Services for patients with Type 2 Diabetes – Group Allied Health Services (Items 81100 to 81125)

ELIGIBLE PATIENTS

Medicare benefits are available for allied health group services for patients with type 2 diabetes. These items (81100 to 81125) apply to services provided by eligible diabetes educators, exercise physiologists and dietitians, on referral from a GP.

Services available under these items are in addition to the five individual allied health services available to patients each calendar year outlined in Parts 1 and 2.

To be eligible for these services, the patient must have in place one of the following:

• a GP Management Plan (GPMP) – item 721; or
• where a patient has an existing GP Management Plan, the GP has reviewed that plan (item 725); or
• for a resident of a residential aged care facility, the GP must have contributed to, or reviewed, a care plan prepared for them by the facility (item 731). [Note: Generally, residents of an aged care facility rely on the facility for assistance to manage their type 2 diabetes. Therefore, the resident may not need to be referred for allied health group services under these items, as the self management approach offered in group services may not be appropriate.]

Unlike the individual allied health services under items 10950 to 10970, there is no additional requirement for a Team Care Arrangement (item 723) in order for the patient to be referred for allied health group services.

Once the patient has been referred by their GP, a diabetes educator, exercise physiologist or dietitian will conduct an individual assessment. A maximum of one (1) assessment service is available per calendar year. After assessment, the patient may receive up to eight (8) group services per calendar year from an eligible diabetes educator, exercise physiologist and/or dietitian. A collaborative approach, where diabetes educators, exercise physiologists and dietitians work together to develop group service programs in their local area, is encouraged.

ASSESSMENT FOR GROUP SERVICES (ITEMS 81100, 81110 AND 81120)

An assessment service is provided by a diabetes educator, an exercise physiologist or a dietitian, on referral from a GP. The purpose of this service is to undertake an individual assessment of the patient preparing him/her for an appropriate group services program. It involves taking a comprehensive patient history, identification of individual goals and preparing the patient for the group service. This may also provide an opportunity to identify any patient who is likely to be unsuitable for group services.

Number of services per year

Patients are eligible for a maximum of one assessment for group services (item 81100 or 81110 or 81120) per calendar year. If more than one assessment service is provided in a calendar year, the subsequent service/s will not attract a Medicare rebate and the MBS safety net arrangements will not apply to costs incurred by the patient for the service/s.

If there is any doubt about a patient’s eligibility, Medicare Australia will be able to confirm the number of assessment services already claimed by the patient during the calendar year. The allied health professionals or the patient can call Medicare Australia on 132 011 to check this information.

Referral form

The GP must refer the patient using the Referral form for allied health group services under Medicare – refer Appendix 3. The allied health professional undertaking the assessment service will need to complete Part B of this form, and the patient will then need to present this form to the provider/s of group services.

Service length and type

This service must be of at least 45 minutes duration and provided to an individual patient. The allied health professional must personally attend the patient.

Reporting requirements

On completion of the assessment service, the allied health professional must provide a written report back to the referring GP outlining the assessment undertaken, whether the patient is suitable for group services and, if so, the nature of the group services to be delivered.

GROUP SERVICES (ITEMS 81105, 81115 AND 81125)

These services are provided in a group setting to assist with the management of type 2 diabetes.

Number of services per year

Patients are eligible for up to eight (8) allied health group services in total per calendar year. Each separate group service must be provided to the patient by only one type of allied health professional (ie either a diabetes educator, exercise physiologist or dietitian). However, the overall group services program provided for the patient could be comprised of one type of service only (eg 8 diabetes education services) or a combination of services (eg 3 diabetes education services, 3 dietitian services and 2 exercise physiology services). An eligible allied health professional 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.

Allied health group service providers are strongly encouraged to deliver multidisciplinary group services programs that allow patients to benefit from a range of interventions designed to assist in the management of their type 2 diabetes.

Where a patient receives more than the limit of 8 group services in a calendar year, the additional service/s will not attract a Medicare benefit and the MBS safety net arrangements will not apply to costs incurred by the patient for the service/s.

If there is any doubt about a patient’s eligibility for group services, Medicare Australia will be able to confirm the number of group services already claimed by the patient in the calendar year. The allied health professional or the patient can call Medicare Australia on 132 011 to check this information.

Multiple services on the same day

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

Referral form

The allied health professional/s undertaking the group services will need to receive the Referral form for allied health group services under Medicare, for which Part B has been completed by the provider who has undertaken the assessment service.

Group size

The service must be provided to a person who is part of a group of between 2 and 12 persons.

Service length

Each group service must be of at least 60 minutes duration.

Reporting requirements

On completion of the group services program, each allied health professional must provide, or contribute to, a written report back to the referring GP in respect of each patient. The report should describe the group services provided for the patient and indicate the outcomes achieved. While each allied health professional is required to provide feedback to the GP in relation to the group services that they provide to the patient, allied health professionals involved in the provision of a multidisciplinary program are encouraged to combine feedback into a single report to the referring GP.

REFERRAL REQUIREMENTS

The patient must be referred by their GP to an eligible allied health professional (diabetes educator, exercise physiologist or dietitian) who will undertake an individual assessment, preparing him/her for an appropriate group services program (under item 81100, 81110 or 81120).

When referring patients, GPs need to use the Referral form for allied health group services under Medicare (refer Appendix 3) provided by the Commonwealth Department of Health and Ageing. The referral form can be downloaded from the Department of Health and Ageing website at www.health.gov.au/epc or ordered by faxing (02) 6289 7120. The form can be modified to suit practice needs (for example, relevant software packages) as long as the information is substantially retained.

GPs are also encouraged to provide a copy of the relevant part of the patient’s care plan to the allied health professional.

Allied health professionals are required to retain a copy of the referral form for 24 months from the date the service was rendered (for Medicare Australia auditing purposes).

ALLIED HEALTH PROFESSIONAL ELIGIBILITY

Items 81100 to 81125 only apply to services provided by eligible diabetes educators, exercise physiologists and dietitians who are registered with Medicare Australia. If providers are already registered with Medicare Australia to use item 10951, 10953 or 10954, they do not need to register separately for items 81100 to 81125. Eligibility criteria are as follows:

Diabetes Educator: must be a ‘Credentialed Diabetes Educator’ (CDE) as credentialed by the Australian Diabetes Educators Association (ADEA).

Exercise Physiologists: must be an ‘Accredited Exercise Physiologist’ as accredited by the Australian Association for Exercise and Sports Science (AAESS).

Dietitian: must be an ‘Accredited Practising Dietitian’ as recognised by the Dietitians Association of Australia (DAA).

Registering with Medicare Australia

Medicare Australia registration forms may be obtained from Medicare Australia on 132 150 or at www.medicareaustralia.gov.au.

Changes to provider details

Allied health providers must notify Medicare Australia in writing of all changes to mailing details to ensure that they continue to receive this publication and any updates about Medicare rebateable allied health services.

ADDITIONAL INFORMATION

Out-of-pocket expenses and Medicare Safety Net

Allied health professionals are free to determine their own fees for both the assessment and group professional services. Charges in excess of the Medicare benefit are the responsibility of the patient. However, such out of pocket costs will count toward the Medicare safety net for that patient.

Publicly funded services

Items 81100 – 81125 do not apply for services that are provided by any other Commonwealth or State or Territory 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 81100-81125 can be claimed for services provided by eligible allied health professionals salaried by, or contracted to, the Service or health clinic. All requirements of the relevant item must be met, including registration of the allied health professional with Medicare Australia.

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.