Australian Government
Department of Health
Medicare Benefits Schedule Book
Category 1
Operating from 01 November 2016
Online ISBN: 978-1-76007-226-1
Publications approval number: 11291
Copyright Statements:
Paper-based publications
© Commonwealth of Australia 2015
This work is copyright. You may reproduce the whole or part of this work in unaltered form for your own personal use or, if you are part of an organisation, for internal use within your organisation, but only if you or your organisation do not use the reproduction for any commercial purpose and retain this copyright notice and all disclaimer notices as part of that reproduction. Apart from rights to use as permitted by the Copyright Act 1968 or allowed by this copyright notice, all other rights are reserved and you are not allowed to reproduce the whole or any part of this work in any way (electronic or otherwise) without first being given the specific written permission from the Commonwealth to do so. Requests and inquiries concerning reproduction and rights are to be sent to the Online, Services and External Relations Branch, Department of Health, GPO Box 9848, Canberra ACT 2601, or via e-mail to .
Internet sites
© Commonwealth of Australia 2015
This work is copyright. You may download, display, print and reproduce the whole or part of this work in unaltered form for your own personal use or, if you are part of an organisation, for internal use within your organisation, but only if you or your organisation do not use the reproduction for any commercial purpose and retain this copyright notice and all disclaimer notices as part of that reproduction. Apart from rights to use as permitted by the Copyright Act 1968 or allowed by this copyright notice, all other rights are reserved and you are not allowed to reproduce the whole or any part of this work in any way (electronic or otherwise) without first being given the specific written permission from the Commonwealth to do so. Requests and inquiries concerning reproduction and rights are to be sent to the Online, Services and External Relations Branch, Department of Health, GPO Box 9848, Canberra ACT 2601, or via e-mail to .
At the time of printing, the relevant legislation giving authority for the changes included in this edition of the book may still be subject to the approval of Executive Council and the usual Parliamentary scrutiny. This book is not a legal document, and, in cases of discrepancy, the legislation will be the source document for payment of Medicare benefits.3
TABLE OF CONTENTS
G.1.1. The Medicare Benefits Schedule - Introduction 8
G.1.2. Medicare - an outline 8
G.1.3. Medicare benefits and billing practices 8
G.2.1. Provider eligibility for Medicare 9
G.2.2. Provider Numbers 10
G.2.3. Locum tenens 10
G.2.4. Overseas trained doctor 10
G.2.5. Contact details for the Department of Human Services 11
G.3.1. Patient eligibility for Medicare 11
G.3.2. Medicare cards 11
G.3.3. Visitors to Australia and temporary residents 11
G.3.4. Reciprocal Health Care Agreements 11
G.4.1. General Practice 12
G.5.1. Recognition as a Specialist or Consultant Physician 13
G.5.2. Emergency Medicine 14
G.6.1. Referral Of Patients To Specialists Or Consultant Physicians 14
G.7.1. Billing procedures 17
G.8.1. Provision for review of individual health professionals 17
G.8.2. Medicare Participation Review Committee 18
G.8.3. Referral of professional issues to regulatory and other bodies 19
G.8.4. Comprehensive Management Framework for the MBS 19
G.8.5. Medical Services Advisory Committee 19
G.8.6. Pathology Services Table Committee 19
G.8.7. Medicare Claims Review Panel 19
G.9.1. Penalties and Liabilities 19
