

In general, Medicare benefits may be paid for more than one service for a patient on the same day, provided that:

• the second (and any following) service is not a continuation of an earlier service

• each service is distinct and clinically relevant

• the requirements of each item, including any time requirements, are fully and independently met

• there is no duplication of services.

A service is clinically relevant if it is generally accepted in the profession as necessary for the appropriate treatment of the patient. MBS items are complete medical services. Tasks that are integral to one service should not be claimed separately under another item. A second item on the same day may only be appropriate if it represents a separate and distinct clinically relevant service and all requirements for that item are met.

When considering whether two services can be billed on the same day, ask:

• Is the second service genuinely separate?

• Is it clinically relevant?

• Does it meet the full item descriptor in its own right?

• Is it supported by adequate records?

If the answer to all these questions is yes, a separate claim may be appropriate.

If a patient has seen two GPs around the same time, can Medicare be billed twice? For example, the patient sees GP 1 first for a few issues, then sees GP 2 for one of the issues (eg skin issue where GP 1 required the expertise of GP 2)?

Medicare may only be billed where each service is clinically relevant and meets the relevant item descriptor. If the second GP provides a separate and distinct service that is not simply duplicating or completing the first service, a separate claim may be appropriate. Records should clearly explain the clinical reason for the second attendance, the service provided and why it was necessary. Note that Medicare benefits are not payable where more than one medical practitioner attends the patient simultaneously.

What if the patient makes a telehealth appointment in the morning and then comes later in person for the same problem? Can I bill for total time spent with the patient, or should I bill both a telehealth and face-to-face item (e.g. 91900 and 36)?

The provider should consider whether the services are genuinely separate and whether each item descriptor is met. If the later face-to-face attendance is part of completing the same service, it should not be separately claimed simply because it occurred in two parts. If there are separate clinically relevant services, each claim must be supported by adequate records showing what was provided, when, and why each service was required. Where a single attendance comprises both face-to-face and telehealth elements, the appropriate item to claim (face-to-face or telehealth) for the total duration is determined by the modality by which the greater part of the attendance was provided.

If a care plan is prepared in the morning and there is a follow up of results via telehealth in the afternoon, can we bill separate items?

Planning and review items for GP Chronic Condition Management Plans (GPCCMPs) cannot be co-claimed by the same practitioner for the same patient as an attendance item on the same day. This applies to all general attendance items, including face-to-face, telehealth, after-hours and out of consulting rooms items.

For other types of plans, such as Mental Health Treatment Plans (MHTPs), separate items may only be billed if each service is clinically relevant, separate and distinct, and the full requirements of each item are met. If the follow-up is integral to the care plan service or part of completing that service, it should not be claimed separately. Also, it would not be appropriate to use MBS telehealth services for the simple communication of test results, as a standalone service where no other clinical interactions have been undertaken. The records should clearly support the clinical need and item requirements for each claim. Note that MBS telehealth items are considered direct substitutes for face-to-face attendances and are governed by the same principles and requirements. Telehealth items should not be billed for purposes that would not normally be billed to Medicare.

If a patient has a phone consult in the morning and the doctor notes another issue which requires face-to-face care on the same day, can I bill two separate items?

A second item may be appropriate where the face-to-face service addresses a separate and distinct clinical issue, and all MBS requirements are met. The record should clearly identify the separate issue, the clinical reason for the additional attendance, and the service provided. Providers should avoid claiming separately for tasks that are integral to the earlier service. Time requirements for one service cannot contribute to the time requirements of a second service if rendered.

Can you complete a health assessment and GPCCMP on the same day?

A health assessment and care plan should only be claimed on the same day if both services are clinically relevant, separate and distinct, and each item’s requirements (as specified in the item descriptor and explanatory notes) are met. Providers should ensure the records clearly support the need for both services and demonstrate that one service was not simply an integral component of the other. However, it is not expected that the co-claiming of a chronic condition management (CCM) item with a health assessment would routinely occur. The expectation would be that a GPCCMP would be prepared following a health assessment as a result of a risk being identified, including confirmation of a chronic condition/s.

