Health Insurance (General Medical Services Table) Regulations 2003

2 Commencement

These Regulations commence on 1 November 2003.

3 Health Insurance (General Medical Services Table) Regulations 2002 — repeal

The following Statutory Rules are repealed:

 2002 Nos. 244 and 254

 2003 No. 69.

4 Definitions

In these Regulations:

Act means the Health Insurance Act 1973.

this table means the table of general medical services set out in Schedule 1.

5 General medical services table

The table of medical services (other than diagnostic imaging services and pathology services) set out in Schedule 1 is prescribed for subsection 4 (1) of the Act.

Schedule 1 Table of general medical services

(regulation 5)

Part 1 Prescription of table

1 Prescription of table

For section 4 of the Act, these Regulations prescribe a table of general medical services that sets out:

(a) in Part 2 — rules for interpretation of the table; and

(b) in Part 3:

(i) items of general medical services; and

(ii) the amount of fees applicable for each item.

Part 2 Rules of interpretation

2 Application of table

An item in Part 3 does not apply to a service provided in contravention of a law of the Commonwealth or of a State or Territory.

3 General

(1) In this table, unless the contrary intention appears:

ACRRM means the Australian College of Rural and Remote Medicine.

attendance of a minor nature or minor attendance, for an attendance on a patient by a consultant physician, means an attendance that:

(a) is a second or subsequent attendance on the patient, in the course of a single course of treatment by the consultant physician, during which it is not necessary for the consultant physician to carry out a physical examination of the patient; and

(b) does not result in a substantial alteration to the treatment of the patient.

closed reduction:

(a) means treatment of a dislocation or fracture by non‑operative reduction; and

(b) includes the use of percutaneous fixation, or external splintage by cast or splints.

comprehensive hyperbaric medicine facility means a separate hospital area that, on a 24-hour basis:

(a) is equipped and staffed so that it is capable of providing to a patient:

(i) hyperbaric oxygen therapy at a treatment pressure
of at least 2.8 atmospheric pressure absolute (180 kilopascal gauge pressure); and

(ii) mechanical ventilation and invasive cardiovascular monitoring within a monoplace or multiplace chamber for the duration of the hyperbaric treatment; and

(b) is under the direction of at least 1 practitioner who is rostered, and immediately available, to the facility during normal working hours and who:

(i) is a specialist with training in diving and hyperbaric medicine; or

(ii) holds a Diploma of Diving and Hyperbaric Medicine of the South Pacific Underwater Medicine Society; and

(c) is staffed by:

(i) at least 1 medical practitioner with training in diving and hyperbaric medicine who is present in the facility and immediately available at all times when patients are being treated at the facility; and

(ii) at least 1 registered nurse with specific training in hyperbaric patient care to the published standards of the Hyperbaric Technicians and Nurses Association, who is present during hyperbaric oxygen therapy; and

(d) has admission and discharge policies in operation.

general intensive care unit means a separate hospital area that:

(a) is equipped and staffed so that it is capable of providing to a patient:

(i) mechanical ventilation for a period of several days; and

(ii) invasive cardiovascular monitoring; and

(b) is supported by:

(i) during normal working hours — at least 1 specialist, or consultant physician, in the specialty of intensive care, who is immediately available, and exclusively rostered, to that area; and

(ii) at all times — at least 1 registered medical practitioner who is present in the hospital and immediately available to that area; and

(iii) at least 18 hours each day — at least 1 registered nurse; and

(c) has admission and discharge policies in operation.

general practitioner means:

(a) a practitioner who is vocationally registered under section 3F of the Act; or

(b) a practitioner who:

(i) is a Fellow of the RACGP; and

(ii) participates in the quality assurance and continuing medical education program of the RACGP; and

(iii) meets the RACGP requirements for quality assurance and continuing education; or

(c) a practitioner who is undertaking a placement in general practice that is approved by the RACGP:

(i) as part of a training program for general practice leading to the award of Fellowship of the RACGP; or

(ii) as part of another training program recognised by the RACGP as being of an equivalent standard; or

(iii) as part of the Rural and Remote Area Placement Program administered by the Australian College of Rural and Remote Medicine; or

(d) an eligible non-vocationally recognised medical practitioner; or

(e) a practitioner who is undertaking a placement in general practice as part of the Pre-vocational General Practice Placements Program administered by the ACRRM, RACGP or GPET.

GPET means the body registered under the Corporations Act 2001 as General Practice Education and Training Limited (ACN 095 433 140).

institution means a place (other than a hospital or residential aged care facility) at which residential accommodation or day care is, or both residential accommodation and day care are, made available to:

(a) disadvantaged children; or

(b) juvenile offenders; or

(c) aged persons; or

(d) chronically ill psychiatric patients; or

(e) homeless persons; or

(f) unemployed persons; or

(g) persons suffering from alcoholism; or

(h) persons addicted to drugs; or

(i) physically or intellectually disabled persons.

intensive care unit means a general intensive care unit or a neo-natal intensive care unit.

item means:

(a) an item mentioned, by number, in column 1 of:

(i) Part 3; or

(ii) Part 3 of the diagnostic imaging services table; or

(iii) Part 3 of the pathology services table; and

(b) in a reference immediately followed by a number — the item so numbered.

