Medicare rebates for obstetrics

What is changing about Medicare rebates for obstetrics?

(PDF version of the Obstetrics Factsheet)

As foreshadowed in the 2009-2010 Budget, three new pregnancy consultation items have been introduced into the obstetrics section of the Medicare Benefits Schedule (MBS) and the Medicare rebates for 15 obstetrics services have been increased.

The new and increased rebates are effective from 1 January 2010.

What are the new and amended attendance items?

Three new items have been introduced into the obstetrics section of the MBS.

16401 Professional attendance at consulting rooms or a hospital by a specialist in the practice of his or her specialty of obstetrics, after referral of the patient to him or her — each INITIAL attendance, in a single course of treatment, relating to pregnancy or pregnancy related conditions or complications – not being a service to which items 104 or 105 apply.
Schedule fee: $80.85 EMSN Cap: $50.75

16404 Professional attendance at consulting rooms or a hospital by a specialist in the practice of his or her specialty of obstetrics after referral of the patient to him or her — each attendance SUBSEQUENT to the first attendance in a single course of treatment, relating to pregnancy or pregnancy related conditions or complications.
Schedule fee: $40.60 EMSN Cap: $30.45

The two new items above are intended to be used instead of items 104 and 105 for any initial and subsequent attendance with a specialist obstetrician for discussion of pregnancy or pregnancy related conditions or complications. However, it is still intended that item 16500 will be billed for routine antenatal attendances.

16591 Planning and management of a pregnancy that has progressed beyond 20 weeks provided the fee does not include any amount for the management of the labour and delivery if the care of the patient will be transferred to another medical practitioner, payable once only for any pregnancy that has progressed beyond 20 weeks, not being a service to which item 16590 applies.
Schedule fee: $134.80 EMSN Cap: $101.50

The above item has been introduced to reflect the different responsibilities of GPs and obstetricians who plan to manage the pregnancy, labour and birth, and those who are part of a shared care arrangement.

Item 16590 has also been amended in the obstetric section of the MBS.

16590 Planning and management of a pregnancy that has progressed beyond 20 weeks provided the fee does not include any amount for the management of the labour and delivery, payable once only for any pregnancy that has progressed beyond 20 weeks where the practitioner intends to undertake the delivery for a privately admitted patient, not being a service to which item 16591 applies.
Schedule fee: $306.30 EMSN Cap: $203.00

The above item has been amended to clarify that this planning and management service should be used where the medical practitioner is intending to undertake the delivery for a privately admitted patient.

What obstetrics services have had the rebates increased?

The Medicare rebates have been increased for 15 obstetrics services, including:

Over a standard course of maternity care, the base MBS rebates have been increased by about $300 per patient. This means patients will now receive a higher rebate before they qualify for the Extended Medicare Safety Net (EMSN).

This will help to reduce out-of-pocket costs for these services and will be of particular benefit for those women from rural and regional areas and for those families who do not quality for EMSN benefits.

How will patients be affected by changes to the EMSN?

Patients will still receive the standard Medicare rebate for the services. Patients will still be eligible to receive EMSN benefits for all out-of-hospital Medicare services once they have reached the EMSN threshold. Further information on the EMSN and EMSN capping can be found at: Changes to the Extended Medicare Safety Net in the 2009-10 Budget . There will be a maximum limit (the EMSN benefit cap) placed on the amount that patients will get back through the EMSN for obstetrics services items from 1 January 2010.

How will the EMSN benefit caps work in practice?

The EMSN benefit cap will be applied at the item level. This means that the same level of EMSN benefit cap will apply to all claims for that item, regardless of the fee charged by the doctor.

All patients are eligible to receive up to the EMSN benefit cap, each time that they have a claim for the service.

Under the changes the method for determining the EMSN benefit will be the same, that is, 80% of the patient’s out-of-pocket cost once the patient has reached the EMSN threshold. If this amount is greater than the EMSN benefit cap, then the patient receives the EMSN benefit cap amount. If the calculated benefit is less than the EMSN benefit cap, then the patient receives the calculated benefit (which is equal to 80% of the out-of-pocket costs for the claim).

Why are EMSN benefit caps applied on labour and delivery items when these services are usually provided in-hospital?

EMSN benefit caps are only relevant for out-of-hospital services, as EMSN benefit are only paid for out-of-hospital, there are a small proportion of patients that receive these services out-of-hospital.

EMSN benefit caps are also applied to items in recognition that some patients and doctors choose to have these services out-of-hospital and to ensure consistency in the application of EMSN benefit caps across MBS obstetrics services.