Billing processes

As a locum, I do not control billings to a great extent and do not always check. Managing new patients and practices is enough, and we are dependent on staff accuracy. Do you have any comment?

If you have delegated your billing to a practice staff member, you should still double check all claims made. You are personally responsible for any MBS service billed using your provider number.

Can you hold billings until a new provider number comes in?

Yes, you can hold billings and lodge later once your new location provider number is active, provided you do not use anyone else’s provider number.

Care and management plans

Does my patient need to spend 45 minutes with me for a service under item 139? Can they see the nurse instead?

To complete the item requirements of item 139 the GP must spend at least 45 minutes attending the patient. Practice nurses may assist with administrative or clinical support activities consistent with their scope of practice. However, any time spent with a practice nurse cannot contribute to the minimum 45‑minute attendance requirement for item 139.

The 45‑minute minimum duration for MBS item 139 is intentional and reflects the nature and purpose of the service, rather than the complexity of any single presenting issue.

The item is designed to support the development of a diagnosis and comprehensive, structured management plan for patients with severe and pervasive disabilities, not to fund brief or targeted assessments for isolated conditions. The time requirement signals that the service involves more than diagnosis and referral alone, with the expectation that the service includes all the activities listed in MBS Note AN.0.73.

Can my patient have a GPCCMP and a MHTP?

There is nothing precluding a patient from having both a GPCCMP and a MHTP, provided they meet the relevant eligibility requirements for each plan. Patient eligibility for each plan remains at the clinical discretion of the relevant GP or prescribed medical practitioner.

Where a GP determines that a patient is eligible for both a MHTP for the treatment of their mental health disorder, and a GPCCMP for the treatment of their chronic condition, it is permissible for both plans to be put in place.

Further, it must be noted that eligibility requirements differ between both plans. To be eligible for CCM services, the patient must have at least one medical condition that has been (or is likely to be) present for at least six months or is terminal. There is no prescribed list of chronic conditions. Whether a patient’s condition, including their mental health disorder, qualifies as a chronic condition is a matter for the clinical judgement of the referring GP.

To be eligible to receive services under Better Access, patients must have a clinically diagnosed mental disorder as defined by the World Health Organisation ICD-10 classification (not including dementia, delirium, tobacco use disorder or mental retardation). To access allied health treatment under an MHTP, the patient must have a valid referral from a GP or prescribed medical practitioner who is managing the patient under a MHTP who is from the general practice they are enrolled in for MyMedicare, or their usual medical practitioner. Patients may also be referred directly by a psychiatrist or a paediatrician.

Where both plans are in place, the patient would be eligible for the full allocation of referred allied health services under both plans, as determined by their GP or prescribed medical practitioner. Currently, these allocations are:

For CCM, up to:

• five individual allied health CCM services in a calendar year (or 10 for First Nations patients)

• five services provided by a practice nurse or Aboriginal and Torres Strait Islander health practitioner on behalf of a medical practitioner

• if the patient has type 2 diabetes, one assessment of their suitability for group allied health services and, if they are suitable, up to eight group allied health sessions

For MHTPs:

• 10 individual and 10 group therapy mental health treatment (Better Access) services in a calendar year.

A separate referral is required for each plan that details the treatment specific to that plan. The treatment provided by the allied health practitioner must be consistent with the plans, referrals, and requirements of the relevant MBS item/s.

Can my patient have a MHTP and an eating disorder treatment and management plan (EDTMP)?

There is nothing precluding a patient from having both an MHTP and an EDTMP where they meet the clinical criteria for both. Each plan is assessed separately, therefore having a MHTP does not prevent a patient from accessing an EDTMP.