A reference (if any) by number to item 55028 is a reference to the item so numbered in the diagnostic imaging services table.

neo-natal intensive care unit means a separate hospital area that:

(a) is equipped and staffed so that it is capable of providing to a patient who is a newly born child:

(i) mechanical ventilation for a period of several days; and

(ii) invasive cardiovascular monitoring; and

(b) is supported by:

(i) during normal working hours — at least 1 consultant physician in paediatric medicine who is immediately available, and exclusively rostered, to that area; and

(ii) at all times — at least 1 registered medical practitioner who is present in the hospital and immediately available to that area; and

(iii) at least 18 hours each day — at least 1 registered nurse; and

(c) has admission and discharge policies in operation.

open reduction means treatment of a dislocation or fracture by either:

(a) operative exposure, including the use of any internal or external fixation; or

(b) non-operative (closed) reduction using intra-medullary fixation or external fixation.

RACGP means the Royal Australian College of General Practitioners.

referring practitioner, for the referral of a patient, means:

(a) in the case of all referrals — a medical practitioner; and

(b) for a referral made to a specialist who is an ophthalmologist — an optometrist; and

(c) for a referral that arises out of a dental service provided by a dental practitioner and that is made to a specialist (but not a consultant physician) — a dental practitioner; and

(d) for a referral that arises out of a dental service provided by a dental practitioner who is approved by the Minister for the purposes of paragraph (b) of the definition of professional service in subsection 3 (1) of the Act and that is made to a consultant physician — a dental practitioner.

residential aged care facility means a facility where residential care (within the meaning given by section 41‑3 of the Aged Care Act 1997) is provided.

Rural, Remote and Metropolitan Areas Classification means the document so titled, as in force on 1 January 2001, setting out certain categories of areas in Australia that have been determined by the Department by reference to population size and remoteness of locality on the basis of 1991 census data published by the Australian Bureau of Statistics in 1994.

(2) A reference to a Group in the table includes every item in the Group, and a reference to a Subgroup in the table includes every item in the Subgroup.

(3) A reference in the table to an eligible non-vocationally recognised medical practitioner is a reference to:

(a) a medical practitioner (including an overseas trained practitioner or a temporary resident medical practitioner) who:

(i) is registered as a medical practitioner under the Rural Other Medical Practitioners’ Program; and

(ii) is providing general medical services in accordance with that Program; or

(b) a medical practitioner who:

(i) is registered as a medical practitioner under the Outer Metropolitan (Other Medical Practitioners) Relocation Incentive Program; and

(iii) is not vocationally registered under section 3F of the Act, but is required under that Program to undertake additional training or other activities:

(A) that could enable vocational registration within 4 years or, on written application, 5 years, after commencing the training or other activities; and

(B) of which the Commission has written notice; or

(c) a medical practitioner who:

(i) is registered as a medical practitioner under the MedicarePlus for Other Medical Practitioners Program; and

(iii) is not vocationally registered under section 3F of the Act; or

(d) a medical practitioner who:

(i) is registered as a medical practitioner under the Medical Deputising Service — After Hours Other Medical Practitioners Program; and

(iii) is not vocationally registered under section 3F of the Act.

(4) For subrule (3):

(a) the Rural Other Medical Practitioners’ Program is a program administered by the Commission that, in relation to medical services provided in accordance with the Program, provides a particular level of medicare benefits; and

(b) the Outer Metropolitan (Other Medical Practitioners) Relocation Incentive Program is a program administered by the Department that, in relation to medical services provided in accordance with the Program, provides a particular level of medicare benefits; and

(c) the MedicarePlus for Other Medical Practitioners Program is a program administered by the Commission that, in relation to medical services provided in accordance with the Program, provides a particular level of medicare benefits; and

(d) the Medical Deputising Service — After Hours Other Medical Practitioners Program is a program administered by the Commission that, in relation to medical services provided in accordance with the Program, provides a particular level of medicare benefits.

4 Meaning of symbols (S) and (G)

(1) An item including the symbol (S) applies only to a service performed by a specialist (and not to a service performed by a consultant physician) in the practice of his or her specialty, being:

(a) a service that:

(i) is provided to a patient who has been referred to the specialist; and

(ii) is the first service performed by the specialist in accordance with the referral; or

(b) a service that:

(i) is provided to a patient who has been referred to the specialist; and

(ii) is part of a single course of treatment given for the condition identified in the referral or, if no condition was identified in the referral, part of a single course of treatment for the condition identified by the specialist; and

(iii) is provided within the period of validity of the referral that is applicable under regulation 31 of the Health Insurance Regulations 1975; or

(c) a service that:

(i) is provided to a patient who has declared that a written referral completed by a named referring practitioner has been lost, stolen or destroyed before the service was provided; and

(ii) is the first service performed by the specialist in accordance with the referral; or

(d) a service that:

(i) is provided to a patient who has not been referred to the specialist; and

(ii) is a service that, in an emergency within the meaning of subregulation 30 (5) of the Health Insurance Regulations 1975, the specialist decides is necessary in the patient’s interests to be provided as soon as practicable without a referral.

(2) An item including the symbol (G) applies only to a service provided otherwise than by a specialist in accordance with subrule (1).

5 Meaning of single course of treatment in certain circumstances

(1) In subrules 3 (1), 4 (1) and 7 (1) and items 104, 105, 106, 107, 108, 110, 116, 119, 122, 128, 131, 385, 386, 387 and 388, single course of treatment, in relation to a patient, includes:

(a) the initial attendance on the patient by a specialist or consultant physician; and

(b) the continuing management or treatment up to and including the stage when the patient is referred back to the care of the referring practitioner; and

(c) any subsequent review of the patient’s condition by the specialist or consultant physician that may be necessary, whether the review is initiated by the referring practitioner or by the specialist or consultant physician.

(2) For subrule (1), single course of treatment does not include treatment of an unrelated illness that requires referral of the patient to the specialist’s or consultant physician’s care.

