Articles and Case Studies

Beware Medicare

28 May 2015

Julian Walter clover

by Dr Julian Walter

Checking the accounts

MDA National has become aware of a number of recent Medicare audit activities affecting GPs and other specialists.

General Practice – Chronic Disease Management Plans (CDMP)

These services include item numbers 721 (Care Plan), 723 (Team Care Arrangements), 732 (GP Management Plan), 732 (Coordinating a Team Care Arrangement), 731 (Contribution/Review of Multidisciplinary Aged Care Resident Plan) and 729 (Contribution/Review of Multidisciplinary Care Plans).

Importantly, since 1 November 2014, a time-based consultation and a CDMP cannot be billed on the same day.1

It is crucial to ensure that the relevant Medicare descriptors are met,2 including that the CDMP is more than just a template “cut and paste” of other data, and that formal requirements such as patient consent and collaboration, as appropriate, are met. Otherwise partial or complete repayment of these services may be required by Medicare, potentially including an administration penalty of up to 20% if the payment is more than $2500.3

Radiologists – provision of diagnostic imaging services

The Department of Human Services is auditing diagnostic imaging providers, concentrating on billing and incoming referrals. This will include confirmation that the specific service was requested by a referring doctor. Referrers may also be contacted for a copy of the original referral and associated reports (patient test results can be redacted).

Other non-GP specialists – initial and subsequent attendances

A number of non-GP specialist Members (particularly Ophthalmologists) have contacted us regarding Medicare audits of item numbers 104 (initial attendance, referred consultation) and 105 (subsequent attendance) in relation to the need for a new referral. These matters also raise a number of questions regarding referrals and what constitutes an initial attendance.

Some Members have been required to repay incorrectly rendered services. It is important to ensure your administrative staff are trained to recognise such situations prior to the consultation to allow for a referral to be provided.

A patient attends with no referral

If a patient attends without a valid referral, a non-GP specialist will need to consider several options:

  • Is the consultation for emergency treatment that needs to be rendered “as quickly as possible”?4 In this case, the account, receipt or assignment form must be endorsed “emergency referral”. No referral is required for this initial consultation.
  • Will the consultation be billed to Medicare using unreferred (time-based) MBS item numbers (52, 53, 54, 57)?
  • Has the referral been lost, stolen or destroyed? If so, the assignment form must show the referring practitioner and their address/provider number, if known. The words “lost referral” must be included when billing the initial consultation. A copy of the referral should be obtained for subsequent consultations.
  • Can a new referral be obtained before the service is rendered?

A patient attends with a new problem and has an existing unrelated referral

The presentation of an unrelated illness, normally requiring the referral of the patient to the specialist’s care to initiate a new course of treatment, requires a new referral. For example, a pre-existing referral for glaucoma will not cover an unreferred presentation for a pterygium – a new referral will be required.5

If no new referral is available, an initial attendance (104) can only be billed in circumstances described above.

A subsequent attendance (105) can only be charged if the consultation relates to the continuing management encompassed by the original referral. This may mean that a broad initial referral may allow several subsidiary conditions relevant to that referral to be billed as part of the ongoing treatment. However, this will still not permit multiple initial attendances (104) to be billed to the same referral. An example would be a referral for “assessing the patient’s visual symptoms” which might encompass both an initial 104 for glaucoma and a later 105 (not 104) for a pterygium under the same referral.

New referral for an existing condition              

A new initial attendance (104) may be billed where the initial referral has expired, a new referral for the same condition has been issued, and more than nine months have elapsed since the last consultation with the specialist.

Definition of a single course of treatment

A single course of treatment involves an initial attendance by a specialist or consultant physician and the continuing management/treatment up to the stage where the patient is referred back to the care of the referring practitioner. It also includes any subsequent review of the patient’s condition by the specialist or the consultant physician that may be necessary. Such a review may be initiated by either the referring practitioner or the specialist/consultant physician.

The presentation of an unrelated illness, requiring the referral of the patient to the specialist’s or the consultant physician’s care would initiate a new course of treatment in which case a new referral would be required.

The receipt by a specialist or consultant physician of a new referral following the expiration of a previous referral for the same condition(s) does not necessarily indicate the commencement of a new course of treatment involving the itemisation of an initial consultation. In the continuing management/treatment situation the new referral is to facilitate the payment of benefits at the specialist or the consultant physician referred rates rather than the unreferred rates.

However, where:

(a) the referring practitioner deems it necessary for the patient’s condition to be reviewed; and

(b) the patient is seen by the specialist or the consultant physician outside the currency of the last referral; and

(c) the patient was last seen by the specialist or the consultant physician more than nine months earlier

the attendance following the new referral initiates a new course of treatment for which Medicare benefit would be payable at the initial consultation rates.

Source: Australian Government, Department of Health, Medicare Benefits Schedule Book – Operating from
1 April 2015. Section G.6.1.Page 27.

Indefinite referrals

These will permit an initial consultation (104) charge, then ongoing subsequent attendances (105) thereafter, irrespective of the timeframe between consultations.4 Repeat initial consultations (104) should not be billed against an indefinite referral,5 even if the consultation is held more than nine months later.

Dr Julian Walter
Medico-legal Adviser
MDA National

1. Department of Human Services. Budget 2013-14: Medicare Benefits Scheme – Removing Double Billing.
2. Department of Health. Questions and Answers on the Chronic Disease Management (CDM) items. Available at:
3. Department of Human Services. Medicare Compliance Audits and Reviews. Available at:
4. Department of Health. Medicare Benefits Schedule Book G.6.1. Current version reviewed 1 January 2015. Available at:
5. Department of Human Services. Indefinite Referrals: What You Need to Know.

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