How service allocations interact

There is an interaction between the service allocations available under an EDTMP and an MHTP, depending on the order in which services are provided and claimed.

• Better Access services provided before an EDTMP is developed do not count towards the patient’s EDTMP allocation.

• Better Access services provided after an EDTMP is developed will count towards the patient’s allocation of 40 EDTMP services.

Better Access service limits apply on a calendar year basis (1 January to 31 December), while EDTMP service limits apply over a 12‑month period from the commencement of the plan.

Under an EDTMP

Eligible patients may access:

• up to 40 eating disorder psychological treatment services

• up to 20 eating disorder dietetic services.

These services are available over a 12-month period from the date of the EDTMP and are subject to review requirements.

Review requirements

Patients must progress through the required review stages before accessing the full allocation of services. The review process determines whether further treatment remains clinically appropriate and whether additional services can be accessed. To access more than 20 psychological treatment services under their EDTMP, a patient will require a specialist review and recommendation from a consultant psychiatrist or consultant paediatrician in addition to a review conducted by a GP or medical practitioner.

Case conferencing items

Can I claim an item both for organising and participating in a case conference?

No. The item for organising and coordinating a case conference includes participating in the conference.

Can I participate in a case conference by telehealth?

Yes. Case conference items can be used for face-to-face, phone and video attendances. Some participants may be present in the room and others may attend via video or phone – however, there must be continuous communication throughout the whole case conference by all participants.

Chronic condition management

Could you please specify when item 10997 can be billed and how many times per year?

Patients with a GPCCMP or a multidisciplinary care plan (MCP) can access up to five services per calendar year provided by a practice nurse or Aboriginal and Torres Strait Islander health practitioner on behalf of a medical practitioner to support management of their chronic condition (MBS items 93201 [video], 93203 [telephone] and 10997 [face-to-face]).

The services provided must be consistent with the patient’s GPCCMP. Examples of the types of services that can be provided include but are not limited to:

• providing immunisations consistent with the plan

• monitoring a patient’s progress between reviews and recording the results

• dressing wounds

• providing advice to the patient on the self-management of their condition.

The intent of item 10997 is to assist patients who require access to ongoing care, routine treatment and ongoing monitoring and support between the more structured reviews of the care plan by the patient's usual GP. Importantly, item 10997 cannot be used for a practice nurse or Aboriginal and Torres Strait Islander health practitioner’s assistance with the preparation of a GPCCMP.

How many GPCCMPs can we do safely in a day?

There is no specific limit on the number of GPCCMPs you can prepare or review in a day. GPs must exercise their clinical judgement when determining how many of these services they can safely provide, ensuring each plan is delivered as a complete, clinically relevant service and meets all item requirements.

The 80/20 prescribed pattern of service rule applies generally to GP services. Any breaches of this rule will result in a referral to the Professional Services Review (PSR) Director.

When doing a care plan review, does that need to be in a form or in the patient’s notes?

The process of reviewing a GPCCMP must include:

• recording the patient’s consent and agreement to the updates

• offering a copy of the updated plan to the patient and the patient’s carer (if any) if the practitioner considers it appropriate and the patient agrees

• adding a copy of the updated plan to the patient’s medical records.

While the RACGP and DoHDA don’t have care plan templates available, most practice software companies have indicated they have or will update their templates to reflect the CCM framework changes.

Why does Medicare have the rule of not being able to bill 965 and another item number?

The restriction on same day co-claiming of chronic condition plan and review items and attendance items is long standing. The restriction on item 965 is consistent with the restrictions that previously applied to items 721 and 723. The list of items that cannot be co-claimed is available in MBS Note AN.0.47.

If needed, the attendance associated with a claim for item 965 can incorporate broader consideration of a patient’s health needs. If the appointment is for a general consultation and the need to create a plan is identified, GPs can claim the attendance item and consider providing the plan at another time.

Complete medical service

Can you please further explain what a ‘complete service’ means?