(3) For subrule (1), an attendance (the later attendance) on the patient by the specialist or consultant physician, after the end of the period of validity of the last referral to have application under regulation 31 of the Health Insurance Regulations 1975, initiates a new course of treatment if:

(a) the referring practitioner considers the later attendance necessary for the patient’s condition to be reviewed; and

(b) the patient was most recently attended by the specialist or consultant physician more than 9 months before the later attendance.

6 Meaning of professional attendance in certain items

(1) In items 1 to 338, 348 to 388, 410 to 417, 501 to 536, 601, 602, 697, 698, 2501 to 2727 and 10900 to 10929, professional attendance includes (but is not limited to) the provision, in relation to a patient, of any of the following services:

(a) the evaluation of the patient’s condition or conditions including, if applicable, evaluation using a health screening service mentioned in subsection 19 (5) of the Act;

(b) the formulation of a plan for the management and, if applicable, for the treatment of the patient’s condition or conditions;

(c) the provision of advice to the patient about the patient’s condition or conditions and, if applicable, about treatment;

(d) if authorised by the patient, the provision of advice to another person, or other persons, about the patient’s condition or conditions and, if applicable, about treatment;

(e) the recording of the clinical details of the service or services provided to the patient.

(2) If:

(a) in connection with a professional attendance mentioned in any of items 3 to 96, vaccine is supplied to a patient; and

(b) the cost of the vaccine is not subsidised by the Commonwealth or a State;

the professional attendance is taken not to include that supply.

7 Interpretation of items 104 to 131 and 300 to 388

(1) In items 104 to 131 and 300 to 388, a reference to an attendance on a patient by a specialist, or consultant physician, in the practice of his or her specialty following referral of the patient to him or her:

(a) includes such an attendance on a patient who:

(i) has declared that a written referral of the patient was completed by a medical practitioner; or

(ii) in an emergency (within the meaning of subregulation 30 (5) of the Health Insurance Regulations 1975) has not been referred to the specialist, or consultant physician, if the specialist or consultant physician decides that it is necessary in the patient’s interests to provide the service mentioned in the item as soon as practicable without a referral; but

(b) does not include such an attendance if:

(i) the attendance forms part of a single course of treatment in which the first service was provided more than 12 months (or such other period, if any, set by the referring practitioner in, or in connection with, the referral) before the attendance; and

(ii) a later referral has not been made.

(2) For this rule, referral means referral by a referring practitioner.

8 Meaning of amount under rule 8 in certain items

(1) In items 4, 13, 19 and 20, amount under rule 8 means an amount equal to the sum of:

(a) the fee for item 3; and

(i) if not more than 6 patients are attended at a single attendance — $20.60 divided by the number of patients attended; or

(2) In items 24, 25, 33 and 35, amount under rule 8 means an amount equal to the sum of:

(a) the fee for item 23; and

(i) if not more than 6 patients are attended at a single attendance — $20.60 divided by the number of patients attended; or

(3) In items 37, 38, 40 and 43, amount under rule 8 means an amount equal to the sum of:

(a) the fee for item 36; and

(i) if not more than 6 patients are attended at a single attendance — $20.60 divided by the number of patients attended; or

(4) In items 47, 48, 50 and 51, amount under rule 8 means an amount equal to the sum of:

(a) the fee for item 44; and

(i) if not more than 6 patients are attended at a single attendance — $20.60 divided by the number of patients attended; or

(5) In items 58, 81, 87 and 92, amount under rule 8 means an amount equal to the sum of:

(a) $8.50; and

(i) if not more than 6 patients are attended at a single attendance — $15.50 divided by the number of patients attended; or

(6) In items 59, 83, 89, 93, 2610, 2631 and 2673, amount under rule 8 means an amount equal to the sum of:

(a) $16.00; and

(i) if not more than 6 patients are attended at a single attendance — $17.50 divided by the number of patients attended; or

(7) In items 60, 84, 90, 95, 2613, 2633, 2675 and 2707, amount under rule 8 means an amount equal to the sum of:

(a) $35.50; and

(i) if not more than 6 patients are attended at a single attendance — $15.50 divided by the number of patients attended; or

(8) In items 65, 86, 91, 96, 2616, 2635, 2677 and 2708, amount under rule 8 means an amount equal to the sum of:

(a) $57.50; and

(i) if not more than 6 patients are attended at a single attendance — $15.50 divided by the number of patients attended; or

(9) In item 195, amount under rule 8 means an amount equal to the sum of:

(a) the fee for item 193; and

(i) if not more than 6 patients are attended at a single attendance — $20.60 divided by the number of patients attended; or

(10) In item 414, amount under rule 8 means an amount equal to the sum of:

(a) the fee for item 410; and

(i) if not more than 6 patients are attended at a single attendance — $20.60 divided by the number of patients attended; or

(11) In item 415, amount under rule 8 means an amount equal to the sum of:

(a) the fee for item 411; and

(i) if not more than 6 patients are attended at a single attendance — $20.60 divided by the number of patients attended; or

(12) In item 416, amount under rule 8 means an amount equal to the sum of:

(a) the fee for item 412; and

(i) if not more than 6 patients are attended at a single attendance — $20.60 divided by the number of patients attended; or

(13) In item 417, amount under rule 8 means an amount equal to the sum of:

(a) the fee for item 413; and

(i) if not more than 6 patients are attended at a single attendance — $20.60 divided by the number of patients attended; or

9 Items 10809 and 10929 not to apply in certain circumstances

Items 10809 and 10929 do not apply if the patient’s requirement for contact lenses is only for any of the following reasons:

(a) because the patient does not want to wear spectacles for reasons of appearance;

(b) because the patient wants contact lenses for work or sporting purposes;

(c) because the patient has difficulty in using, or cannot use, spectacles for psychological reasons.

