by Ms Alice Cran
Changes to skin service items, introduced on 1 November 2016, saw a reduction of skin excision items from 48 to 21. The aim was to simplify items and reflect best clinical practice.1 Choosing the wrong item number and/or failing to appropriately document the excision can expose practitioners to financial penalties and, in more serious cases, the imposition of sanctions where the conduct constitutes inappropriate practice.
In a case that went before the Professional Services Review Committee, a General Practitioner was directed to repay $366,734.71 to the Commonwealth in relation to the rendering of a number of MBS items.2 One of these items was for skin excision, where the practitioner was found to have failed to provide adequate clinical input, comply with MBS requirements and keep adequate records.
Deficiencies identified in the practitioner’s records included failing to describe the lesions and the nature of the wound closure, the patient’s comorbidities or other issues affecting the procedures, such as the patient’s relevant medications, history of wound infections, or any history relating to the use of local anaesthetic.
In relation to some services, the Committee found inappropriate billing of a consultation item for pre-procedural and post-procedural work where a procedural item was also billed. Claiming the consultation item was inappropriate in these instances because there was no discrete clinical content to justify the claim, as all work was part of the procedural service.
Since 9 April 2011, the Department of Human Services (DHS) has had the power to audit Medicare services provided on or after that date. DHS may issue a notice to a practitioner, or a person in charge of the practitioner’s records, if there is a reasonable concern that a Medicare benefit that has been paid exceeds the amount that should have been paid. This typically arises where the criteria in the item descriptor are not fully met in order to justify billing under that item.
In the case of audits concerning skin cancer lesion removal, DHS seeks confirmation that practitioners have met the histopathological requirements, and that the lesion size and location correlate strictly with the item descriptor. As illustrated in the above case study, adequate and contemporaneous records are therefore vital.
When rendering a service under Medicare involving skin lesion removal, it is good practice to keep in mind the following when documenting the excision:
You can get more information on skin lesion and biopsy items from the education guide available on the DHS website: humanservices.gov.au.4
In cases where you think you may have received an incorrect Medicare benefit, or if you have received a notice to produce documents from Medicare, you should seek assistance immediately from your medical defence organisation.
MDA National’s risk categorisation of skin grafts and flaps has been reviewed and amended from Level 2 GP Limited Procedures and Level 3 GP Procedural as follows:
It is important to be aware that it is a requirement under your Professional Indemnity Insurance Policy that you are acting within your field of practice and have the appropriate training and qualifications for any procedures undertaken.
The details of the changes are outlined on Page 14 in the 2018/19 Risk Category Guide for Medical Students and Medical Practitioners. If you believe the above amendments may impact the risk category in which you are currently indemnified, please contact our Member Services team for further discussion by phone: 1800 011 255 or email: peaceofmind@mdanational.com.au.
See articles from our previous GP Updates.
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