The principle of the complete medical service means that any tasks that would be considered integral to a particular service should not be claimed separately under another MBS item. As such, all procedural items include any associated clinical interactions which would be reasonably required for the routine performance of the service, including obtaining informed consent, routine pre-operative examination and post-operative review, discussion with the patient of post-operative care and, unless otherwise stated, the provision of routine aftercare.

Where the clinical interactions with a patient do not extend beyond what would be reasonably required for the routine performance of the service, no additional MBS item should be claimed. However, where clinical interactions do extend beyond what would be reasonably required for the routine performance of the service, then an appropriate attendance item for such a service may be claimed. An attendance item may also be claimed on the same day as a procedure where a separate and distinct clinical issue is being addressed. In both cases, the item requirements, as set out in the item descriptor and associated explanatory notes, must be met in full.

Completion of forms/paperwork

Does Medicare cover the completion of forms such as Centrelink, work, driver’s licence?

Medicare benefits are only payable for clinically relevant services. A medical service is considered clinically relevant if it is generally accepted in the medical profession as necessary for the appropriate treatment of the patient. The payment of Medicare benefits for ‘screening’ services, defined as a medical examination or test that is not reasonably required for the management of the medical condition of the patient, is prohibited. Exemptions to this rule are set out in MBS Note GN.13.33 (eg age or health related medical examinations to obtain or renew a licence to drive a private motor vehicle).

The completion of paperwork of any kind, as a standalone service with no clinical interactions, is not considered a clinically relevant service and is not eligible for Medicare benefits. However, where the paperwork is completed in the course of a broader attendance which is directly concerned with the management of the patient’s condition, and the requirements of an attendance item are fully met, that attendance item may be claimed. Only the time spent in active attention on the patient can be counted towards the duration of the attendance for the purposes of determining the appropriate item. As always, the medical practitioner is responsible for assessing clinical relevance in individual cases.

Compliance processes

Is it correct that compliance reviews are generally for GPs that primarily do bulk billing?

No. All providers that claim or request any type of Medicare service and/or prescribe or supply Pharmaceutical Benefits Scheme (PBS) medicines may be subject to compliance review and action.

After an audit is triggered, and if the provider’s post-audit billing behaviour is appropriate and not fraudulent, will the provider continue to trigger audits?

The end of an audit does not prevent future audits. Providers must ensure their Medicare claiming remains compliant, as all claiming is subject to ongoing monitoring and review. Future audits will only occur if DoHDA has a reasonable concern that benefits have been paid for services that did not meet legislative requirements.

Audits are undertaken in circumstances where a provider appears to be routinely claiming in a manner that does not meet legislative requirements. They account for a small percentage of all Medicare compliance interventions.

I am a GPT1 registrar who billed mainly items 36 and 44 during the first four months, trying my best to be safe, double-checking guidelines and taking time to explain concepts to patients. The time was spent with the patient. Am I at risk of an audit?

DoHDA monitors claiming data, collects intelligence and carries out a range of targeted data analysis to identify potential non-compliance. Audits are undertaken in circumstances where a provider appears to be routinely claiming in a manner that does not meet legislative requirements.

Enforcement action is not taken based on the items claimed alone, with factors such as patient demographics, clinical context, location and other environmental influences considered before any decision to act is made. Providers are also given the opportunity to self-reflect and provide further information to substantiate their claiming.

As a health practitioner, you are responsible for keeping accurate records and being able to produce them to substantiate your Medicare claims if DoHDA requests them as part of a review or audit. Records should:

• clearly identify the name of the patient

• contain a separate entry for each attendance by the patient

• include the date when the service took place

• contain adequate and clear clinical information

• be completed at the time of the service or as soon as possible after.

How are audit repayments calculated?

The Health Insurance Act 1973 enables the recovery of amounts paid in respect of professional services in certain circumstances. For example, a Medicare benefit may be recoverable if a professional service was not rendered in accordance with relevant item requirements.