G.10.1. Schedule fees and Medicare benefits 20
G.10.2. Medicare safety nets 21
G.11.1. Services not listed in the MBS 21
G.11.2. Ministerial Determinations 22
G.12.1. Professional services 22
G.12.2. Services rendered on behalf of medical practitioners 22
G.12.3. Mass immunisation 23
G.13.1. Services which do not attract Medicare benefits 23
G.14.1. Principles of interpretation of the MBS 25
G.14.2. Services attracting benefits on an attendance basis 25
G.14.3. Consultation and procedures rendered at the one attendance 25
G.14.4. Aggregate items 26
G.14.5. Residential aged care facility 26
G.15.1. Practitioners should maintain adequate and contemporaneous records 26
A.1.. Personal Attendance by Practitioner 29
A.2.. Professional Attendances 29
A.3.. Services not Attracting Medicare Benefits 29
A.4.. Multiple Attendances on the Same Day 29
A.5.. Attendances by General Practitioners (Items 3 to 51, 193, 195, 197, 199, 597, 599, 2497-2559 and 5000-5067) 29
A.6.. Professional Attendances at an Institution (Items 4, 24, 37, 47, 58, 59, 60, 65, 5003, 5023, 5043, 5063, 5220, 5223, 5227 and 5228) 31
A.7.. Attendances at a Hospital (Items 4, 24, 37, 47, 58, 59, 60, 65) 31
A.8.. Residential Aged Care Facility Attendances (Items 20, 35, 43, 51, 92, 93, 95, 96, 5010, 5028, 5049, 5067, 5260, 5263, 5265, 5267) 31
A.9.. Attendances at Hospitals, Residential Aged Care Facility and Institutions and Home Visits 31
A.10.. After-Hours Attendances (Items 597, 598, 599, 600, 5000, 5003, 5010, 5020, 5023, 5028, 5040, 5043, 5049, 5060, 5063, 5067, 5220, 5223, 5228, 5260, 5263 and 5265) 31
A.11.. Minor Attendance by a Consultant Physician (Items 119, 131) 33
A.12.. Referred Patient Consultant Physician Treatment and Management Plan (Items 132 and 133) 33
A.13.. Referred patient assessment, diagnosis and treatment and management plan for autism or any other pervasive developmental disorder (items 135 and 289) 34
A.14.. Patient Assessment, Diagnosis and Treatment and Management Plan for a Child with Disability (Items 137 and 139) 36
A.15.. Geriatrician Referred Patient Assessment and Management Plan (Items 141-147) 37
A.16.. Prolonged Attendance in Treatment of a Critical Condition (Items 160 164) 37
A.17.. Family Group Therapy (Items 170, 171, 172) 38
A.18.. Acupuncture (Item 173, 193, 195, 197 and 199) 38
A.19.. Consultant Psychiatrist - Initial consultations for NEW PATIENTS (Items 296 to 299 and 361) Referred Patient Assessment and Management Plan (Items 291, 293 and 359) and referral to Allied Mental Health Professionals 38
REFERRED PATIENT ASSESSMENT AND MANAGEMENT PLAN 39
A.20.. Psychiatric Attendances (Item 319) 41
A.21.. Interview of Person other than a Patient by Consultant Psychiatrist (Items 348, 350, 352) 41
A.22.. Consultant Occupational Physician Attendances (Items 385 to 388) 42
A.23.. Contact Lenses (Items 10801-10809) 42
A.24.. Refitting of Contact Lenses (Item 10816) 42
A.25.. Health Assessments (Items 701, 703, 705, 707) 42
A.26.. Health Assessment provided as a type 2 diabetes risk evaluation for people aged 40-49 years with a high risk of developing type 2 diabetes as determined by the Australian Type 2 Diabetes Risk Assessment Tool 44
A.27.. Health Assessment provided for people aged 45-49 years who are at risk of developing chronic disease 45
A.28.. Health Assessment provided for people aged 75 years and older 45
A.29.. Health Assessment provided as a comprehensive medical assessment for residents of residential aged care facilities 46
A.30.. Health Assessment provided for people with an intellectual disability 46
A.31.. Health Assessment provided for refugees and other humanitarian entrants 47
