A second initial consultation can be
claimed under the original referral
when the patient presents with a
new condition, unrelated to the first
condition. In my work we see this very
often and it will usually be necessary
to add the words `not duplicate
service' and `new condition' to the
claim to ensure it is paid.
regularly reviewed for glaucoma who
then develops a pterygium. This would
commence a new episode of care and
a new initial consultation item would
be payable. And as long as the original
referral was worded broadly enough,
there is no requirement contained
anywhere in the legislation specifically
indicating that a new referral must be
issued in these circumstances and
sometimes it's just not possible.
glaucoma, then you'll need a new
referral for the pterygium.
a hospital and it is not possible to
obtain a referral, you can obviously
proceed and treat the patient without
a referral. The detailed records you will
include in the hospital file will be all
that's required should the claim ever
need to be substantiated.
treatment?
down to the definition of a single
course of treatment and determining
when one course of treatment ends
and another begins. This is not always
easy. Medicare describes a single
course of treatment by a specialist
as including an initial consultation
and the continuing management and
treatment of the patient up to the
point where the patient is referred
any subsequent follow-ups of the
same condition.
of an admission, and this doesn't always
occur at the start of that admission.
An episode in acute care does not
necessarily commence a new course
of treatment, for which a new initial
consultation would be payable. The
patient can go to intensive care or
theatre, or even be discharged home and
return, and still be receiving care for the
same problem under the same referral.
treatment and a new referral will
be required and this does not
automatically commence a new course
of treatment. If you are managing
the same condition then an initial
consultation should not be claimed
again. The new referral simply ensures
claims are paid at the specialist rate.
you to do?
request contained in the referral
should not be overlooked. This
Professional Standards Review
case is a cautionary tale:
in Gastroenterology
overall number of rendered services
and daily servicing by Dr D (13,602
services at a Medicare benefit of
$1,507,595 and 60 or more services
a day on 33 occasions) and the level
of consultations in association with
procedural items on the same day.
from a senior consultant physician
in gastroenterology, the Director
formed the view that Dr D did
not receive a proper referral to
a consultant physician to justify
a claim for an MBS item 110
(initial consultation), nor did
Dr D document that he had
rendered a service that justified
an item 110 consultation.
a procedural item (endoscopy etc.)
rather than a referral to a consultant
physician for management of a
patient's problem. Dr D's medical
records focused on a history of the
gastrointestinal problem but there
taken of other problems or of the
general health of the patient.
had significant medical problems.
Also, there was no evidence that
a physical examination was made
prior to the procedure. On advice
provided by Dr D, he allows five
minutes for the consultation and
10 minutes for the procedure.
inappropriate practice, that the
`request' to perform a procedural
item was not a valid referral (as
required by the legislation), and
agreed to be reprimanded and to
repay $70,000 in Medicare benefits.