Changes to the Medicare Benefits Schedule: What GPs need to know

Morgan Liotta

18/10/2018 11:17:55 AM

A number of changes to the Medicare Benefits Schedule will be implemented from 1 November.

The GP-related MBS changes pertain to referrals for respiratory function and sleep studies, skin-prick testing and dermatology items, and plastic and reconstructive surgery items.
The GP-related MBS changes pertain to referrals for respiratory function and sleep studies, skin-prick testing and dermatology items, and plastic and reconstructive surgery items.

The Department of Health (DoH) has announced several changes to the Medicare Benefits Schedule (MBS), a number of which will affect general practice. These relate to:

  • GP referrals for respiratory function and sleep studies
  • skin-prick testing and dermatology items
  • plastic and reconstructive surgery items.
The revised structure of the MBS items was based on recommendations from the MBS Review Taskforce. These changes are outlined below.
GP referrals for respiratory function and sleep studies

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 on each occasion where three or more spirometry recordings are made and is applicable for a patient once per year.
  • Item 11506 for monitoring can be billed on each occasion where spirometry recordings are made.
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.

In order to directly refer patients for a diagnostic home or laboratory-based sleep study to confirm a diagnosis of sleep apnoea, GPs will need to use approved assessment tools, which include either one of the below:
  • STOP-BANG score ≥4
  • OSA50 score ≥5
  • Berlin Questionnaire – high risk
Plus an Epworth Sleepiness Scale score ≥8.

Preparing a referral
There is no requirement for referrals to be made to a specific specialist or consultant physician. There is also nothing to prevent a referral being addressed to a non-named specialist, such as a business, as long as the referral includes the:
  • relevant clinical information about the patient’s condition for investigation, opinion, treatment and/or management
  • date of referral
  • 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.
MBS Online has published more information about the respiratory function (including new item descriptors) and sleep studies changes.

Skin-prick testing and dermatology items
As announced as part of the 2018–19 Federal Budget, the Government has accepted a suite of dermatology item recommendations put forward by the MBS Review Taskforce.

Updates to skin-prick testing items are intended to discourage testing for more than 20 allergens at a time and to align with clinical guidelines, which recommend testing for specifically chosen allergens.
Allergen-testing items will be restructured into separate items for environmental, food and latex, medication, and anaesthetic-related allergies. Doctors (excluding dermatologists) will be able to bill two aeroallergen skin-prick testing services per 12-month period. Dermatologists will be able to bill multiple aeroallergen skin-prick testing services.
Visit the DoH website for more information.

Plastic and reconstructive surgery items
The DoH dissolved the Medicare Claims Review Panel (MCRP) in September. The MCRP was responsible for assessing doctors’ claims for various MBS items that require demonstration of clinical need before Medicare benefits are payable, many of which are for potentially cosmetic services.
With the dissolution of the MCRP, the Government has amended a number of plastic and reconstructive surgery items to align them with appropriate clinical practice. GPs who claim these services will no longer need to seek assessment by the MCRP on their clinical relevance.

The changes include amending the item for:
  • the correction of congenital deformities of the ear, such as ‘bat ear’ (item 45659). The amendment clarifies the clinical indications for the procedure, limited to in-hospital only procedures and restricted to patients less than 18 years of age to help prevent cosmetic misuse
  • upper-eyelid reduction (item 45617) to specify where the indication for surgery is skin redundancy causing a visual field defect. The item will require confirmation by an optometrist or ophthalmologist. It is expected that patient records will include photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service.
MBS Online has published more information about the changes to plastic and reconstructive surgery items (including new item descriptors).

GP resource
The RACGP’s Medicare Benefits Schedule (MBS) fee summary is designed to provide a quick and easy reference to Medicare item numbers and patient rebates relevant to general practice. A one-page guide covering the most commonly used items in general practice is also available.

fee summary MBS review taskforce Medicare Benefits Schedule

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Dr Arshad Merchant   19/10/2018 6:49:30 AM

This is to demoralise the GPs & support specialists.. where is RACGP stand?? The time has come when RACGP stop the MBS bull billing & introduce realist CPI base payment structure

Daniel Byrne   19/10/2018 9:02:57 AM

Thanks for the update and the links to further resources.
Much appreciated.

Kerry Hancock   19/10/2018 10:12:04 AM

Re Spirometry item numbers - please note that pre and post bronchodilator tests are still required for both item numbers. For the new 11505 item number in order to meet quality requirements to make or confirm a diagnosis then patients must have three acceptable tests for each testing period (pre/post bronchodilator), and meet repeatability criteria with the best effort recorded. Spirometry should be performed by a person who has undergone training and is qualified to perform it to recommended standards.
(hope that link work!)