How billing works in private practice 

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A beginners guide to billing in private practice  

The Medicare Benefit schedule (MBS) is the governments system of providing remuneration to doctors. It defines all procedures and consultations and sets a fee for each. The MBS is made up of “items”. Each carrying a definition and associated fee. Each item has a unique number to identify it. For each episode of care, a specialists permitted to select the best item numbers that reflect the care provided. Medicare will pay 75% of the associated fee and by law, health funds are required to pay the remaining 25% s a minimum.  

Each health fund sets their own rebate, which is higher than the MBS fee and includes any component payable by Medicare. In order to receive this higher benefit, health funds attach their own conditions, most importantly relating to the amount specialist may charge patients above the set rebate. Some funds have more than one scheme with different conditions attached. 

For intensivists

For each day of care by intensivists, an item number applies. There are two separate item numbers for the first and subsequent days of care. Additional to this is an item number for each day of respiratory or cardiovascular support (such as bypass or balloon pump). 

You can also claim for non-ICU patients, such as when you provide a ward consultation. Some procedures also have item numbers. 

Solo’s ICU billing sheet is a simple solution to ensuring you don’t miss out on anything. Simply attach a sticker and tick the relevant boxes. Once the admission is complete, simply submit to us via email or fax and we’ll take care of the rest. 

For anaesthetists

Anaesthetists have a system of billing that is unique compared to other specialists, called the Relative Value Guide (RVG). The RVG allocates a number of “units” to each item number. Medicare and health funds then set how much a unit is worth. Currently, the unit value for Medicare is $20.95 and for health funds it varies between $26 and $41. A guide to health fund unit rebates is included in our full guide. The maximum unit value recommended by the AMA is $94. 

The relative value guide (RVG)

For each anaesthetic delivered, the anaesthetist selects the appropriate item numbers, which dictates the number of units and subsequently dollar value of the anaesthetic episode. Each case has five components that the anaesthetist must select items number for. The first three apply to all anaesthetic cases, the last two are “optional extras”. 

1. Consultation

A pre-operative consultation is applicable to each anaesthetic. The item numbers are in the range 17610 (0 to 15 minutes) to 17625 (greater than 45 minutes). Note that the definitions for each of these item number contain more components that just the time taken. 

Alternatively, you may use item numbers 591 and 600. These are after hours emergency numbers where you are required to go to a hospital to see the patient. You may only use the item number for the first patient you attend to per recall – if you attend a hospital and do three after hours emergency cases, only the first can have a 591 or 600.  

2. Initiation of anaesthesia

Each case has a “flagfall” item number, with the number of units increasing with the complexity of the case. You will need to select the most appropriate definition for the case you are performing. You may only select one item number in this section, even if multiple procedures are being performed under the same anaesthetic. A good example for this is a gastroscopy and colonoscopy: while there are separate item numbers for each, you may only choose one item number. Note that regardless of the mode of anaesthesia (ie GA, sedation or regional), the item number attracts the same number of units. 

3. Time

The time taken for the anaesthetic is defined as the time that you provide exclusive and continuous care of a patient for anaesthesia. Units accrue at one unit per 15 minutes for the first two hours, then one unit for each 10 minutes or part thereof. There is a unique item number for each quantity of units. You are required to record the start and finish time of your anaesthetic – not just the item number.  

4. Modifiers

There are optional item numbers for the patient’s level of health and emergency surgery. Patients with an ASA of 3 or more attract extra units, and there are item numbers for in-hours and after hours emergency surgery. After hours emergency surgery attracts a 50% increase in the number of units earned (excluding consultation item number). 

5. Procedures

There are optional item numbers for procedures the anaesthetist perform. Examples include central venous or arterial cannulation, invasive pressure monitoring, blood transfusions and block for shoulder or lower limb surgery. 

There is plenty more to learn, for a copy of our complete billing guide with plenty of tips to maximise your billing, please email our team at .