Helping Children with Autism

Overview of the pervasive developmental disorder Medicare items

A full explanation of the allied health professional Medicare items for PDDs. Allied health professionals should refer to this information before providing services under this initiative.

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MBS items (82000 to 82025) are available for allied health professional services for children (aged under 13 years for diagnosis and under 15 years for treatment) with autism or any other pervasive developmental disorder (PDD). These items apply to services provided by eligible psychologists, speech pathologists and occupational therapists, on referral from a consultant psychiatrist or paediatrician. These items cover two specific types of service that allow the relevant allied health professionals to:

• assist the referring practitioner in the diagnosis of the child ─ aged under 13 years ─ and/or development of the child’s PDD treatment plan (items 82000, 82005 and 82010); and
• provide treatment to the child ─ aged under 15 years (and who was aged under 13 years at the time of receiving their PDD treatment plan) for their particular condition, consistent with the treatment plan prepared by the referring practitioner (items 82015, 82020 and 82025).

Assessment services attracting Medicare rebates

Eligible allied health assessment services

There are three MBS items available for eligible psychologists, speech pathologists and occupational therapists to assist a referring practitioner in the diagnosis of a child (aged under 13 years) and/or preparation of a PDD treatment plan for that child. Allied health professionals wanting to provide these items must meet the provider eligibility requirements set out below (see ‘Eligible allied health professionals’ section) and be registered with Medicare Australia.

Services provided for assisting in the diagnosis of a child and/or preparation of a PDD treatment plan for the child will not attract a Medicare rebate unless:

• a referral has been made by a consultant psychiatrist or paediatrician from an eligible psychiatric or paediatric service (see ‘REFERRAL REQUIREMENTS’ section) who, as part of the referral, requests the allied health professional’s assistance in assessing the patient and/or preparing a treatment plan for the patient.

Number of services

Medicare rebates are available for up to four (4) allied health assessment services in total per eligible child. The four services may consist of any combination of items 82000, 82005 and 82010. It is the responsibility of the referring practitioner to allocate these services in keeping with the child’s individual needs and to refer the child to appropriate allied health professional(s) accordingly.

Treatment services attracting Medicare rebates

Eligible allied health treatment services

There are three MBS items available for eligible psychologists, speech pathologists and occupational therapists to provide treatment services to eligible children ─ aged under 15 years (and who were aged under 13 years at the time of receiving a PDD treatment plan) ─ with a PDD. Allied health professionals wanting to provide these items must meet the provider eligibility requirements set out below (see ‘Eligible allied health professionals’ section) and be registered with Medicare Australia.

Services provided for the treatment of children with a PDD will not attract a Medicare rebate unless:

• a referral has been made by a consultant psychiatrist or paediatrician from an eligible psychiatric or paediatric service (see ‘REFERRAL REQUIREMENTS’ section) who is managing the child under a PDD treatment plan (item 135 or 289);

Number of services

Medicare rebates are available for up to twenty (20) allied health treatment services in total per eligible child. The twenty services may consist of any combination of items 82015, 82020 and 82025. It is the responsibility of the referring practitioner to allocate these services in keeping with the child’s individual treatment needs and to refer the child to appropriate allied health professional(s) accordingly.

Conditions governing the provision and claiming of items

Please note that these conditions apply to both the assessment (items 82000-82010) and treatment
(items 82015-82025) services.

Service length and type

Services under these items must be for the time period specified within the item descriptor. The allied health professional must personally attend the child.

It is anticipated that professional attendances at places other than consulting rooms would be provided where treatment in other environments is necessary to achieve therapeutic outcomes.

It is also expected that participating allied health providers will deliver treatment under these items that is consistent with the PDD treatment plan prepared by the psychiatrist or paediatrician, and in keeping with commonly established PDD interventions as practised by their profession and appropriate for the age and particular needs of the child being treated.

Course of treatment and reporting back to the referring practitioner

Children are eligible to receive up to a total of four (4) PDD assessment services and twenty (20) PDD treatment services with an eligible allied health professional(s).

A written report must be provided to the referring consultant psychiatrist or paediatrician by the allied health professional(s) after having provided the PDD assessment service(s) to the child.

Within the maximum service allocation of twenty services for the PDD treatment items, the allied health professional(s) can provide one or more courses of treatment. For the purposes of these services, a course of treatment will consist of the number of services stated on the child’s referral (up to a maximum of 10). This enables the referring practitioner to consider a report from the allied health professional(s) about the services provided to the child, and the need for further treatment.

On completion of the course of treatment, the eligible psychologist, speech pathologist and occupational therapist must provide a written report to the referring consultant psychiatrist or paediatrician which includes information on:

• treatment provided;
• recommendations on future management of the child's disorder;
• any advice provided to third parties (eg. parents, schools).

A written report must also be provided to the referring consultant psychiatrist or paediatrician at the completion of any subsequent course(s) of treatment provided to the child.

Out of pocket expenses and Medicare safety net

Charges in excess of the Medicare benefit for these items are the responsibility of the patient. Such out-of-pocket costs will count toward the Medicare safety net for that patient. Any allied health PDD assessment services that are in excess of the maximum of four (4) and any allied health PDD treatment services that are in excess of the maximum of twenty (20) allowable per child will not attract a Medicare benefit and the safety net arrangements will not apply to costs incurred by the child for such services.

