Medicare is conducting compliance audits of
specialists’ billing; particularly where more than one initial consultation is
rendered in respect of a single referral.
The consequences of incorrect
itemisation or rendering services without a valid referral can be expensive -
repayment to Medicare of 100% of the benefits paid for the service and
significant additional administrative penalties. The audits emphasise the
importance to specialists of ensuring correct administrative practices with
respect to referrals.
Do you have a valid referral?
valid referral is required before a referred specialist consultation can be
itemised. Pre-anaesthetic consultations, emergencies and referrals of private
patients in hospital are exceptions.
A valid referral must be:
- in writing;
- signed and dated by the referrer;
- in date at the time the consultation service
is rendered; and
- received prior
to or at the time of the specialist consultation.
unlawful to back-date a referral, so referring practitioners should not be asked
to do so.
Referrals may be specified to be for any relevant period
(including indefinitely if necessary). If the duration is unspecified it is
assumed to be for 12 months (if referred by a GP) or three months (if referred
by another specialist).
The duration of the referral commences on the day
of the initial consultation, not the date on which the referral is written.
When is a new referral required?
Broadly, a new referral will be
- where the patient requires
further specialist input to the management of the condition for which they were
previously referred but the referral has expired; and
- where specialist input to an unrelated condition
It is important that a new referral is sought
where an unrelated condition requires specialist treatment and that the new
valid referral is received prior to the commencement of treatment for that
It is equally important to ensure your practice staff are
aware that the need for a new referral does not necessarily enable an initial
consultation service to be itemised.
When can you itemise an initial
The Medicare Benefits Schedule (MBS) item descriptor for
initial consultation items (e.g. 104, 110 etc) states the items are an “initial
consultation in a single course of treatment”. A single course of treatment is
defined as follows:
“… an initial attendance by a specialist
or consultant physician and the continuing management/treatment up to the stage
where the patient is referred back to the care of the referring practitioner.
It also includes any subsequent review of the patient's condition by the
specialist or the consultant physician that may be necessary. Such a review may
be initiated by either the referring practitioner or the specialist/consultant
The presentation of an unrelated illness, requiring the
referral of the patient to the specialist's or the consultant physician's care
would initiate a new course of treatment in which case a new referral would be
Where an unrelated
condition requires treatment an initial consultation can be itemised but a new
valid referral must be received prior to consulting the patient.
However, simply because the patient requires a new referral
because the previous referral has expired does not entitle the specialist to
bill another initial consultation service unless it is at least nine months
since the patient was last seen for that condition and the referring
practitioner deems further review necessary.
six-monthly consultations for management of a single condition may require a new
referral if an indefinite referral has not been given but will ordinarily not
allow more than one initial consultation service to be billed.
Conversely, a single yearly consultation for an ongoing condition seen on the
basis of a 12 month referral may allow an initial consultation item to be billed
for each consultation if review is deemed necessary.
- Specialists need to be aware of the
importance of correctly itemising initial and subsequent referred
- Check that you
have a valid referral – in writing, signed and dated by the referrer and
received prior to or at the time of the specialist consultation.
- Back-dating a referral is
- Check that you
understand when you need a new referral – particularly where a patient presents
with an unrelated condition.
- Ensure your practice staff understand the circumstances
in which you can bill for an initial consultation.
Specialist referrals and initial consultations: decision-making
For more information on specialist referrals and initial
consultations refer to Avant’s decision-making flowchart.
If you have any specific questions or are requested to complete an
audit, it is imperative that you seek advice from our Medico-legal Advisory
Service on 1800 126 268 promptly to maximise your opportunity to correct any
errors and avoid or reduce administrative penalties.
Read our Risk IQ fact sheet, Take a R.E.S.T and stay out of
trouble with Medicare.
Share your view
We welcome your feedback on this article – email the Editor at: email@example.com