10 Personal attendance by medical practitioners generally

(1) The items mentioned in subrule (2) apply only to a service provided in the course of a personal attendance by a single medical practitioner on a single patient on a single occasion.

(2) The items are items 1 to 164, 173 to 338, 348 to 10816, 11012, 11015, 11018, 11021, 11212, 11304, 11500, 11600, 11627, 11701, 11712, 11724, 11921, 12000, 12003, 12201, 13030, 13100, 13103, 13106, 13109, 13110, 13112, 13209, 13290, 13292, 13300, 13303, 13306, 13309, 13312, 13318, 13319, 13400, 13500, 13503, 13506, 13700, 13815, 13818, 13830, 13839, 13842, 13845, 13848, 13851, 13854, 13857, 13870, 13873, 13876, 13879, 13882, 13885, 13888, 14100, 14103, 14106, 14109, 14112, 14115, 14118, 14120, 14122, 14124, 14126, 14128, 14130, 14132, 14200, 14203, 14206, 14209, 14212, 14215, 14224, 15600, 16003 to 16512 and 16515 to 51318.

(3) Items 170, 171, 172, 342, 344 and 346 apply only to a service provided in the course of a personal attendance by a single medical practitioner.

(4) For this rule, an attendance by a medical practitioner on a patient by way of a telepsychiatry consultation, to which any of items 353 to 358 applies, is taken to be a personal attendance by the medical practitioner on the patient.

11 Personal attendance by certain medical practitioners

(1) The items mentioned in subrule (3) apply only to a service provided in the course of a personal attendance by:

(a) a medical practitioner (other than a medical practitioner employed by the proprietor of a hospital that is not a private hospital); or

(b) a medical practitioner who:

(i) is employed by the proprietor of a hospital that is not a private hospital; and

(ii) provides the service otherwise than in the course of employment by that proprietor.

(2) Paragraph (1) (b) applies whether or not another person provides essential assistance to the medical practitioner in accordance with accepted medical practice.

(3) The items are items 1 to 10816, 11012, 11015, 11018, 11021, 11212, 11304, 11500, 11600, 11627, 11701, 11712, 11724, 11921, 12000, 12003, 12201, 13030, 13100, 13103, 13106, 13109, 13110, 13112, 13209, 13290, 13292, 13300, 13303, 13306, 13309, 13312, 13318, 13319, 13400, 13500, 13503, 13506, 13700, 13815, 13818, 13830, 13839, 13842, 13845, 13848, 13851, 13854, 13857, 13870, 13873, 13876, 13879, 13882, 13885, 13888, 14100, 14103, 14106, 14109, 14112, 14115, 14118, 14120, 14122, 14124, 14126, 14128, 14130, 14132, 14200, 14203, 14206, 14209, 14212, 14215, 14224, 15600, 16003 to 16512 and 16515 to 51318.

(4) For this rule, an attendance by a medical practitioner on a patient by way of a telepsychiatry consultation, to which any of items 353 to 358 applies, is taken to be a personal attendance by the medical practitioner on the patient.

12 Certain services may be provided by persons other than medical practitioners

(1) The items mentioned in subrule (2) apply whether the medical service is given by:

(a) a medical practitioner; or

(b) a person, other than a medical practitioner, who:

(i) is employed by a medical practitioner; or

(ii) in accordance with accepted medical practice, acts under the supervision of a medical practitioner.

(2) The items are items 11000, 11003, 11004, 11005, 11006, 11009, 11024, 11027, 11200, 11203, 11204, 11205, 11210, 11211, 11215, 11218, 11221, 11222, 11224, 11225, 11235, 11237, 11240, 11241, 11242, 11243, 11300, 11303, 11306, 11309, 11312, 11315, 11318, 11321, 11324, 11327, 11330, 11332, 11333, 11336, 11339, 11503, 11506, 11509, 11512, 11602, 11604, 11605, 11610, 11611, 11612, 11614, 11615, 11700, 11702, 11708, 11709, 11710, 11711, 11713, 11715, 11718, 11721, 11800, 11810, 11830, 11833, 11900, 11903, 11906, 11909, 11912, 11915, 11919, 12012, 12015, 12018, 12021, 12200, 12203, 12207, 12210, 12213, 12215, 12217, 12500 to 12533, 13020, 13025, 13200, 13203, 13206, 13212, 13215, 13218, 13221, 13703, 13706, 13709, 13750, 13755, 13757, 13760, 13915 to 13948, 14050, 14053, 14218, 14221, 15000 to 15336, 15339 to 15357, 15500 to 15539 and 16514.

13 Conditions under which certain services to be provided

Items 11309, 11312, 11315, 11318 and 11321 apply only to a service provided:

(a) in conditions that allow the establishment of determinate thresholds; and

(b) in a sound-attenuated environment with background noise conditions that comply with Australian Standard AS1269‑1983 of the Standards Association of Australia, as in force on 1 August 1987; and

(c) using calibrated equipment that complies with Australian Standard AS2586-1983 of the Standards Association of Australia, as in force on 1 August 1987.

14 Application of items 51700 to 53706

Items 51700 to 53706 apply only to a service provided in the course of dental practice by a dental practitioner approved by the Minister for the purposes of the definition of professional service in subsection 3 (1) of the Act.

15 Meaning of amount under rule 15 in certain items

(1) In item 15003, amount under rule 15 means an amount equal to the sum of:

(a) the fee for item 15000; and

(b) $13.85 for each field separately treated in excess of 1.

(2) In item 15009, amount under rule 15 means an amount equal to the sum of:

(a) the fee for item 15006; and

(b) $15.05 for each field separately treated in excess of 1.

