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Public patient discharge process, aftercare and transition of care

There are many situations that can arise in the administration of Medicare billing in public hospitals. These case studies have been constructed to help you find how you can improve your Medicare billing practices.

Case study

Day 1: A patient sees their GP for fever and cough. The GP, with appropriate history and examination, diagnoses a viral illness and advises review in 3 days if the patient is not better. The GP then bills MBS item 23.

Day 4: The patient returns to the GP feeling unwell. The GP, after review of the patient's history and appropriate examination. Suspects it could be pneumonia and requests a full blood count (FBC) test and a chest X-ray (both MBS funded). The GP also prescribes amoxicillin and doxycycline (PBS) and over the counter paracetamol (private). The GP then bills item 23 (MBS).

Day 5: The GP rings the patient to check how the patient is feeling. The FBC shows white cell counts are high. While the chest X-ray reveals bronchopneumonia and an apical nodule, which could be indicative of a cancerous growth. The patient advises the doctor that he has pain while breathing, feels a bit short of breath and has had a restless night. The GP recalls the patient for reassessment and refers the patient to the local public hospital. For management of bronchopneumonia and investigation of the apical pulmonary nodule. The GP contacts the admitting officer of the hospital and briefs him on the referral. The GP bills MBS item 36.

Days 5-9: The patient is admitted at the local public hospital as a public patient by a medical registrar. The registrar briefs the respiratory physician on call and admits the patient, under the physician's bed card, for IV antibiotics. The patient is reviewed by the treating team and the physician (funded through activity based funding (ABF)). The respiratory physician advises the patient that antibiotics are expected to resolve the patient's illness. But that the apical nodule may need further review as it has a small possibility of being cancerous. The patient confirms that they would like the review to be carried out by the public physician as a public patient.

The patient is discharged on day 9 with 3 days of antibiotics (funded by ABF). While the IV antibiotics appear to have resolved the patient's illness. The respiratory physician asks the patient to come back and be seen in a public outpatient clinic with scans to review the patient's apical nodule.

From the ward the patient is discharged and referred to:

  1. the respiratory physician's (public) outpatient clinic with an appointment to be seen 6 weeks after discharge.
  2. the originating GP with a discharge letter advising them:
    • that the patient will be seen in the public respiratory clinic in 6 weeks
    • to review the patient in a week's time for recurrence of symptoms and/or general health markers that may indicate the apical nodule is significant
    • to do a CT scan of the chest with contrast medium, FBC, kidney and liver function tests (UEC/LFT) in five weeks' time
    • to refer the patient to the public hospital's respiratory outpatient clinic and to include the CT report and the blood results.

Note: the patient has not been asked if they wish to, nor made a decision to see the GP for aftercare and testing.

Day 16 – The GP reviews the patient and the patient appears to be symptom-free (MBS).

Day 45 – The GP requests a CT scan of the chest with contrast material, FBC, UEC/LFT and bills item 23 (all MBS).

Day 52 – The patient is seen by the respiratory physician at the public hospital outpatient clinic. The physician, after an appropriate history and examination. Reviews the available results (from the GP's investigations) and reassures the patient that the bronchopneumonia is completely resolved. The nodule on the chest X-ray appears innocuous (ABF).

Is this appropriate?

Day 1-5: Appropriate as the patient is a general practice patient (MBS).

Day 5-9: Appropriate as the patient is a public patient (ABF).

Day 16: Appropriate (MBS). This is a general post discharge consultation as part of the transition of care, not clinical aftercare. General practitioners are central to the holistic management and integration of care and will commonly, and appropriately, review patients after discharge from hospital.

Day 45: Not appropriate. The CT scan and blood tests are for the patient's public outpatient review. Public outpatient reviews and tests required by a public patient are considered part of an episode of public care. They are funded under public hospital arrangements. In this case, the hospital has shifted essential follow-up of a public patient with resolving pneumonia to a GP who has billed Medicare. Billing of Medicare and to hospital funding for the same services will lead to duplicate payments for the services (MBS and ABF).

Day 52: Appropriate as the patient is a public patient (services are funded through ABF).

Patient discharge and transition of care

It is expected that patients being discharged from hospital should have a discharge summary sent to their GP. Including any plans or recommendations for appropriate management of the patient's condition post discharge.

However, any necessary follow-up component of the medical intervention that is an intrinsic part of the public hospital episode of care is covered by public hospital funding. This follow-up treatment should not be billed to the MBS. In this case study, the patient has elected for a review to be conducted in a public clinic as a public patient. Therefore the tests required for the follow-up should have been requested by the hospital prior to discharge. The NHRA clause G16 states that: "Where care is directly related to an episode of admitted patient care. It should be provided free of charge as a public hospital service where the patient chooses to be treated as a public patient. Regardless of whether it is provided at the hospital or in private rooms."

In practice, this means that even if some tests or care cannot be provided on public hospital grounds. For example, in rural/remote areas where certain testing facilities may not be located at the public hospital. The hospital remains responsible for funding required tests and services for public patients. If a public hospital requests an external (to the premises) provider, such as a GP, pathologist, radiologist or other provider to provide components of public patient care. The hospital should organise remuneration as appropriate.

Key Points

What each party can do to ensure compliant billing in this type of circumstance:

  • The hospital, discharging officer, or practitioner preparing a discharge summary should clearly identify the patient's election status. In terms of the services requested (as being for public patient follow-up), and consider requesting the tests directly rather than through a GP.
  • The GP should ensure any requests they generate for radiology or pathology identify the patient's election status (in this case, that the patient is public).
  • The pathologist or radiologist should bill according to the patient's election status.
Last updated: 
9 June 2021

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