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We’ve provided these scenarios for example purposes only.
Complete medical service
Each professional service listed in the MBS is a complete medical service.
A complete medical service covers all components required to perform the service described. There are also items that describe comprehensive or combined services. This means the item includes other individual services which are essential to that complete medical service.
If you bill a comprehensive or combined item, you can’t also bill the individual services that make up these items.
If more than one item covers a service, you need to understand each item’s description and requirements. This will help you bill the correct item and prevent claiming errors.
Item descriptions relevant to your procedure:
- MBS item A - open tenotomy of foot, with or without tenoplasty
- MBS item B - correction of contracted joint, involving tissues deeper than skin and subcutaneous tissue
- MBS item C - foot, correction of claw or hammer toe.
Cutting the tendon (item A) and correcting the contracted joint (item B) are essential procedures in correcting a claw or hammer toe (item C).
This means you only bill comprehensive service MBS item C if performed on the same toe. You can’t bill the other individual procedure items.
Your patient is referred for 2 Computed Tomography (CT) services. The item descriptions say:
- MBS item D - scan of brain without intravenous contrast medium
- MBS item E - scan of facial bones, without intravenous contrast medium
- MBS item F - scan of facial bones with scan of brain, without intravenous contrast medium.
Both scan of the brain (item D) and scan of the facial bones (item E) are described in a combined service (item F).
This means you can only bill combined service MBS item F when they’re performed on the same occasion. You can’t bill the individual imaging items.
Multiple attendances on the same day
You can bill multiple attendances for the same patient on the same day if:
- they’re separate attendances with a reasonable lapse of time between them
- the subsequent attendances aren’t a continuation of the other attendances.
You see a patient to treat a sore throat in the morning. The same patient returns at 4 pm the same day seeking treatment for a sprained ankle.
You can bill the appropriate attendance item for each attendance. The second attendance was not a continuation of the earlier consultation. There was a reasonable lapse of time between the 2 visits.
Make note of the time of each attendance on the account or include service text for electronic claims. This will help us assess the claim.
You see a patient for a preliminary eye examination with the instillation of mydriatic. The patient returns after 30 minutes and you undertake an eye refraction.
You can only bill one attendance item. The second visit was a continuation of the first attendance.
Encourage patients presenting with multiple clinical matters to book a separate consultation.
If urgent clinical treatment is required and another attendance is unrelated to the vaccine assessment item, you can bill both items. You must meet requirements of both services.
Make a note on the account or include service text for electronic claims. Suitable text may include:
- times of each attendance
- ‘Unrelated to COVID-19 assessment’ on the attendance item.
This helps us assess the claim.
Read more about MBS COVID-19 Vaccine Support Services on the MBS online website.
Attendances with other health services
You can bill attendance items in association with another MBS item if:
- the attendance is clinically relevant
- you meet the item description of all items.
There are certain restrictions that prevent billing attendance items in association with other MBS items.
You can’t count the time spent performing non-attendance items when selecting the appropriate attendance item to bill.
You can’t bill an attendance item with an item containing one of the following phrases in the item description:
- ‘each attendance’
- ‘attendance at which’
- ‘including associated consultation’.
These items already include an attendance.
You see a patient for a consultation before performing electroconvulsive therapy.
The description says, ‘MBS item G - Electroconvulsive therapy, with or without the use of stimulus dosing techniques, including any electroencephalographic monitoring and associated consultation’.
You can’t bill a consultation item because this service is included in the item description.
Read more about co-claiming restrictions.
Magnetic Resonance Imaging (MRI) scans
You can’t claim a consultation in conjunction with MRI scans at the same attendance.
The following consultation items restrict with MRI scan items:
- 52
- 53
- 54
- 57
- 104
- 105.
Your consultation is payable if you determine it’s necessary for the treatment of your patient’s condition.
You’ll need to provide supporting text with your claim indicating the need for the consultation.
You perform an MRI scan. You can consider item 52, 53, 54, 57, 104 or 105 at the same attendance if the following apply:
- you need to consult with your patient to alter, or potentially alter, the course of your patient’s management and treatment
- you take primary responsibility for the management decisions made during the consultation
- the consultation includes components of history taking, physical examination, discussion with the patient, formulation of management plans and referral for additional opinions or tests.
You must have a referral to bill specialist referred consultation items 104 or 105 that’s different from the request for the MRI.
Independent procedure
There are MBS item descriptions that include the phrase ‘as an independent procedure’. Medicare benefits are not payable for both an item containing this phrase and another procedure where either:
- you perform the procedure through the same incision as another procedure
- the procedure occurs in the same body area as another procedure
- one procedure is an integral part of another procedure.