(3) In item 15103, amount under rule 15 means an amount equal to the sum of:

(a) the fee for item 15100; and

(b) $15.25 for each field separately treated in excess of 1.

(4) In item 15109, amount under rule 15 means an amount equal to the sum of:

(a) the fee for item 15106; and

(b) $18.40 for each field separately treated in excess of 1.

(5) In item 15115, amount under rule 15 means an amount equal to the sum of:

(a) the fee for item 15112; and

(b) $38.35 for each field separately treated in excess of 1.

(6) In item 15214, amount under rule 15 means an amount equal to the sum of:

(a) the fee for item 15211; and

(b) $25.85 for each field separately treated in excess of 1.

(7) In items 15230, 15233, 15236, 15239, 15242, 15260, 15263, 15266, 15269 and 15272, amount under rule 15 means an amount equal to the sum of:

(a) $48.40; and

(b) $30.75 for each field separately treated in excess of 1.

16 Meaning of amount under rule 16 in certain items

In item 44376 (reamputation), amount under rule 16 means an amount equal to 75% of the fee specified for the item relating to an original amputation (any of items 44325 to 44373) of the body part for which the reamputation is performed.

16A Cleft lip and cleft palate services

An item in Group C1, C2 or C3 applies only to a service provided to a prescribed dental patient.

Note For the meaning of prescribed dental patient, see section 3BA of the Act.

17 Meaning of (AD) in Group C2 — Oral and maxillofacial surgical services and Group C3 — General and prosthodontic services

An item in the range 75200 to 75206 and 75800 to 75854 that includes the symbol (AD) applies only to a service provided by a dental practitioner.

18 Orthodontic services

(1) An item in the range 75001 to 75006 or 75024 to 75051 that includes the symbol (AO) applies only to a service provided by an accredited orthodontist.

(2) An item in the range 75009 to 75023 that includes the symbol (AO) and the symbol (AOS) applies only to a service provided by:

(a) an accredited orthodontist; or

(b) a dental practitioner who is:

(i) registered or licensed as an oral and maxillofacial surgeon under a law of the State or Territory in which the service is rendered that provides for the registration or licensing of oral and maxillofacial surgeons; and

(ii) a dental practitioner approved by the Minister for the purposes of the definition of professional service in subsection 3 (1) of the Act.

(3) In this rule:

accredited orthodontist means:

(a) a dental practitioner who is:

(i) registered or licensed as an orthodontist under the relevant law; and

(ii) accredited by the Minister for the purposes of this rule; or

(b) a dental practitioner:

(i) who is not registered or licensed under the relevant law as an orthodontist or who practises in a State or Territory in which there is no provision for the registration or licensing of orthodontists; and

(ii) whose qualifications or experience demonstrate to the Committee his or her competence in the field of orthodontics that is applicable to the giving of the services specified in items 75001 to 75051; and

(iii) who is accredited by the Minister for the purposes of this rule.

Committee means the Medical Benefits (Dental Practitioners) Advisory Committee established under section 136 of the National Health Act 1953.

relevant law, in relation to a service provided to a patient, means a law of the State or Territory in which the service is provided that provides for the registration or licensing of orthodontists.

19 Oral surgery services

An item in the range 75150 to 75621 that includes the symbol (AOS) applies only to a service provided by a dental practitioner who is:

(a) registered as an oral and maxillofacial surgeon under a law of the State or Territory in which the service is rendered that provides for the registration or licensing of oral and maxillofacial surgeons; and

(b) a dental practitioner approved by the Minister for the purposes of the definition of professional service in subsection 3 (1) of the Act.

20 Meaning of report in Group D1 — Miscellaneous diagnostic procedures and investigations

In items 11000 to 12217, report means a report prepared by a medical practitioner.

21 Meaning of treatment cycle of a patient

In rule 22 and items 13200 to 13221, treatment cycle, of a patient, means a series of treatments of the patient that:

(a) begins:

(i) if treatment with superovulatory drugs is given — on the day on which that treatment begins; or

(ii) if treatment with superovulatory drugs is not given — on the first day of a menstrual cycle of the patient; and

(b) ends not more than 30 days after that day.

22 Items provided as part of treatment cycle relating to assisted reproductive services not to apply

(1) Subrule (2) applies to a service mentioned in:

(a) an item in Subgroup 3 of Group T1 (assisted reproductive services); and

(b) any other item (the associated item) associated with an item in Subgroup 3 of Group T1.

(2) A service provided as part of a treatment cycle to which an item in paragraph (1) (a) applies, is not a medical service for the purposes of the associated item.

23 Items relating to assisted reproductive services not to apply in certain pregnancy-related circumstances

Items 13200 to 13221 do not apply to a service provided in relation to a patient’s pregnancy, or intended pregnancy, that is, at the time of the service, the subject of an agreement, or arrangement, under which the patient makes provision for transfer to another person of the guardianship of, or custodial rights to, a child born as a result of the pregnancy.

24 Meaning of embryology laboratory services in items 13200 and 13206

In items 13200 and 13206, embryology laboratory services does not include semen preparation but includes:

(a) egg recovery from aspirated follicular fluid; and

(b) insemination; and

(c) monitoring of fertilisation and embryo development; and

(d) preparation of gametes or embryos for transfer or freezing.

25 Meaning of delivery in certain items

In items 16515, 16519 and 16522, delivery includes:

(a) induction of labour by surgical or intravenous infusion methods; and

(b) forceps or vacuum extraction; and

(c) breech delivery; and

(d) management of multiple deliveries; and

(e) episiotomy; and

(f) repair of tears; and

(g) evacuation of the products of conception by manual removal.

