Curly questions to AskMBS

8 minute read

The advice service expects GPs to count the minutes. Let’s see what it says about billing for this complex patient.

This morning I saw Melissa, a 45-year-old woman with three teenage boys.

She was originally booked in for 20 minutes to discuss her rheumatoid arthritis, but her pathology tests also indicate she has developed type 2 diabetes, which I need to manage.

She has multiple stressors in her life, and I know I often need to address her mental wellbeing as well as her physical health. She lives with domestic violence, and her three sons have mental health issues of their own which can be stressful. I ask my receptionist to contact Melissa to check if she happy to see me for a long consultation (so there is informed financial consent for the additional cost) and extend her appointment to 30 minutes to make sure I have time to address her needs.

The consultation lasts 45 minutes. As soon as I mention her pathology results, Melissa breaks down and tells me this is the “last straw” in her difficult life. We focus on a broad range of needs, including the domestic violence, the mental health of her sons, the financial burden of her chronic illnesses, the chronic pain and, of course, the new diagnosis of diabetes.

Given this recent advisory bulletin from the Medicare advisory service AskMBS, which states that a GP must use a mental health item number when one is available or risk being “inappropriate” (see p14), I asked a few questions regarding this patient.

Dear AskMBS,

I wanted to ask your advice about the billing of a recent consultation that involved the physical and mental health care of one of my patients.

I am anxious to bill correctly, because the Department of Health has made it very clear through it’s threat letters that I may be subject to “compliance action” if I make a mistake. The “voluntary compliance team”, tells me that my billings will be monitored and legal action may be undertaken if I do not comply so I’m increasingly worried about the PSR. It may be rare to be subject to their scrutiny, but apparently it’s getting more common and seeing as the “conviction” rate is nearly 100% I am afraid it might ruin my reputation and career.

I feel it is now imperative that I contact AskMBS whenever I feel unsure of appropriate billing codes. I am not sure if your advice will hold up against the PSR, because the advice seems to often be contradictory, and has no legislative authority and is therefore not accountable for your responses, but it is the best option I have.

So I wanted to discuss the case of “Melissa” who needed care across a number of domains today.

Compulsory use of mental health item numbers

You have written that “It is a fundamental principle of Medicare that the item that best describes the service is the item that should be claimed for that service. This means, for example, that it would not be appropriate to claim a general attendance item for mental health treatment service if it were possible to claim a dedicated mental health treatment item.”

 I think this means I have three choices to obtain a rebate for Melissa:

  • If the consultation was only about her mental health, she is eligible to claim a mental health item number (2713) which attracts a rebate of $75.80
  • If I restrict the mental health component of the consultation to less than 20 minutes, she is eligible to claim a normal consultation item number (44) which attracts a rebate of $113.30
  • If I do more than 20 minutes on her mental health and less than 20 minutes on her physical health, you state it “would be theoretically possible” to claim a mental health item number (2713) and a normal consultation item number (23) giving Melissa a rebate of $115.55

I can see that if I want Melissa to suffer no financial discrimination simply due to the fact that her presenting issue is a mental health rather than a physical health one, I am best to co-claim two item numbers, or keep the mental health component of the consultation less than 20 minutes. Am I correct?

Which is which? Allocating minutes to the mental or physical health component of the consultation

During the consultation, I have kept a running tally on minutes spent on each component of care. However, I seem to have several minutes unallocated. Can you please give me a ruling as to whether the following elements of the consultation are related to her “mental disorder”? Or should I allocate a 50/50 split to mental and physical health?

  • Taking a family history
  • Taking a domestic violence history to ensure Melissa and her children are safe
  • Listening to Melissa disclose the mental trauma of enduring physical violence in the home
  • Discussing the risks associated with her son’s drug use
  • Discussing lifestyle factors like diet and exercise that have an impact on her physical and mental health
  • Recording the minute by minute use of my time to ensure Medicare compliance

In physical health care, it is easy to determine when to use a procedural item number. I know when I start and finish an excision for instance. I am having a great deal of difficulty approaching mental health care the same way. I know you also expect co claims to “note the times of each service and specify that they were distinct and separate”. Because it is impossible to divide the consultation into two sequential parts (physical and mental) do you require a template with my minute by minute analysis to submit with my Medicare claim?

The problem with the classification of “mental disorders”

A mental health item number must be used if the patient fulfills the Medicare requirements. Which includes the statement that the item is used “in relation to a mental disorder”. The term “mental disorder” is a little problematic for GPs, particularly when the consultation focusses on trauma. We are a little like orthopaedics here, I think. Orthopaedics would classify a disease like osteoporosis as a disorder, but would call fractures conditions or injuries 

The ICD 10 from 1995 ,which you are still using as a basis for this item number, describes a mental disorder as “a clinically recognizable set of symptoms or behaviours associated in most cases with distress and with interference with personal functions” There has been significant criticism recently of the way GPs use mental health item numbers, claiming that we are skewing health data by not using mental health item numbers for mental health work.

Can I clarify that it is inappropriate to bill a mental health consultation using a mental health item number if the patient does NOT have a disorder? There is no category in ICD 10 for the mental distress associated with domestic violence, interpersonal stress or pain, but I would describe all three as “a clinically recognizable set of symptoms or behaviours associated in most cases with distress and with interference with personal functions”.

So is this a disorder (perhaps “mental disorder not otherwise specified”). Or is this a condition or injury, and not a disorder? My colleagues, I think, would not see her as “disordered” and I doubt Melissa would see herself as “disordered” either. Do I need informed patient consent to apply this classification? Calling her “mentally disordered” when she isn’t may impact her future insurance, so ethically, I may be doing harm. Which is more important, the ethic of care or the counting of time?

The order of physical and mental health management

I know in your recent AskMBS Advisory Document you are very clear that it doesn’t matter which order I address a patient’s concerns. You specifically state that “the order in which multiple services are provided has no bearing on Medicare claiming, provided that there is no duplication of services and the claims note the times of each service and specify that they were distinct and separate.”

However, the MBS descriptor of a 2713 adds a note saying I can only claim a mental health item number (2713) and a general consultation item number (23) “if a GP Mental Health Treatment item is undertaken or initiated during the course of a consultation for another purpose…the relevant item for the other consultation may both be claimed”. Does this mean that if the original intent was to see Melissa for her rheumatoid arthritis and diabetes, it doesn’t matter if the consultation starts with me managing her distress?

I am also concerned because if I read the other note in the descriptor which says that if the purpose of the consultation is for mental health concerns “a separate and additional consultation should not be undertaken in conjunction with the mental health consultation, unless it is clinically indicated that a separate problem must be treated immediately.” To be honest, her diabetes is not of immediate concern, but she did make the appointment to discuss it. Should I explain that Medicare requires me to make another appointment to discuss her results because once she became distressed, I need to restrict her care to mental health only? 

These difficult questions of billing are impeding care, lengthening the consultation and distracting my clinical attention. I am also aware that the PSR criteria for inappropriate practice is “whether a practitioner’s practice/conduct when providing or initiating Medicare services would be unacceptable to the general body of their peers”. My peers seem to be equally confused by these requirements.

I am telling the most truth I can. Is it enough for the voluntary compliance team?

Dr Louise Stone is a GP practising in Canberra and an Associate Professor at the Social Foundations of Medicine Unit at ANU Medical School; she tweets @GPswampwarrior.

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