Once the Chief Executive Medicare or a delegate has assessed the available evidence in an audit, they may decide to claim an amount as a debt due to the Commonwealth. If an amount is claimed, the health provider will be advised in writing, given reasons for the decision, and information about how to apply for a review of the decision.

The Act sets out circumstances in which administrative penalties apply in respect of amounts recoverable as debts due to the Commonwealth. Administrative penalties may be reduced, in part or in full, in certain circumstances. Penalties may be reduced in full where a health provider voluntarily informs the Department, before compliance activity has commenced, that an amount paid exceeds that which should have been paid. Other opportunities for full or partial reduction of penalties are available after compliance activities have commenced and are made clear in relevant communications.

What is the period of review? Will the PSR investigate something from five years ago?

The PSR process begins when the Chief Executive Medicare requests that the PSR Director undertake a review of your provision of services during a specified period (the review period). The review period must be within the two years prior to the request.

How extensive and frequent are any random spot checks and audits for MBS billing?

DoHDA does not undertake random spot checks or audits. The department monitors claiming data, collects intelligence and carries out a range of targeted data analysis to identify potential non-compliance. Audits are undertaken in circumstances where a provider appears to be routinely claiming in a manner that does not meet legislative requirements.

How are PSR repayment amounts calculated? Some of these seem very high.

In arriving at proposed terms for an agreement, the PSR Director will have regard to the likely outcome if your matter were to proceed onto a Committee and the Determining Authority.

The Director may consider:

• the amount expended by the Commonwealth for MBS or Child Dental Benefits Schedule (CDBS) services you provided where the Director considers there to be a possibility of inappropriate practice

• the proportion of possible inappropriate practice in the Director’s review

• the seriousness of the conduct considered to constitute possible inappropriate practice

• any mitigating factors, including your willingness to acknowledge inappropriate practice, and steps taken by you to mitigate the risk of repeating the conduct (for example, undertaking training courses and changes made to your practice since you received notice of the review)

• your circumstances, and whether the totality of the proposed agreement (for example, a combination of a repayment and disqualification) might suit those circumstances

• whether you have any relevant previous PSR history, if applicable

• your submissions as to the appropriate way forward.

The most you could be asked to repay is the amount expended for MBS or CDBS services you provided during the review period for which the Director considers there to be a possibility of inappropriate practice. The Director cannot ask for an additional ‘penalty’ amount.

Consultation time

What activities count toward the consultation time?

MBS Note AN.0.9 includes information on what activities count towards the consultation time. When claiming time-tiered MBS items, the total consultation time includes the time required to communicate effectively with the patient. Where more time than usual is required to communicate effectively with a particular patient, it is considered reasonable to claim a longer attendance item than might otherwise be expected for the service. This applies to both face-to-face and telehealth services.

Communicating effectively with patients is crucial to achieving clinical outcomes and a key part of a clinical service. A wide range of factors may affect the time needed to communicate effectively with a patient during a consultation. These include, but are not limited to, situations where a language barrier exists between the medical practitioner and patient (including when an interpreter is required), or when a patient has hearing problems, difficulty with speech, an intellectual disability, and/or dementia.

In such situations, medical practitioners and other providers should make a brief record in the patient’s notes including details about why the additional time was required. For example, stating ‘consultation extended due to use of interpreter’ and, if relevant, citing the Translating and Interpreting Service (TIS) job number.

When calculating the duration of an attendance for the purpose of item selection, only the time spent in active attention on the patient can be counted. Time spent discussing the patient’s care with, for example, a parent or carer, in the patient’s absence, cannot be counted.

What about adding My Health Record upload time to the consult time with item number claiming?

Time spent reviewing, creating or updating entries in the patient’s My Health Record while the patient is present counts toward the consultation time.

Time taken to write clinical notes, complete forms, reports or other paperwork, upload records in My Health Record (or other systems), or talk to carers or relatives when the patient is not present cannot be included in the consultation time.

