Education guide - Multi-item billing

Information for health professionals about when multi-item billing is or is not appropriate.

These scenarios are designed to help you understand when multi-item billing is or is not appropriate.

We recommend you also read the relevant Medicare Benefits Schedule (MBS) item descriptors and explanatory notes available at the MBS Online website.

Multiple attendances on the same day

Payment of benefit may be made for each of several attendances on a patient on the same day by the same medical practitioner provided the subsequent attendances are not a continuation of the initial or earlier attendances.

Scenario - Separate attendances

A patient sees a general practitioner (GP) at 9.00am to seek treatment for a sore throat. The same patient returns at 4.00pm the same day seeking treatment for a sprained ankle.

In this case, 2 attendance items are payable on the 1 day because the second attendance is not a continuation of the earlier consultation. The GP can bill the appropriate attendance item for each occasion. The time of each attendance should be written on the account or included in the service text of an electronic claim to us assess the benefits.

Scenario - Continuation of the initial or earlier attendance

A patient sees a GP and is given a prescription for a vaccine. The patient returns the same day to have the injection administered after it is dispensed by the chemist. For benefit purposes these sessions are regarded as 1 attendance only, and multi-item billing is not possible.

Attendance with another service

A consultation may be billed in association with another MBS item provided the consultation is a clinically relevant service and the item descriptor for the consultation is met.

Scenario 1

A patient with facial bruising and a leg wound caused by a fall sees a GP. The GP assesses and treats the facial injury and sutures the leg wound. Both the consultation to manage the facial injury and the wound repair were clinically relevant services. Therefore the GP is entitled to bill both an attendance item and a wound repair item.

Attendance not payable with another service

MBS attendance items are not payable in association with a procedural service containing 1 of the following phrases in its item descriptor:

  • 'each attendance'
  • 'attendance at which'
  • 'including associated consultation'

Scenario 2

MBS item referred to in this scenario:

  • item 14050—PUVA therapy or UVB therapy administered in whole body cabinet, not being a service associated with a service to which item 14053 applies including associated consultations other than an initial consultation

A patient has an initial consultation with a dermatologist where arrangements are made for the patient to undertake a course of whole body PUVA therapy for psoriasis (Item 14050 as shown above).

During 1 of the PUVA therapy sessions, the dermatologist has a subsequent consultation with the patient to assess progress. Claiming for this subsequent consultation is precluded by the item descriptor, even if it could be considered a clinically relevant consultation.

As an independent procedure

Some MBS item descriptors include the term 'as an independent procedure'. Medicare benefits are not payable for both an item containing this term and another procedure where:

  • the procedure is performed through the same incision as another procedure
  • the procedure occurs in the same body area as another procedure, or
  • where 1 procedure is an integral part of another procedure

Scenario - Independent procedure not payable

MBS items referred to in this scenario:

  • item 30064—subcutaneous foreign body, removal of, requiring incision and exploration, including closure of wound if performed, as an independent procedure
  • item 30029—skin and subcutaneous tissue or mucous membrane, repair of wound, other than wound closure at time of surgery, not on face or neck, small (not more than 7cm long), involving deeper tissue, not being a service to which another item in Group T4 applies.

A patient has a foreign body in their left forearm. A medical practitioner removes the foreign body and closes the wound.

In this scenario, item 30064 should not be claimed with item 30029. This is because item 30064 includes the term 'as an independent procedure' and there is only 1 incision. Also, item 30064 includes closure of wound and item 30029 is for repair of wound.

Scenario - Independent procedure payable

However, if a foreign body is removed from the left forearm and a laceration sutured on the right forearm, both items 30064 and 30029 would be payable. If this happens, the account needs to be endorsed with the term 'separate sites' or the restrictive override indicator for electronic claims set to 'separate sites' (SP).

Refer to MBS explanatory note T8.1 for more information.

Not being a service associated with a service to which another item in this 'group' applies

Some MBS item descriptors include the term 'not being a service associated with a service to which another item in this group applies'. This means a benefit is not payable for any other item in that group when it is performed on the same occasion.

Scenario

MBS items referred to in this scenario:

  • item 30107—Specialist - ganglion or small bursa, excision of, not being a service associated with a service to which another item in this group applies
  • item 49558—knee, arthroscopic surgery of, involving 1 or more of: debridement, osteoplasty or chondroplasty—not associated with any other arthroscopic procedure of the knee region

A surgeon excises a ganglion from a patient's left wrist on the same occasion as an arthroscopic debridement of the patient's right knee.

On this occasion the surgeon can only claim item 49558. Item 30107 prevents payment of a benefit when performed on the same occasion as another item in the same group (Group T8).

In this instance the 'group' refers to Group T8, Surgical Operations and includes MBS items 30001–50952.

Not being a service associated with a service to which another item in this 'subgroup' applies

Some MBS item descriptors include the term 'not being a service associated with a service to which another item in this subgroup applies'. This means a benefit is not payable for any other item in that subgroup when it is performed on the same occasion.

Scenario

MBS items referred to in this scenario:

  • item 35578—le fort operation for genital prolapse, not being a service associated with a service to which another item in this subgroup applies
  • item 35630—hysteroscopy, with endometrial biopsy, performed in the operating theatre of a hospital not being a service associated with a service to which items 35626 or 35627 apply

A gynaecologist performs a Le Fort operation for genital prolapse. On the same occasion a hysteroscopy with endometrial biopsy is performed as part of an investigation for abnormal uterine bleeding.

On this occasion the surgeon can only claim item 35578. Item 35578 prevents payment of a benefit for another item in the same subgroup when performed on the same occasion. Item 35630 is in the same 'subgroup'.

In this instance the subgroup refers to subgroup 4 (Gynaecological) of Group T8, Surgical Operations and includes MBS items 35500–35759.

Not being a service to which another item in this group or subgroup applies

Some MBS item descriptors include the term 'not being a service to which another item in this 'Group' (or Subgroup) applies'. This means that the item may be claimed if there is no specific item relating to the service. This rule is often applied to an item that describes a service in generic terms. Where another item, or items, exists that may describe the service more specifically, then that item should be used. It is inappropriate to claim the generic item when an item that better describes the service provided is available. Other MBS items can still be claimed for further services performed on the same occasion.

Scenario

MBS items referred to in this scenario:

  • item 33172—aneurysm of major artery, replacement by graft, not being a service to which another item in this Subgroup applies
  • item 33115—infrarenal abdominal aortic aneurysm, replacement by tube graft, not being a service associated with a service to which item 33116 applies

A patient is found to have an infrarenal abdominal aortic aneurysm. The surgeon performs an open operation aneurysm repair by replacement with tube graft.

Item 33172 cannot be claimed as the item description includes the wording 'not being a service to which another item in this 'Subgroup' applies'. The Subgroup includes item 33115 which specifically describes the service provided. In this instance the subgroup refers to subgroup 3 (Vascular) of Group 8, Surgical Operations and includes MBS items 32500-35412.

Refer to MBS explanatory note T8.1 for more information.

More information

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Page last updated: 13 October 2016

This information was printed Wednesday 7 December 2016 from humanservices.gov.au/health-professionals/enablers/education-guide-multi-item-billing It may not include all of the relevant information on this topic. Please consider any relevant site notices at humanservices.gov.au/siteinformation when using this material.