Requirements of services for complex neurodevelopmental disorders and eligible disabilities

Patient eligibility

Your patient must be under 25 years of age to have:

allied health Medicare Benefits Schedule (MBS) items for assistance in diagnosing your patient or contributing to a treatment plan
a treatment and management plan prepared by a specialist, consultant physician or general practitioner
allied health MBS items for treatment services.

Complex neurodevelopmental disorders

A complex neurodevelopmental disorder covers patients who’ll require support across multiple domains.

Diagnosing a complex neurodevelopmental disorder requires:

evidence that support is needed
impairment across 2 or more neurodevelopmental domains with complex multi-domain cognitive and functional disabilities.

It’s up to the diagnosing practitioner’s clinical judgement whether their patient meets the definition of a complex neurodevelopmental disorder.

Check patient eligibility and look up item numbers through the MBS items online checker in Health Professional Online Services (HPOS). Read about the relevant MBS item descriptions at MBS Online website.

Eligible disabilities

Eligible disabilities include:

sensory problems such as hearing and vision impairment
chromosomal disorders such as Fragile X syndrome
conditions with multiple causes such as cerebral palsy.

Hearing and sight loss

Hearing loss is an eligible disability if the patient has either:

a hearing loss of 40 decibels or greater in the better ear, across 4 frequencies
permanent conductive hearing loss and auditory neuropathy.

Sight loss is an eligible disability if it results in vision of less than or equal to 6/18 vision or equivalent field loss in the better eye, with correction.

Deafblindness is also eligible.

Microcephaly

Microcephaly is an eligible disability if a child has both of the following:

a head circumference less than the third percentile for age and sex
a functional level at or below 2 standard deviations below the mean for age on a standard development test or an IQ score of less than 70 on a standardised test of intelligence.

When diagnosing children with microcephaly a standard developmental test refers to either:

a Bayley Scales of Infant Development
the Griffiths Mental Development Scales standard development test.

A standardised test of intelligence refers to:

the Wechsler Intelligence Scale for Children
the Wechsler Preschool and Primary Scale of Intelligence.

It’s up to the diagnosing practitioner’s clinical judgement whether other tests are appropriate.

Other eligible disabilities

Other eligible disabilities include:

Cerebral palsy
Down syndrome
Fragile X syndrome
Prader-Willi syndrome
Williams syndrome
Angelman syndrome
Kabuki syndrome
Smith-Magenis syndrome
CHARGE syndrome
Cri du Chat syndrome
Cornelia de Lange syndrome
Rett’s disorder
Fetal Alcohol Spectrum Disorder (FASD)
Lesch-Nyhan syndrome
22q deletion syndrome.

MBS Billing and claiming

To be eligible for Medicare benefits:

you, as the medical practitioner or allied health professional, must provide all services to the eligible patient personally
you must provide the service to a single patient on a single occasion
your patient must be present for all services provided.

Where clinically appropriate, medical practitioners and allied health professionals can use telehealth video and phone consultations.

Allied health services don’t attract Medicare benefits until we’ve paid the prerequisite medical practitioner item.

Allied health professionals must provide allied health assessment and treatment items as non-admitted or outpatient services.

Read about billing Complex Neurodevelopmental Disorders and eligible disabilities.

Referrals to allied health professionals

There’s no specific referral form for allied health services. A signed and dated referral letter or note that includes the required number of services is acceptable.

Your patient needs a separate referral for each allied health professional they’re referred to. They also need a separate referral for assessment and diagnosis services.

Referrals for allied health treatment services can include up to 10 services per course of treatment. A maximum limit of 4 allied health services per day applies for the eligible patient.

You must retain referrals and management plans for 2 years.

At the end of each stage, the responsible health professional should provide a written document. This could be a referral, a treatment plan or a report.

If you’re an allied health professional, reports to the referring medical practitioner should include:

assessments carried out
treatment provided
recommendations on future management for your patient’s disability
advice given to third parties, for example, parents and schools.

Treatment and management plan

Treatment and management plans must include an assessment and diagnosis of a patient’s condition and a risk assessment.

The risk assessment should cover:

risk of contributing co-morbidity
environmental, physical, social and emotional risk factors that may apply to your patient or to another individual.

The treatment and management plan must also include treatment options and decisions and recommendations for medicine if required.

If you’ve allocated treatment services to allied health professionals, you must give them a copy of the completed treatment and management plan along with the referral. If you’re a specialist or consultant physician, you should also give a copy of the treatment and management plan to the initial referring health professional.

Review and follow up

MBS items are available to review plans or provide additional referrals for the following:

specialists
consultant physicians
general practitioners.

You can check eligibility and look up item numbers through the MBS items online checker in HPOS. Read about the relevant MBS item descriptions on the MBS Online website.

You can read more information and view infographic resources about complex neurodevelopment disorders and eligible disabilities on the Health Professional Education Resources website.

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