Eligible MBS item numbers

Is there any specific list of item numbers that GPs have access to? Especially those that we can claim as well as non-GP specialists.

There is no exhaustive list of all MBS item numbers that GPs are eligible to claim, as this depends on the specific skills and expertise of the individual doctor. Many MBS procedural items do not specify which practitioner is eligible to bill the item, and the GP must determine if they meet the requirements of the descriptor.

You may wish to consult the RACGP’s MBS online tool (member login required), which includes a Full MBS list containing all the items listed in our various MBS guides. This includes a comprehensive list of GP attendance items (face-to-face and telehealth), as well as the most commonly used procedural items by GPs. Given the size of the MBS, there may be other items used by GPs not included in this list.

Opportunistic billing

There are a lot of times where opportunistic health assessments have led me to diagnose chronic undiagnosed asymptomatic conditions, which no one else investigated because the patient presented for one problem and only that was dealt with. Isn’t opportunistic assessment then a good thing?

Opportunistic assessments are appropriate if clinically relevant. A clinically relevant service is one that is generally accepted by the relevant profession as necessary for the appropriate treatment of the patient.

A provider is responsible for determining what services are relevant for their patients. When claiming Medicare benefits for those services, the provider must ensure that all elements of the MBS item descriptor are met.

DoHDA reviews and monitors claiming data to identify patterns that may indicate incorrect, inappropriate, or fraudulent claiming. This includes claiming higher benefit items than the services rendered, adding services to claims that were not required or never performed, or routinely performing services without considering the needs of each patient. Factors such as provider specialty, patient demographics, location, peer comparisons, expert stakeholder insights and broader environmental influences are considered to assess whether there is a reasonable concern.

Medicare benefits are generally not payable for health screening services. A health screening service is defined as a medical examination or test that is not reasonably required for the management of the medical condition of the patient.

What does ‘unbundling’ services mean?

Unbundling refers to billing separate aspects of a service under multiple MBS items when those aspects are already included in a single, comprehensive item. Each MBS item is considered a complete medical service, and claiming individual components separately to maximise benefits is not permitted.

Overseas claiming

If a doctor is overseas and a patient has tests like a pathology holter done during that time (with the referral done prior to travel), how does that work?

If you travel overseas, no MBS services can be provided or supervised using your provider number. If you have referred a patient for tests and these are performed by another practitioner in Australia while you are overseas, under that practitioner’s provider number, you have not breached any rules.

If I work a half day and then fly overseas at 8pm, will I get flagged for being overseas?

Services performed on the date of exit/entry to Australia are not considered a compliance concern. DoHDA’s data matching focuses on items claimed with a date of service where Home Affairs records indicate the provider was out of the country for the full day.

The department does not make compliance decisions based on data matching alone. While unlikely to occur, if a provider was contacted about services performed on the date of exit/entry to Australia, they will be given the opportunity to provide additional information to substantiate their claiming.

If we deactivate our provider number because we are going overseas, what happens when another specialist or radiology or pathology provider tries to provide the service?

The other provider should be using their own provider number for any service they perform. It shouldn’t matter that you have temporarily deactivated your own provider number.

Prescribed pattern of services

Can you explain what 80/20 means in plain English?

The 80/20 rule is a prescribed pattern of services rule. In plain English, it is designed to identify very high daily claiming patterns by medical practitioners. If a provider renders or initiates 80 or more professional attendance services on each of 20 or more days (cumulative, not consequently) within a rolling 12-month period, this may trigger referral to the PSR. Providers should monitor their claiming patterns and ensure all services are clinically relevant, properly documented and meet MBS requirements. Note that the rule is not activated by a single day’s claiming activity. The threshold is reached cumulatively.

Can you explain the 30/20 rule simply?