Medicare items for obstetrics services from 1 January 2010

Item number	Description	MBS Schedule Fee (1 Jan 2010) ($)	A: MBS benefit (1 Jan 2010) (out-of-hospital) ($)	B: EMSN Cap (1 Jan 2010) ($)	Maximum Medicare benefit payable per claim out-of-hospital (A+B) ($) #
16400	Antenatal attendance by a nurse or midwife on the behalf of a medical practitioner	25.80	21.95	10.15	32.10
16401 new	Initial specialist attendance by a practitioner in the practice of obstetrics	(80.85) Standard increase only	68.75	50.75	119.50
16404 new	Subsequent specialist attendance by a practitioner in the practice of obstetrics	(40.60) Standard increase only	34.55	30.45	65.00
16500	Antenatal attendance	44.55	37.90	30.45	68.35
16501	External Cephalic Version for Breech Presentation, After 36 Weeks	(132.85) Standard increase only	112.95	60.90	173.85
16502	Attendance for treatment of Polyhydramnios, Unstable Lie, Multiple Pregnancy, Pregnancy Complicated by Diabetes or Anaemia, Threatened Premature Labour Treated by Bed Rest Only or Oral Medication,	44.55	33.40*	20.30	Usually provided in hospital*
16504	Attendance for the treatment of Habitual Miscarriage by Injection of Hormones Each Injection Up to a Maximum of 12 Injections	44.55	33.40*	20.30	58.20
16505	Attendance for threatened Abortion, Threatened Miscarriage or Hyperemesis Gravidarum,	44.55	33.40*	20.30	Usually provided in hospital*
16508	Attendance for Pregnancy Complicated by Acute Intercurrent Infection, Intrauterine Growth Retardation, Threatened Premature Labour With Ruptured Membranes or Threatened Premature Labour Treated by Intravenous Therapy	44.55	33.40*	20.30	Usually provided in hospital*
16509	Attendance for the treatment of Preeclampsia, Eclampsia or Antepartum Haemorrhage	44.55	33.40*	20.30	Usually provided in hospital*
16511	Purse String Ligation of Cervix	(207.85) Standard increase only	155.90*	101.50	Usually provided in hospital*
16512	Removal of Purse String Ligature of Cervix	(60.00) Standard increase only	51.00*	30.45	Usually provided in hospital*
16514	Antenatal Cardiotocography in the Management of High Risk Pregnancy	($34.65) Standard increase only	29.50	15.25	44.75
16515	Management of Vaginal Delivery As An Independent Procedure Where the Patient's Care Has Been Transferred by Another Medical Practitioner for Management of the Delivery	425.95	319.50*	162.40	Usually provided in hospital*
16518	Management of Labour, Incomplete, Where the Patient's Care Has Been Transferred to Another Medical Practitioner for Completion of the Delivery	425.95	319.50*	162.40	Usually provided in hospital*
16519	Management of Labour and Delivery by Any Means (Including Caesarean Section) Including Post-partum Care for 5 Days	655.85	491.90*	304.50	Usually provided in hospital*
16520	Caesarean Section and Post-operative Care for 7 Days Where the Patient’s Care Has Been Transferred by Another Medical Practitioner	766.55	574.95*	304.50	Usually provided in hospital *
16522	Management of complicated birth	1,539.90	1,154.95*	406.00	Usually provided in hospital*
16525	Management of Second Trimester Labour, With or Without Induction, for Intrauterine Fetal Death, Gross Fetal Abnormality or Life Threatening Maternal Disease	363.25	272.45*	142.10	Usually provided in hospital*
16564	Evacuation of Retained Products of Conception (Placenta, Membranes or Mole) As a Complication of Confinement, With or Without Curettage of the Uterus	(206.05) Standard increase only	175.15*	203.00	Usually provided in hospital*
16567	Management of Postpartum Haemorrhage by Special Measures Such As Packing of Uterus	(301.30) Standard increase only	256.15*	203.00	Usually provided in hospital*
16570	Vaginal Correction of Acute Inversion of the Uterus	(393.20) Standard increase only	294.90*	203.00	Usually provided in hospital*
16571	Repair of Extensive Laceration or Lacerations of the Cervix	(301.30) Standard increase only	226.00*	203.00	Usually provided in hospital*
16573	Repair of Third Degree Tear, Involving Anal Sphincter Muscles and Rectal Mucosa	(245.55) Standard increase only	184.20*	203.00	Usually provided in hospital*
16590	Planning and Management of a Pregnancy That Has Progressed Beyond 20 Weeks.	306.30	260.40	203.00	463.40
16591 new	Planning and Management of a Pregnancy where the care of the patient will be transferred to another medical practitioner for the labour and delivery	134.80	114.60	101.50	216.10
16600	Amniocentesis	(60.00) Standard increase only	51.00	30.45	81.45
16603	Chorionic Villus Sampling	(115.20) Standard increase only	97.95	60.90	158.85
16606	Fetal Blood Sampling From Umbilical Cord or Fetus	(229.85) Standard increase only	195.40	121.80	317.20
16609	Fetal Intravascular Blood Transfusion, Using Blood Already Collected, Including Neuromuscular Blockade, Amniocentesis and Fetal Blood Sampling.	(468.75) Standard increase only	339.65	233.45	573.10
16618	Amniocentesis, Therapeutic	(196.40) Standard increase only	166.95	96.45	263.40
16624	Drainage of Fetal Fluid Filled Cavity	(282.65) Standard increase only	240.30	131.95	372.25
16627	Feto-amniotic Shunt, Insertion of, Into Fetal Fluid Filled Cavity, Including Neuromuscular Blockade and Amniocentesis	(575.55) Standard increase only	506.45	284.20	790.65
16633	Procedure On Multiple Pregnancies Relating to Items 16606, 16609, 16612, 16615 and 16627	No increase	The rebate depends on the item number claimed for the first foetus	213.15	The rebate depends on the item number claimed for the first foetus
16636	Procedure On Multiple Pregnancies Relating to Items 16600, 16603, 16618, 16621 and 16624	No increase	The rebate depends on the item number claimed for the first foetus	81.20	The rebate depends on the item number claimed for the first foetus

# Note: Actual rebate payable depends on the amount of out-of-pocket cost that a patient needs to reach the EMSN threshold and the fee charged by the doctor.

* Note: This service is usually provided to an admitted patient in a hospital. Therefore, EMSN benefits are not payable. It is difficult to determine the maximum benefit payable for in-hospital services as different private health insurance funds provide different levels of coverage and different patients have different policies. The MBS rebate for in-hospital services is 75% of the MBS Schedule fee.

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