26 Meaning of maxilla in certain items

In items 45720 to 45752 and 52342 to 52375, maxilla includes the zygoma.

27 Items 46300 to 46534 apply only in certain circumstances

Items 46300 to 46534 apply only to a service provided in the course of an operation on a hand or hands.

28 Assistance at operations

(1) Items 51300 to 51318 apply only to assistance rendered by a medical practitioner other than:

(a) the practitioner performing the operation; or

(b) the anaesthetist administering the anaesthetic in connection with the operation, if any; or

(c) the assistant anaesthetist, if any.

(2) Items 51800 and 51803 apply only to assistance rendered by an approved dental practitioner other than:

(a) the practitioner performing the operation; or

(b) the anaesthetist administering the anaesthetic in connection with the operation, if any; or

(c) the assistant anaesthetist, if any.

29 Meaning of amount under rule 29 in items 51303 and 51803

In items 51303 and 51803, amount under rule 29, in relation to assistance at an operation or series of operations, means an amount equal to 20% of the sum of the fees payable under the Act for the services provided at that operation, or series of operations, by the practitioner to whom the assistance was given.

30 Meaning of amount under rule 30 in item 51309

(1) In item 51309, amount under rule 30, in relation to assistance at a series or combination of operations, means an amount equal to 20% of the sum of the fees payable under the Act for the services provided at those operations by the practitioner to whom the assistance was given.

(2) For subrule (1), the fee for the caesarean section component of the operations is the fee applicable to item 16520.

31 Meaning of amount under rule 31 in items 18219 and 18227

(1) In item 18219, amount under rule 31 means an amount equal to the sum of:

(a) the fee for item 18216; and

(b) $15.45 for each additional period of 15 minutes, and part of a period of 15 minutes, of continuous attendance beyond the first hour of attendance.

(2) In item 18227, amount under rule 31 means an amount equal to the sum of:

(a) the fee for item 18226; and

(b) $23.15 for each additional period of 15 minutes, and part of a period of 15 minutes, of continuous attendance beyond the first hour of attendance.

32 Histopathological proof of malignancy in certain cases for purposes of certain items relating to surgical procedures

For items 30196 to 30205, the requirement for histopathological proof of malignancy is satisfied in a case where multiple lesions are to be removed from a single anatomical region if a single lesion from that region is histologically tested and proven positive for malignancy.

33 Meaning of amount under rule 33 in items 16633 and 16636

(1) In item 16633, amount under rule 33 means, for a second or subsequent foetus, the amount that is equal to 50% of the amount of the fee specified in items 16606, 16609, 16612, 16615 and 16627 for services provided in relation to the multiple pregnancy.

(2) In item 16636, amount under rule 33 means, for a second or subsequent foetus, the amount that is equal to 50% of the amount of the fee specified in items 16600, 16603, 16618, 16621 and 16624 for services provided in relation to the multiple pregnancy.

34 Meaning of amount under rule 34 in item 51312

In item 51312, amount under rule 34, in relation to assistance at a procedure, means an amount equal to 20% of the sum of the fees payable under the Act for the services provided at that procedure by the practitioner to whom the assistance was given.

35 Meaning of amount under rule 35 in item 31340

In item 31340, amount under rule 35, in relation to the excision of muscle, bone or cartilage in association with the excision of a malignant tumour of skin under another item, means an amount equal to 75% of the fee payable under that other item.

36 Meaning of previous significant surgical complication in item 51318

In item 51318, previous significant surgical complication means:

(a) vitreous loss; or

(b) rupture of posterior capsule; or

(c) loss of nuclear material into the vitreous; or

(d) intraocular haemorrhage; or

(e) intraocular infection (endophthalmitis); or

(f) cystoid macular oedema; or

(g) corneal decompensation; or

(h) retinal detachment.

37 Meaning of amount under rule 37 in item 30001

In item 30001, amount under rule 37 means 50% of the specified fee that would normally apply for a surgical procedure if the surgical procedure had not been discontinued before completion.

38 Consultant occupational physicians

A fee specified for an attendance by a consultant occupational physician only applies if the attendance relates to 1 or more of the following matters:

(a) evaluation and assessment of a patient’s rehabilitation requirements where, in the consultant’s opinion, the patient has an accepted medical condition that:

(i) may be affected by the patient’s working environment; or

(ii) affects the patient’s capacity to be employed;

(b) management of an accepted medical condition that, in the consultant’s opinion, may affect a patient’s capacity for continued employment, or return to employment, following a non-compensable accident, injury or ill-health;

(c) evaluation and forming an opinion, including management as the case requires, of a patient’s medical condition where causation may be related to acute or chronic exposure to scientifically acknowledged environmental hazards or toxins.

39 Meaning of qualified sleep medicine practitioner

(1) For items 12203 to 12217, qualified sleep medicine practitioner means a qualified adult sleep medicine practitioner or a qualified paediatric sleep medicine practitioner.

(2) A person is a qualified adult sleep medicine practitioner or a qualified paediatric sleep medicine practitioner if:

(a) the person has been assessed by the Credentialling Subcommittee or the Appeal Committee as having had, before 1 March 1999, sufficient training and experience in the relevant field of sleep medicine to be competent in independent clinical assessment and management of patients with respiratory sleep disorders and in reporting sleep studies; or

(b) the person has been assessed by the Credentialling Subcommittee or the Appeal Committee as having had, before 1 March 1999, substantial training or experience in adult sleep medicine, but requiring further specified training or experience in the relevant field of sleep medicine to be competent in independent clinical assessment and management of patients with respiratory sleep disorders and in reporting sleep studies, and either:

(i) the period of 2 years immediately following that assessment has not expired; or

(ii) the person has been assessed by the Credentialling Subcommittee as having satisfactorily finished the further training or gained the further experience specified for that person; or

(c) the person has attained Level I or Level II of the relevant Advanced Training Program of the Thoracic Society of Australia and New Zealand and the Australasian Sleep Association, after having completed at least 12 months core training, including clinical practice in the relevant field of sleep medicine and in reporting sleep studies; or

(d) the Advisory Committee has recognised the person, in writing, as having training equivalent to the training mentioned in paragraph (c).