Any GP, prescribed medical practitioner or consultant physician who claims 30 or more relevant telephone attendance services on each of 20 or more (cumulative and/or consecutive) days in a rolling 12-month period will be in breach of the 30/20 telephone rule. All breaches of the 30/20 rule will be referred to the Director of the PSR.

A full list of MBS items subject to the 30/20 rule is provided in this fact sheet.

Are items 23 and 10990 considered two separate services under the 80/20 rule?

Bulk billing incentive items, including item 10990, are not included in the 80/20 rule.

Record keeping

I want to keep my notes as brief yet adequate as possible to allow me to refer to them as needed. My colleagues tell me that a longer consultation requires a lot more writing, which seems subjective to me.

Records do not need to be lengthy, but they must be adequate and contemporaneous. To be adequate, they should clearly identify the patient, include a separate entry for each attendance, record the date of service, contain enough clinical information to explain the service provided, and be clear enough for another practitioner to understand and rely on for the patient’s ongoing care. To be contemporaneous, the patient or clinical record should be completed at the time the service was rendered or initiated or as soon as practicable afterwards. Longer consultations do not automatically require lengthy notes, but the record must be sufficient to substantiate the item claimed and the clinical relevance of the service.

Services Australia, in consultation with DoHDA, has developed a health practitioner guideline to substantiate that a specific treatment was performed. Information is also provided in MBS Note GN.15.39.

Referrals

How long do indefinite referrals last for?

An indefinite referral does not expire. An indefinite referral is intended to cover the continuing care and management of the original medical condition for which it is written. If a GP agrees to write an indefinite referral, it must be clear to all relevant parties, including the patient’s non-GP specialist or consultant physician, that the referral is for an indefinite period.

An indefinite referral is not intended to cover new medical conditions which arise after the referral has been issued. If the patient develops a condition clinically distinct from the condition for which the patient was originally referred to the non-GP specialist, the patient’s GP can issue a new referral, and a new course of treatment will commence once that referral has been accepted.

Once an indefinite referral has been accepted by a non-GP specialist or consultant physician, that referral cannot be replaced with a referral for a shorter period for the same condition.

Specialists are asking to have their names on referrals, rather than accepting open general referrals. This causes delays and further costs for patients to go back to their GP to amend the referral.

An open referral contains the minimum requirements and can be presented to any specialist practising in the relevant specialty. In some instances, a patient presenting to a public hospital may elect to be treated as private patient. Where this occurs, the specialist must be named on the referral consistent with clause G19 of the National Health Reform Agreement.

A named referral is only required for private services in an outpatient setting. Public hospitals mandating named referrals as a way of claiming MBS items is illegal and should be flagged with DoHDA via the Report suspected fraud online form.

Even where a referral is named, the patient has the right to choose to see a different specialist, provided this decision is made prior to the commencement of treatment under the referral.

Services that cannot be billed to Medicare

There is no item for the service I provided. What can I claim?

General attendance items are claimed for a professional attendance when no other MBS item applies. It is a general principle of the MBS that the item that best describes the service is the item that should be claimed. This means that where a more specific MBS items exists (for example a skin biopsy under MBS item 30071), the more specific item should be claimed. If no other MBS item accurately reflects the service provided, and the requirements of a general attendance item are met, the general attendance item is claimed.

For example, iron infusions may be claimed under a general attendance item that reflects the time spent by the GP in active attention on the patient.

What services do not attract a Medicare benefit?

Medicare generally won’t pay for services that are not part of clinical patient care, are funded by another source, or are specifically excluded. Common GP examples include issuing repeat prescriptions without seeing the patient, insurance and pre-employment medicals, employer-requested assessments, health screening services (commercial driver’s licence, aviation medicals), mass immunisation programs, non-therapeutic cosmetic procedures, and treatment where a public hospital, workers’ compensation insurer, Transport Accident Commission (TAC), or another compensation body is responsible for the cost. It also excludes several specific treatments listed in MBS Note GN.13.33.