A.32.. Health Assessment for Aboriginal and Torres Strait Islander People (MBS Item 715) 47
A.33.. A Health Assessment for an Aboriginal and Torres Strait Islander child (less than 15 years of age) 49
A.34.. A health assessment for an Aboriginal and Torres Strait Islander adult (aged between 15 years and 54 years) 49
A.35.. A health assessment for an Aboriginal and Torres Strait Islander older person (aged 55 years and over) 50
A.36.. Chronic Disease Management Items (Items 721 to 732) 51
A.37.. Medicare Dental Items For Patients With Chronic Conditions And Complex Care Needs - Services Provided By A Dental Practitioner On Referral From A GP [Items 85011-87777] 54
A.38.. Multidisciplinary Case Conferences by Medical Practitioners (Other Than Specialist or Consultant Physician) - (Items 735 to 758) 54
A.39.. Public Health Medicine - (Items 410 to 417) 55
A.40.. Case Conferences by Consultant Physician - (Items 820 to 838, 6029 to 6034 and 6064 to 6075) 55
A.41.. Medication Management Reviews - (Items 900 and 903) 57
A.42.. Taking a Cervical Smear from a Person who is Unscreened or Significantly Under-screened - (Items 2497 - 2509 and 2598 - 2616) 60
A.43.. Completion of the Annual Diabetes Cycle of Care for Patients with Established Diabetes Mellitus - (Items 2517 - 2526 and 2620 - 2635) 61
A.44.. Completion of the Asthma Cycle of Care - (Items 2546 - 2559 and 2664 - 2677) 62
A.45.. GP Mental Health Treatment Items - (Items 2700 to 2717) 63
A.46.. Provision of Focussed Psychological Strategies - (Items 2721 to 2727) 68
A.47.. Pain and Palliative Medicine (Items 2801 to 3093) 69
A.48.. Telepsychiatry - (Items 353 to 370) 70
A.49.. Attendances by Medical Practitioners who are Emergency Physicians - (Items 501 to 536) 71
A.50.. Prolonged Attendance by an Emergency Physician in Treatment of a Critical Condition - (Items 519 to 536) 72
A.51.. Case Conferences by Consultant Psychiatrists - (Items 855 to 866) 72
A.52.. Case Conference by Consultant Physicians in Geriatric/Rehabilitation Medicine - (Item 880) 73
A.53.. Neurosurgery Specialist Referred Consultation - (Items 6007 to 6015) 74
A.54.. Cancer Care Case Conference - (Items 871 and 872) 75
A.55.. Non-directive Pregnancy Support Counselling Service - (Item 4001) 75
A.56.. Telehealth Patient-end Support Services by Health Professionals 76
A.57.. Telehealth Specialist Services 78
A.58.. Australian Defence Force Post-discharge GP Health Assessment 80
O.1.. Benefits For Services 80
O.2.. Provider Numbers 81
O.3.. Patient Eligibility 81
Medicare Cards 81
Visitors to Australia and temporary residents 81
Reciprocal Health Care Agreements 82
O.4.. Benefits For Optometrists 82
O.5.. Schedule Fees and Medicare Benefits 83
O.6.. Billing Procedures 88
O.7.. Referrals (Read in Connection with the Relevant Paragraphs at O.6) 91
O.8.. Provision for Review of the Schedule 92
O.9.. Provision for Review of Practitioner Behaviour 92
O.10.. Visiting Optometrists Scheme (VOS) 94
O.11.. Telehealth Patient-end Support Services by Optometrists 94
GROUP A1 - GENERAL PRACTITIONER ATTENDANCES TO WHICH NO OTHER ITEM APPLIES 105
LEVEL A 105
LEVEL B 105
LEVEL C 106
LEVEL D 106
GROUP A2 - OTHER NON-REFERRED ATTENDANCES TO WHICH NO OTHER ITEM APPLIES 108
SUBGROUP 1 - OTHER MEDICAL PRACTITIONER ATTENDANCES 108
CONSULTATION AT CONSULTING ROOMS 108
CONSULTATION AT A PLACE OTHER THAN CONSULTING ROOMS OR A RESIDENTIAL AGED CARE FACILITY 108
CONSULTATION AT A RESIDENTIAL AGED CARE FACILITY 108
GROUP A3 - SPECIALIST ATTENDANCES TO WHICH NO OTHER ITEM APPLIES 110
GROUP A4 - CONSULTANT PHYSICIAN ATTENDANCES TO WHICH NO OTHER ITEM APPLIES 111
GROUP A3 - SPECIALIST ATTENDANCES TO WHICH NO OTHER ITEM APPLIES 112
