Medicare Benefits Schedule (Mediguide: section 3)
On this Page:
- Medicare Benefits Schedule Book
- Services attracting Medicare benefits
- Excluded services
- Health screening
- Identifying a suitable item number
- Proposed surgery
- Services requiring clinical and/or photographic information
- Restricted items
- Listing a new procedure or diagnostic test
- Review of services in the Medicare Benefits Schedule
Medicare Benefits Schedule Book
The Medicare Benefits Schedule (MBS) Book contains information on professional services covered by Medicare. It also has notes to explain the Medicare program and each part of the Schedule in detail. It is published by the Department of Health and Ageing and is available in printed format and on the Department’s website at Department of Health and Ageing
.
Services attracting Medicare benefits
Medicare benefits are paid for professional services provided by doctors, some dentists, optometrists and eligible allied health professionals. A professional service must be necessary for the management of the patient’s medical condition and must be clinically relevant. A clinically relevant service is a service provided by a doctor, approved dentist, optometrist or eligible allied health professional that is generally accepted in the medical, dental, optometrical or the relevant allied health profession as being necessary for appropriate treatment of the patient.
For benefits to be payable, practitioners must have face-to-face consultations with their patients. Most services must be performed personally by a medical practitioner to attract benefits. Notable exclusions are telepsychiatry consultations, some diagnostic tests, pathology tests and diagnostic imaging services. These services are listed in the General Explanatory Notes of the Medicare Benefits Schedule Book.
Excluded services
Some services do not attract Medicare benefits including:
- transplantation of a thoracic or abdominal organ other than a kidney
- removal from a cadaver of kidneys for transplantation
- removal of tattoos
- chelation therapy (other than for the treatment of heavy metal poisoning)
- injection of Human Chorionic Gonadotrophin in the management of obesity
- hyperbaric oxygen therapy in the treatment of multiple sclerosis
- services such as physiotherapy, occupational therapy, speech pathology, chiropractic services, and podiatry (except referred patients being managed by their general practitioner under an Enhanced Primary Care plan)
- services by a salaried practitioner in a hospital (other than a private hospital) except when the practitioner is in private practice
- telephone consultations, referrals or repeat prescriptions which do not involve an attendance by the patient
- group counselling (except in limited circumstances), health education, weight reduction or fitness classes
- cosmetic surgery for non-medical reasons
- body piercing
- medical examinations for life insurance, superannuation, provident account scheme or admission to membership of a friendly society
- service rendered by, or on behalf of, Australian, state or local government, or one of their authorities
- service where the medical expense is the responsibility of the patient’s employer
- mass immunisation programs
- health screening
- compensation-related medical service where there is a reimbursement agreement between a compensation claimant and the insurer
- self-treatment by practitioners or treatment of their immediate family
- treatment of a partner or partner’s dependants unless there is provision for a charge to be made for such treatment within the partnership agreement
- laser vision correction or other refractive eye surgery
- vision screening
- compulsory eye examinations to obtain any commercial licence (for example flying or driving)
- eye examination required by an employer (for example to obtain safety glasses)
Practitioners providing these services should bill the patient and write on the account “does not attract Medicare benefits”.
Health screening
Health screening is a test or examination that is not reasonably necessary for the management of the patient’s medical condition. Under the Health Insurance Act 1973, these services are excluded from payment of benefits.
A practitioner is not precluded from providing such services, however accounts for the service should be marked to indicate that a Medicare benefit is not payable.
Services in this category include:
- screening for osteoporosis
- multiphasic health screening
- testing to determine fitness for weight reduction classes, fitness programs, scuba diving or other sporting activities
- examinations for pilot, driving or other commercial licences, excepting medical assessment for private driver licences due to age or medical condition
- mammography (breast screening), except as provided in items 59300 and 59303
- examinations for entrance to educational establishments
- examination of a potential employee for a proposed employer (unless the candidate is currently unemployed and the potential employer requires the examination)
- pathology tests for a person occupationally exposed to the sexual transmission of disease
- pathology services associated with clinical ecology (previously referred to as orthomolecular medicine)
Complete details are set out in the General Explanatory Notes of the Medicare Benefits Schedule Book.
Identifying a suitable item number
Item numbers used in billing must accurately reflect the service. If an item which accurately describes the service cannot be found, call the Schedule Interpretation Section or a Medicare Australia medical adviser on 132 150*.
* Local call rates. Normal mobile and public phone charges apply.
Proposed surgery
Medicare Australia can offer an opinion on whether proposed surgery might attract Medicare benefits for augmentation mammaplasty, meloplasty, blepharoplasty, rhinoplasty, liposuction, varicose veins and laser photocoagulation. Applications should be forwarded directly to:
Medicare Australia
Medicare Claims Review Panel
PO Box 1001
Tuggeranong ACT 2901
Applications should include full clinical and/or photographic evidence to demonstrate the medical reasons for the proposed surgery.
Services requiring clinical and/or photographic information
Specific items in the Medicare Benefits Schedule need Medicare Australia approval where the item descriptor includes the phrase “where it can be demonstrated”. Claims for these services should be accompanied by full clinical details, including pre-operative colour photographs where applicable, and sent to:
Medicare Australia
Medicare Claims Review Panel
PO Box 1001
Tuggeranong ACT 2901
The claim will be reviewed by the review panel for a recommendation to be made. Clinical details and/or photographs accompanying the claim should be in an envelope marked “Medical‑in‑confidence”. Where digital photographs are supplied, the practitioner must sign and certify that the digital photograph has not been altered.
Following the repeal of sections 11 and 12 of the Health Insurance Act 1973 a panel was established to review and make recommendations on claims where clinical and/or photographic information is required for benefit determination. The panel does not have the legislative power to approve benefits for any other items in the MBS or to overrule existing item descriptors. The panel consists of three medical practitioners: two from Medicare Australia and one from the Department of Health and Ageing.
Restricted items
Some services are “restricted” when provided with other services. A benefit may not be paid when these services are provided in conjunction with each other. In general, where a restriction exists between items, benefits are payable for the service attracting the higher benefit only. The Medicare statement will identify the service for which benefits are not payable and provide a reason for this. For further details see the Medicare Benefits Schedule.
Listing a new procedure or diagnostic test
If a practitioner wishes to have a new procedure, diagnostic test or pathology service recognised in the Medicare Benefits Schedule, they should contact the Medical Services Advisory Committee (MSAC). This committee advises the Minister for Health and Ageing on the strength of evidence relating to the safety, effectiveness and cost-effectiveness of new and emerging medical services and technologies and under what circumstances public funding, including listing on the MBS, should be supported.
Membership of the committee comprises a mix of clinical expertise covering pathology, surgery, internal medicine and general practice, plus clinical epidemiology and clinical trials, health economics, consumers, and health administration and planning. Further information relating can be found at the Medical Services Advisory Committee (MSAC) website
Review of services in the Medicare Benefits Schedule
Review of a particular service or group of services within the MBS is undertaken by the Medicare Benefits Consultative Committee.
This informal advisory committee has been established by agreement between the Minister for Health and Ageing and the Australian Medical Association (AMA). The committee consists of representatives of the Department of Health and Ageing, Medicare Australia, the AMA and relevant medical profession groups.
Pathology services are dealt with on a similar basis by the Pathology Services Table Committee.
Some documents on this page may require the free Adobe PDF reader.
Last updated: 28 May, 2008