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MBS Primary Care Items

Group Allied health services under Medicare - People with type 2 diabetes - Item 8110 to 81125

Information for allied health professionals

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People with type 2 diabetes can receive Medicare rebates for group services provided by eligible diabetes educators, exercise physiologists and dietitians, on referral from a GP. Patients who will most benefit from group services are likely to be those who demonstrate a readiness to change, are able to contribute to group processes effectively and have a potential for self management.

Group services are in addition to the five individual allied health services available to eligible patients. (Separate fact sheets “Allied health services under Medicare – People with chronic conditions and complex care needs – items 10950 to 10970” and “Follow-up allied health services for people of Aboriginal and Torres Strait Islander descent – Medicare items 81300 to 81360” - provide details).

Which patients are eligible?

A patient must have type 2 diabetes. Before referring patients, the GP must put in place:

• a GP Management Plan – item 721 (or review item 732); or
• for a resident of a residential aged care facility, the GP must have contributed to, or reviewed, a care plan prepared by the facility (item 731) . ¹

GPs are also encouraged to attach a copy of the relevant part of the patient’s care plan to the referral form that is forwarded to the allied health professional (AHP).

^{1 Generally, residents of an aged care facility rely on the facility for assistance to manage their type 2 diabetes. Therefore, residents may not need to be referred for allied health group services under these items as the self management approach may not be appropriate.}

Patients being referred for allied health group services under items 81100 to 81125 do not need to have a Team Care Arrangements service (item 723). However, if the GP also wishes to refer the patient for individual allied health services under items 10950 to 10970, this service must be in place in order to meet the eligibility requirements of those items.

Eligible allied health professionals

Only diabetes educators, exercise physiologists and dietitians who are registered with Medicare Australia are eligible to provide group services. Registration forms can be obtained from Medicare Australia on 132 150 or by searching for ‘allied health application’ on the Medicare Australia website. Providers who are already registered with Medicare to provide services under items 10951, 10953 and 10954 do not need to register separately for items 81100 to 81125.

Referral forms

To access group allied health services, patients must be referred by their GP to an eligible AHP for an initial assessment.

Patients need to be referred by their GP using the referral form issued by the Department that can be found at the MBS Primary Care Items webpage or a form that contains all the components of the Department’s form.

It is recommended that AHPs involved in providing services retain a copy of the referral form from the GP for 24 months from the date the service was rendered (for Medicare Australia auditing purposes).

Allied health services

There are two elements to provision of allied health services under these items - an initial assessment of individual patients, followed by provision of group services.

Assessment for group services (items 81100, 81110 and 81120)

• Must be undertaken by an eligible diabetes educator, exercise physiologist or dietitian, on referral from a GP (see above).
• Must be provided to an individual patient in person.
• Involves taking a comprehensive patient history, identification of individual goals and preparing the patient for an appropriate group services program. This may also provide an opportunity to identify any patient who is likely to be unsuitable for group services.
• Patients are eligible for one allied health assessment for group services (item 81100 or 81110 or 81120) per calendar year. If there is any doubt about whether a patient has already claimed the maximum number of assessment or group services items in the calendar year, the AHP can call Medicare Australia on 132 150 to check.
• The service must be at least 45 minutes duration.

While the initial assessment can be undertaken by a diabetes educator (81100), exercise physiologist (81110) or dietitian (81120), it is intended to be generic in nature, covering factors relevant to all three professions. Patients can then be directed to any combination of group services. The Australian Diabetes Educators Association, Exercise and Sports Science Australia and the Dietitians Association of Australia have developed a generic assessment checklist that may be useful in undertaking the assessment of patients. The checklist is available on their respective websites.

To direct patients to group services, the AHP undertaking the assessment will need to complete Part B of the referral form. This form is required by each provider of group services.

Group services (items 81105, 81115 and 81125)

• The patient must be assessed as suitable for group services, using items 81100, 81110 or 81120, before group services can be undertaken.
• Must be provided to a person who is part of a group of between 2 and 12 persons.
• The provider/s of the group services program must keep an attendance record.
• Patients are eligible for a maximum of eight group services per calendar year.
• Each service must be at least 60 minutes duration.

Where clinically relevant, up to two group services may be provided consecutively on the same day by the same AHP.

Allied health group services may be delivered by one type of AHP (eg 8 diabetes education services) or by a combination of providers (eg 3 diabetes education services, 3 dietitian services, and 2 exercise physiology services). An eligible AHP with more than one Medicare provider number (eg for the provision of diabetes education and dietetics) may provide separate services under each of these provider numbers.

In some areas, different types of group services may be offered by AHPs (eg courses targeting newly diagnosed patients, refresher courses, or courses covering specific types of treatment and self management).

Reporting requirements

On completion of both the assessment for group services and the group services program, each AHP must provide, or contribute to, a written report back to the referring GP for each patient.

After the assessment service, the AHP should supply the GP with a written report outlining the assessment undertaken, whether the patient is suitable for group services and, if so, the nature of the group services to be provided.

After the group services program, the AHP should supply the GP with a written report describing the group services provided for the patient and indicating the outcomes achieved.

Out-of-pocket expenses and Medicare Safety Net

AHPs are free to determine their own fees for the professional service. Charges in excess of the Medicare benefit for the allied health items are the responsibility of the patient. Out-of-pocket costs for eligible services will count toward the Medicare safety net for that patient.

Private health insurance

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

Publicly funded services

Items 81100 to 81125 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 an exemption under subsection 19(2) of the Health Insurance Act 1973 has been granted to an Aboriginal Community Controlled Health Service or State/Territory Government health clinic, items 81100 to 81125 can be claimed for services provided by eligible AHPs salaried by, or contracted to, the Service or health clinic. These services must also be bulk billed.

Example of how the allied health group services work

GP referral

The GP completes a GP Management Plan for a patient with type 2 diabetes and believes that the patient is likely to benefit from group services provided by an eligible diabetes educator, exercise physiologist and/or dietitian. The GP therefore uses the referral form provided by the Department of Health and Ageing to refer the patient to an AHP (or an allied health practice) for an assessment for group services (item 81100, 81110 or 81120).

Either the patient or the GP must lodge a claim with Medicare Australia for the relevant GP care planning item and receive payment for the claim. If this has not been done, Medicare Australia will not be able to pay a rebate for the assessment service.

Allied health assessment service

The patient takes the referral form to the AHP and receives the requested assessment service. The AHP who undertakes the assessment identifies an appropriate group services program and prepares the patient for that program. The patient is then directed by the AHP to the group services program by completing Part B of the referral form and organising for the patient to be booked on the program.

Where possible, diabetes educators, exercise physiologists and dietitians are encouraged to work together to develop a range of group services programs in their area. However, some programs may be delivered by only one type of provider, or a provider with multiple qualifications.

The AHP bills the assessment item (81100, 81110 or 81120) and provides a written report back to the GP about the assessment undertaken and the group services program to be provided for the patient.

Either the patient or the AHP must lodge a claim with Medicare Australia for the relevant assessment item (81100, 81110 or 81120) and receive payment for the claim. If this has not been done, Medicare Australia will not be able to pay a rebate for the group services.

Allied health group services

The patient attends the recommended group services program, which has between 2 and 12 participants. The AHP keeps an attendance record.

The patient is billed after each service has been provided.

On completion of the group services program, each AHP involved in providing group services writes, or contributes to, a written report back to the GP about the group services provided for the patient.

More information

Further information about items 81100 to 81125 is available on the Department of Health and Ageing website at: the MBS Primary Care Items web page.

Information is also contained in the Medicare Benefits Schedule available online at MBS Online.