GROUP A4 - CONSULTANT PHYSICIAN ATTENDANCES TO WHICH NO OTHER ITEM APPLIES 113
GROUP A29 - EARLY INTERVENTION SERVICES FOR CHILDREN WITH AUTISM, PERVASIVE DEVELOPMENTAL DISORDER OR DISABILITY 115
GROUP A28 - GERIATRIC MEDICINE 117
GROUP A5 - PROLONGED ATTENDANCES TO WHICH NO OTHER ITEM APPLIES 121
PROLONGED PROFESSIONAL ATTENDANCE 121
GROUP A6 - GROUP THERAPY 122
GROUP A7 - ACUPUNCTURE 123
LEVEL A 123
LEVEL B 123
LEVEL C 123
LEVEL D 124
GROUP A8 - CONSULTANT PSYCHIATRIST ATTENDANCES TO WHICH NO OTHER ITEM APPLIES 125
GROUP A12 - CONSULTANT OCCUPATIONAL PHYSICIAN ATTENDANCES TO WHICH NO OTHER ITEM APPLIES 132
GROUP A13 - PUBLIC HEALTH PHYSICIAN ATTENDANCES TO WHICH NO OTHER ITEM APPLIES 134
PUBLIC HEALTH PHYSICIAN ATTENDANCES - AT CONSULTING ROOMS 134
PUBLIC HEALTH PHYSICIAN ATTENDANCES - OTHER THAN AT CONSULTING ROOMS 134
GROUP A21 - MEDICAL PRACTITIONER (EMERGENCY PHYSICIAN) ATTENDANCES TO WHICH NO OTHER ITEM APPLIES 136
SUBGROUP 1 - CONSULTATIONS 136
SUBGROUP 2 - PROLONGED PROFESSIONAL ATTENDANCES TO WHICH NO OTHER GROUP APPLIES 137
GROUP A11 - URGENT ATTENDANCE AFTER HOURS 138
SUBGROUP 1 - URGENT ATTENDANCE - AFTER HOURS 138
SUBGROUP 2 - URGENT ATTENDANCE UNSOCIABLE AFTER HOURS 138
GROUP A14 - HEALTH ASSESSMENTS 139
HEALTH ASSESSMENTS 139
ABORIGINAL AND TORRES STRAIT ISLANDER PEOPLES HEALTH ASSESSMENT 140
GROUP A15 - GP MANAGEMENT PLANS, TEAM CARE ARRANGEMENTS, MULTIDISCIPLINARY CARE PLANS 141
SUBGROUP 1 - GP MANAGEMENT PLANS, TEAM CARE ARRANGEMENTS AND MULTIDISCIPLINARY CARE PLANS 141
SUBGROUP 2 - CASE CONFERENCES 143
GROUP A17 - DOMICILIARY AND RESIDENTIAL MANAGEMENT REVIEWS 147
GROUP A30 - MEDICAL PRACTITIONER (INCLUDING A GENERAL PRACTITIONER, SPECIALIST OR CONSULTANT PHYSICIAN) TELEHEALTH ATTENDANCES 148
SUBGROUP 1 - TELEHEALTH ATTENDANCE AT CONSULTING ROOMS, HOME VISITS OR OTHER INSTITUTIONS 148
SUBGROUP 2 - TELEHEALTH ATTENDANCE AT A RESIDENTIAL AGED CARE FACILITY 148
SUBGROUP 1 - TELEHEALTH ATTENDANCE AT CONSULTING ROOMS, HOME VISITS OR OTHER INSTITUTIONS 149
SUBGROUP 2 - TELEHEALTH ATTENDANCE AT A RESIDENTIAL AGED CARE FACILITY 149
SUBGROUP 1 - TELEHEALTH ATTENDANCE AT CONSULTING ROOMS, HOME VISITS OR OTHER INSTITUTIONS 150
SUBGROUP 2 - TELEHEALTH ATTENDANCE AT A RESIDENTIAL AGED CARE FACILITY 150
SUBGROUP 1 - TELEHEALTH ATTENDANCE AT CONSULTING ROOMS, HOME VISITS OR OTHER INSTITUTIONS 151
SUBGROUP 2 - TELEHEALTH ATTENDANCE AT A RESIDENTIAL AGED CARE FACILITY 151
GROUP A18 - GENERAL PRACTITIONER ATTENDANCE ASSOCIATED WITH PIP INCENTIVE PAYMENTS 152
SUBGROUP 1 - TAKING OF A CERVICAL SMEAR FROM AN UNSCREENED OR SIGNIFICANTLY UNDERSCREENED PERSON 152
LEVEL A 152
LEVEL B 152
LEVEL C 152
LEVEL D 153
SUBGROUP 2 - COMPLETION OF A CYCLE OF CARE FOR PATIENTS WITH ESTABLISHED DIABETES MELLITUS 154
LEVEL B 154
LEVEL C 154
LEVEL D 155
SUBGROUP 3 - COMPLETION OF THE ASTHMA CYCLE OF CARE 155
LEVEL B 155
LEVEL C 156
LEVEL D 156
GROUP A19 - OTHER NON-REFERRED ATTENDANCES ASSOCIATED WITH PIP INCENTIVE PAYMENTS TO WHICH NO OTHER ITEM APPLIES 157
SUBGROUP 1 - TAKING OF A CERVICAL SMEAR FROM AN UNSCREENED OR SIGNIFICANTLY UNDERSCREENED PERSON 157
SUBGROUP 2 - COMPLETION OF AN ANNUAL CYCLE OF CARE FOR PATIENTS WITH ESTABLISHED DIABETES MELLITUS 158
SUBGROUP 3 - COMPLETION OF THE ASTHMA CYCLE OF CARE 159
GROUP A20 - GP MENTAL HEALTH TREATMENT 161
SUBGROUP 1 - GP MENTAL HEALTH TREATMENT PLANS 161
SUBGROUP 2 - FOCUSSED PSYCHOLOGICAL STRATEGIES 162
GROUP A24 - PAIN AND PALLIATIVE MEDICINE 164
SUBGROUP 1 - PAIN MEDICINE ATTENDANCES 164
SUBGROUP 2 - PAIN MEDICINE CASE CONFERENCES 165
SUBGROUP 3 - PALLIATIVE MEDICINE ATTENDANCES 167
SUBGROUP 4 - PALLIATIVE MEDICINE CASE CONFERENCES 168
GROUP A27 - PREGNANCY SUPPORT COUNSELLING 170