(3) In this rule:

Advisory Committee means the Specialist Advisory Committee in Thoracic and Sleep Medicine of the Royal Australasian College of Physicians.

Appeal Committee means the Appeal Committee of the Royal Australasian College of Physicians.

Credentialling Subcommittee means the Credentialling Subcommittee of the Advisory Committee.

relevant Advanced Training Program means:

(a) in relation to an assessment for qualification as a qualified adult sleep medicine practitioner — the Advanced Training Program in Adult Sleep Medicine; and

(b) in relation to an assessment for qualification as a qualified paediatric sleep medicine practitioner — the Advanced Training Program in Paediatric Sleep Medicine.

relevant field of sleep medicine means:

(a) in relation to an assessment for qualification as a qualified adult sleep medicine practitioner — adult sleep medicine; and

(b) in relation to an assessment for qualification as a qualified paediatric sleep medicine practitioner — paediatric sleep medicine.

40 Public health physicians

Items 410 to 417 apply to an attendance on a patient by a public health physician only if the attendance relates to 1 or more of the following matters:

(a) management of a patient’s vaccination requirements for immunisation programs;

(b) prevention or management of sexually transmitted disease;

(c) prevention or management of disease caused by scientifically accepted environmental hazards or toxins;

(d) prevention or management of infection arising from an outbreak of an infectious disease;

(e) prevention or management of an exotic disease.

Note An exotic disease is medically accepted as a disease that is of foreign origin.

41 Application of items in Group A14 to certain patients only

(1) Items 700, 702, 704 and 706 apply only to a service in relation to a patient who:

(a) is either:

(i) at least 75 years old; or

(ii) at least 55 years old and of Aboriginal or Torres Strait Islander descent; and

(b) is not an in-patient of a hospital or day-hospital facility, or a care recipient in a residential aged care facility.

(2) Item 710 applies only to a service in relation to a patient who is:

(a) of Aboriginal or Torres Strait Islander descent; and

(b) at least 15 years old and less than 55 years old; and

(c) not an in-patient of a hospital or day-hospital facility, or a care recipient in a residential aged care facility.

(3) For this rule, a person is of Aboriginal or Torres Strait Islander descent if the person identifies himself or herself as being of that descent.

42 Application of items in Group A15 to certain patients only

(1) Items 720, 724, 726, 740, 742, 744, 759, 762 and 765 apply only to a service in relation to a patient who:

(b) is not an in-patient of a hospital or day-hospital facility, or a care recipient in a residential aged care facility.

(2) Items 722, 728, 746, 749, 757, 768, 771 and 773 apply only to a service in relation to a patient who:

(b) is an in-patient of a hospital or day-hospital facility; and

(c) is not a care recipient in a residential aged care facility.

(3) Items 730, 734, 736, 738, 775, 778 and 779 apply only to a service in relation to a patient who:

(b) is a care recipient in a residential aged care facility; and

(c) is not an in-patient of a hospital or day-hospital facility.

43 Meaning of health assessment

(1) For items 700, 702, 704 and 706, health assessment means the assessment of:

(a) a patient’s health and physical, psychological and social function; and

(b) whether preventative health care and education should be offered to the patient, to improve the patient’s health and physical, psychological or social function.

(2) A health assessment involves all of the following:

(a) a personal attendance by the medical practitioner;

(b) measurement of the patient’s blood pressure, pulse rate and rhythm;

(c) an assessment of the patient’s medication;

(d) an assessment of the patient’s continence;

(e) an assessment of the patient’s immunisation status for influenza, tetanus and pneumococcus;

(f) an assessment of the patient’s physical functions, including the patient’s activities of daily living and whether or not the patient has had a fall in the last 3 months;

(g) an assessment of the patient’s psychological function, including the patient’s cognition and mood;

(h) an assessment of the patient’s social function, including:

(i) the availability and adequacy of paid, and unpaid, help; and

(ii) whether the patient is responsible for caring for another person.

(3) A health assessment also includes:

(a) keeping a record of the health assessment; and

(b) offering the patient a written report about the health assessment, with recommendations about matters covered by the health assessment; and

(c) offering the patient’s carer (if any, and if the practitioner considers it appropriate and the patient agrees) a copy of the report or extracts of the report relevant to the carer.

43A Meaning of adult health check in item 710

(1) For item 710, an adult health check means the assessment of:

(a) a patient’s health and physical, psychological and social function; and

(b) whether preventative health care, education and other assistance should be offered to that patient, to improve the patient’s health and physical, psychological or social function.