If the independent procedure isn’t an integral part of another procedure you’ve performed, check the description of all the items you performed on the same occasion. This will help you determine if you can bill the independent procedure.
If any of the items mention a body area or part, you can only bill the independent procedure if you performed the service on a different body area. If the independent procedure meets this requirement, notate ‘separate body area’ or similar in either the:
- account
- claim text.
If the items don’t mention a body area or part and you performed it through a separate incision, you can bill the independent procedure. Make sure you note ‘separate incision’ or similar on the account or claim text.
You perform a knee reconstruction on your patient. On the same occasion you excise a cyst on the same knee, through a separate incision.
The item descriptions say:
- MBS item H - arthroplasty of knee
- MBS item I - excision of cyst, by open or arthroscopic means, performed as an independent procedure.
Because you performed both services on the same body part described in arthroplasty item H, you can only bill that item. This is true even though you performed the procedures through separate incisions.
You see a patient to remove a subcutaneous foreign body from their left arm. On the same occasion, you insert a hormonal implant in the same arm, through another incision.
The item descriptions say:
- MBS item J - removal of subcutaneous foreign body, requiring incision and exploration, including closure of wound if performed, as an independent procedure
- MBS item K - hormone implantation by cannula.
Because the items don’t specify a body area and you’ve used separate incisions, you can bill both items.
To help us assess the claim, include a note on the account or text indicating ‘separate incisions’ or similar.
Associated services
Some MBS item descriptions prevent us paying Medicare benefits when the service is performed in association and on the same occasion with either:
- a specific MBS item number or item range
- another MBS item within the same group
- another MBS item within the same subgroup
- a similar type of service or procedure.
For example, some item descriptions include ‘not being a service associated with a service to which another item in this group applies’. This means that we can’t pay Medicare benefits when you perform another item from the same group on the same occasion.
Some item descriptions include ‘not being a service associated with a service to which another item in this subgroup applies’. This means we can’t pay Medicare benefits when you perform any other item in the same subgroup on the same occasion.
Other common phrases found in MBS item descriptions with similar definitions include:
- ‘not being a service associated with a service to which item xxx applies’
- ‘not in association with item xxx’
- ‘other than a service associated with a service to which item xxx applies’
- ‘not in conjunction with item xxx’.
You perform 2 laparoscopy services on the same occasion.
The item descriptions say:
- MBS item L - laparoscopy, diagnostic, not being a service associated with any other laparoscopic procedure
- MBS item M - laparoscopy appendectomy.
You can only bill item M because:
- it’s another laparoscopic procedure
- item L doesn’t attract a Medicare benefit with any other laparoscopic procedure performed on the same occasion.
You perform 2 procedures under the same anaesthetic.
The item descriptions say:
- MBS item N - laparoscopy, diagnostic, not being a service associated with any other laparoscopic procedure
- MBS item O - cervical dilatation and uterine curettage.
You can bill both services, as the second service is not a laparoscopic procedure.
You perform a diagnostic laparoscopy at 9 am and a laparoscopic splenectomy at 7 pm on the same day.
The description for the item performed at 9 am states ‘not being a service associated with any other laparoscopic procedure’.
You can bill both laparoscopic procedures because the services were performed:
- on separate occasions
- under different anaesthetics.
Not being a service to which another item in this group or subgroup applies
You can only bill an item with one of the phrases below if there isn’t a more specific item for the service:
- ‘not being a service to which another item in this group applies’
- ‘not being a service to which another item in this subgroup applies’
- ‘other than a service to which another item in the table applies’
- ‘other than a service to which any other item applies’.
These phrases often apply to items that describe a service in generic terms. If another item exists that describes the service more specifically, use that item.
You should only use generically described items if:
- the service is clinically relevant
- the service meets the item description and no other MBS item describes the service.
You can bill other MBS items for additional services performed on the same occasion.
You treat a patient for an aneurysm of iliac artery by grafting a replacement. You consider billing an MBS item as it describes the service performed. When checking Subgroup 3 under T8 - Surgical Operations, you find another item which describes the service more specifically.
The item description says:
- MBS item P - replacement by graft for aneurysm of major artery, not being a service to which another item in this subgroup applies
- MBS item Q - unilateral replacement by graft for aneurysm of iliac artery.
You can bill MBS item Q as it describes the procedure performed. You should only use the less specific first item when no other item within Subgroup 3 describes the procedure.