Eligible patients

These MBS services apply to children ─ aged under 13 years ─ where the child is referred by an eligible consultant psychiatrist or paediatrician, for assessment items 82000-82010 inclusive. The MBS treatment services apply to children ─ aged under 15 years (where the child was aged under 13 years at the time of receiving a PDD treatment plan) ─ for treatment items 82015-82025 inclusive.

The conditions classified as PDD for the purposes of these services are informed by the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR), Washington, DC, American Psychiatric Association, 2000.

Checking patient eligibility for allied health pervasive developmental disorder services

Patients seeking Medicare rebates for the allied health PDD services will need to have a referral from a consultant psychiatrist or paediatrician. If there is any doubt about a child’s eligibility, Medicare Australia will be able to confirm whether a relevant psychiatric or paediatric MBS service has been claimed (to facilitate access to the assessment items); or that a PDD treatment plan has been claimed (to facilitate access to the treatment items), as well as the number of allied health PDD services already claimed by the child.

Allied health professionals can call Medicare Australia on 132 150 to check this information. Parents and carers can seek clarification by calling 132 011.

The child will not be eligible if they have not been appropriately referred and a relevant Medicare service provided to them. If the referring service has not yet been claimed, Medicare Australia will not be aware of the child’s eligibility. In this case the allied health professional should, with the permission of the child’s parent or carer, contact the referring consultant psychiatrist or paediatrician to ensure the relevant service has been provided to the child.

Publicly funded services

Allied health PDD assessment and treatment items 82000 to 82025 do not apply for services that are provided by any other Commonwealth or State funded services or provided to an admitted patient of a hospital. However, where a direction under subsection 19(2) of the Health Insurance Act 1973 has been made in regard to an Aboriginal Community Controlled Health Service or State/Territory clinic, the items apply for services that are provided by eligible allied health professionals salaried by, or contracted to, the service as long as all requirements of the items are met, including registration with Medicare Australia. These services must be direct billed (that is, the Medicare rebate is accepted as full payment for services.)

Private health insurance

Patients need to decide if they will use Medicare or, if available, their private health insurance to pay for these services. Patients cannot use their private health insurance to ‘top up’ the Medicare rebate paid for the services.

Referral requirements (psychiatrists or paediatricians to allied health professionals)

Referrals

Referrals from consultant psychiatrists and paediatricians to allied health professionals for the PDD assessment items must be made from eligible Medicare services.

An eligible allied health professional can provide PDD assessment items (82000-82010) to a child where:

• the child has previously been provided with any MBS service covering items 110 through 131 inclusive, as provided by an eligible consultant paediatrician; or
• the child has previously been provided with any MBS service covering items 296 through 370 (excepting item 359) inclusive, as provided by an eligible consultant psychiatrist.

An eligible allied health professional can provide PDD treatment items (82015-82025) to a child where:

• the child has previously been provided with a PDD treatment plan (MBS item 135) by an eligible consultant paediatrician; or
• the child has previously been provided with a PDD treatment plan (MBS item 289) by an eligible consultant psychiatrist.

An allied health professional wanting to provide any of the items 82000-82025 must be in receipt of a current referral provided by a consultant physician paediatrician or a consultant physician psychiatrist. With specific regard to the treatment items, a patient must have a previous claim for item 135 or 289.

Referring consultant paediatricians and consultant psychiatrists are not required to use a specific form to refer patients for these services. The referral may be a letter or note to an eligible allied health professional signed and dated by the referring practitioner.

The allied health professional must be in receipt of the referral at the initial consultation. Allied health professionals are required to retain the referral for 24 months from the date the service was rendered for Medicare Australia auditing purposes.

Referral validity

Medicare benefits are available for up to four (4) allied health PDD assessment and up to twenty (20) allied health PDD treatment services per patient.

Patients will require a separate referral for each allied health professional they receive services from and will also need fresh referrals for each new course of treatment provided to them.

Psychologist, speech pathologist and occupational therapist professional eligibility

Eligible allied health professionals

Allied health professionals providing services under these items must be registered with Medicare Australia. To be eligible to register with Medicare Australia to provide these services, an allied health professional must be:

• A psychologist registered, without limitation, with the Psychologists Registration Board in the State or Territory in which they are practising. (Psychologists whose State/Territory registration includes any limitation, for example, where marked ‘provisional registration’, are not eligible to register with Medicare Australia to use the items); or
• A speech pathologist (in Queensland) registered with the Speech Pathologist Board of Queensland. In all other States and Territories, participating speech pathologists must be a ‘Practising member’ of Speech Pathology Australia; or
• An occupational therapist in Queensland, Western Australia, South Australia or the Northern Territory who is registered with the Occupational Therapists Board in the State or Territory in which they are practising. In other States and the Australian Capital Territory, the occupational therapist must be a ‘Full-time Member’ or ‘Part-time Member’ of OT AUSTRALIA, the national body of the Australian Association of Occupational Therapists.

In addition to meeting the above mentioned credentialing requirements, it is expected that eligible providers will “self-select” for the pervasive developmental disorder items (that is, possess the skills and experience appropriate for provision of these services and be oriented to work with children with PDD).

Registering with Medicare Australia

Advice about registering with Medicare Australia to provide allied health professional services using items 82000-82025 inclusive is available from the Medicare Australia provider inquiry line on 132 150.

Further information

For further information about Medicare Benefits Schedule items, please go to the Department of Health and Ageing’s website at www.health.gov.au/mbsonline.

For providers, further information is also available for providers from the Medicare Australia provider inquiry line on 132 150.