Providers may elect to charge a private (non-MBS) fee for such services, where informed financial consent is obtained from the patient, including that no Medicare benefit is payable.

Split billing

Can you split billings, where you privately charge for a procedure with the applicable item number and bulk bill an attendance item number if clinically relevant?

Yes, split billing is generally permissible.

Where multiple services are claimed on the same occasion (excluding diagnostic imaging and surgical operation items subject to specific fee reduction rules), a practitioner may bulk bill some services and privately bill others. This is known as split billing, provided the fee for one item is not reduced or otherwise affected by the claiming of another item.

This type of billing arrangement is distinct from split billing practices that raise transparency concerns, such as separate booking or administration fees that obscure the true cost of care or issuing of two bills (one eligible for MBS rebate and one entirely private) for the same healthcare service (MBS item).

Split billing should not be used where fee reduction rules apply, such as under:

• the Multiple Operation Rule (MOR)

• the diagnostic imaging Multiple Services Rule (DMSR).

In these cases, all affected services should be either bulk billed or privately billed to ensure the patient receives the maximum Medicare benefit payable.

Important reminder

A procedure item generally includes the routine clinical interactions reasonably required to perform that procedure, including:

• consent

• routine pre-operative assessment

• post-operative discussion

• routine aftercare.

An attendance item may only be claimed on the same day if there is a separate and distinct clinically relevant service beyond what is integral to the procedure, or a separate clinical issue is addressed. The requirements of each item must be met in full and supported by clear records.

Telehealth

How can I safely bill telehealth for a patient with a landline?

Telehealth services should only be billed where the relevant telehealth item requirements are met, including mode, patient eligibility and clinical relevance.

For a patient using a landline, the provider should ensure the service is an eligible telephone attendance, the full item descriptor is met, and the record clearly documents the service provided, the date, the clinical issue and any consent or assignment of benefit requirements relevant to the claim.

Note that from 1 March 2025, the term ‘telehealth attendance’ collectively refers to both video and phone attendances. Where an MBS item can only be claimed using a particular telehealth modality, the descriptor will specifically state phone attendance or video attendance. Where no telehealth modality is specified, the service must be provided in-person (face-to-face). Where an item descriptor specifies that the service is to be delivered by video, the provider must maintain a visual and audio link with the patient. Where an item descriptor specifies that the service is to be delivered by phone, then only an audio link is required.

How are the many exclusive telehealth services across the country making sure their billings are compliant with Medicare?

All providers, including services operating primarily or exclusively through telehealth, are responsible for ensuring each Medicare claim is compliant. This includes billing only where the service is clinically relevant, meeting the full item descriptor and MBS rules, maintaining adequate and contemporaneous records, and ensuring the provider can substantiate claims if reviewed. Payment of a claim does not confirm compliance, as claims may be subject to post-payment compliance review.

Workers’ compensation

If a patient’s work claim is not approved and the patient is unable or refuses to pay out of pocket, are GPs allowed to claim through Medicare to cover time spent and services already provided?

Medicare benefits are not payable for medical services related to a compensable injury or illness for which an insurer/compensation agency has accepted liability. However, Medicare benefits may be payable for treatment until the liability is accepted or rejected, as in this case (i.e. during the dispute process). Once liability has been accepted, invoices for treatment should be directed to the insurer under the process determined or agreed with the relevant insurer.

Once the insurer accepts liability, any Medicare benefits paid during the dispute period may be recoverable by the Commonwealth. Such Medicare compensation recovery arrangements are administered by Services Australia.

That said, Medicare benefits should only be claimed where the service is eligible for a Medicare benefit, and all MBS requirements are met. A claim should not be made simply to recover payment where another funding arrangement has not been approved, or the patient does not pay. Providers should consider whether the service is excluded from Medicare or subject to another compensation arrangement before claiming, and should keep records that support the basis for any Medicare claim.