(2) An adult health check of a patient involves all of the following:

(a) a personal attendance by a medical practitioner;

(b) taking the patient’s medical history, including the following:

(i) current health problems and risk factors;

(ii) relevant family medical history;

(iii) medication usage (including medication obtained without prescription or from other doctors);

(iv) immunisation status, by reference to the appropriate current age and sex immunisation schedule;

(v) sexual and reproductive health;

(vi) physical activity, nutrition and alcohol, tobacco or other substance use;

(vii) hearing loss;

(viii) mood (including incidence of depression and risk of self-harm);

(ix) family relationships and whether the patient is a carer, or is cared for by another person;

(c) examination of the patient, including the following:

(i) measurement of the patient’s blood pressure, pulse rate and rhythm;

(ii) measurement of height and weight to calculate body mass index and, if indicated, measurement of waist circumference for central obesity;

(iii) oral examination (including gums and dentition);

(iv) ear and hearing examination (including otoscopy and, if indicated, a whisper test);

(v) urinalysis (by dipstick) for proteinurea;

(d) undertaking or arranging any required investigation, considering the need for the following tests, in particular, (in accordance with national or regional guidelines or specific regional needs):

(i) fasting blood sugar and lipids (by laboratory based test on venous sample) or, if necessary, random blood glucose levels;

(ii) pap smear;

(iii) examination for sexually transmitted infection (by urine or endocervical swab for chlamydia and gonorrhoea, especially for those aged from 15 to 35 years);

(iv) mammography, where eligible (by scheduling appointments with visiting services or facilitating direct referral);

(e) assessing the patient using the information gained in the adult health check;

(f) making or arranging any necessary interventions and referrals, and documenting a simple strategy for the good health of the patient.

(3) An adult health check also includes:

(a) keeping a record of the adult health check; and

(b) offering the patient a written report about the health check, with recommendations about matters covered by the health check (including a simple strategy for the good health of the patient).

43B Meaning of comprehensive medical assessment in item 712

(1) For item 712, a comprehensive medical assessment of a resident of a residential aged care facility is a full systems review of the resident, including an assessment of the resident’s health and physical and psychological function.

(2) A comprehensive medical assessment involves all of the following:

(a) a personal attendance by a medical practitioner;

(b) taking a detailed relevant medical history;

(c) conducting a comprehensive medical examination of the resident;

(d) developing a list of diagnoses and medical problems based on the medical history and examination;

(e) providing, for the resident’s records, a written summary of the outcomes of the assessment to inform the provision of care for the resident and to assist in the provision of medication management review services for the resident.

(3) A comprehensive medical assessment also includes:

(a) making a written summary of the comprehensive medical assessment; and

(b) providing a copy of the summary to the residential aged care facility; and

(c) offering the resident a copy of the summary or relevant parts of the summary.

44 Meaning of multidisciplinary care plan

(1) For items 720, 722, 724, 726, 728 and 730 preparation of a multidisciplinary care plan means the preparation of a written plan describing all of the following matters:

(a) an assessment of the patient’s health care needs;

(b) an assessment of the kinds of treatment, health services and health care that the patient is likely to need;

(c) an assessment of any other kinds of services and care that the patient is likely to need;

(d) arrangements for giving the treatment, services and care referred to in paragraphs (b) and (c);

(e) management goals with which the patient agrees;

(f) arrangements to review the plan by a day specified in the plan.

For paragraph (c), other kinds of services and care may include home and community care service providers.

(2) Preparation of a plan also includes:

(a) discussing the preparation of the plan with the patient and the patient’s carer (if any, and if the practitioner considers it appropriate and the patient agrees); and

(b) telling the patient which persons will be included in the multidisciplinary care plan team; and

(c) recording the plan and the patient’s agreement to the preparation of the plan; and

(d) giving copies of relevant parts of the plan to persons who, under the plan, will give the patient the treatment, service and care mentioned in the plan; and

(e) offering a copy of the plan (and evidence of the contribution made to the plan by members of the team) to the patient and the patient’s carer (if any, and if the medical practitioner considers it appropriate and the patient agrees).

45 Meaning of multidisciplinary care plan team

(1) A multidisciplinary care plan team:

(a) includes a medical practitioner; and

(b) includes at least 2 other members, each of whom provides a different kind of care or service to the patient and is not a family carer of the patient, and 1 of whom may be another medical practitioner; and

(c) may additionally include a family carer of the patient.

Examples of persons who, for paragraph (b), may be included in a team are:

Note: (a) allied health professionals such as:

 Aboriginal health care workers

 asthma educators

 audiologists

 dental therapists

 dentists

 diabetes educators

 dieticians

 mental health workers

 occupational therapists

 optometrists

 orthoptists

 orthotists or prosthetists

 pharmacists

 physiotherapists

 podiatrists

 psychologists

 registered nurses

 social workers

 speech pathologists; and

Note: (b) home and community service providers, or care organisers, such as:

 education providers

 ‘meals on wheels’ providers

 personal care workers

 probation officers.

(2) In subrule (1):

family carer includes a person who:

(a) is a relative or friend of the patient; and

(b) is providing care to the patient other than as a paid service.

46 Meaning of multidisciplinary discharge care plan

For items 722 and 728, a multidisciplinary discharge care plan is a multidisciplinary care plan that is prepared for a patient before the patient is discharged from a hospital.

47 Meaning of review of a multidisciplinary care plan

(1) For item 724, review of a multidisciplinary care plan means a process by which the medical practitioner:

(a) reviews the matters mentioned in subrule 44 (1); and

(b) considers whether the arrangements for treatment, service and care have been carried out; and

(c) considers, in consultation with other members of the multidisciplinary care plan team, whether different arrangements need to be made to achieve the management goals mentioned in the plan; and

(d) if different arrangements need to be made, prepares a revised multidisciplinary care plan stating those arrangements.

(2) The review of a plan also includes:

(a) discussing the review of the plan with the patient and the patient’s carer (if any, and if the practitioner considers it appropriate and the patient agrees); and

(b) recording the patient’s agreement to reviewing the plan; and

(c) offering a copy of relevant parts of the revised multidisciplinary care plan (if any) to the patient and the patient’s carer (if any, and if the practitioner considers it appropriate and the patient agrees), and giving copies to persons who, under the revised plan, will give the patient the treatment, service and care mentioned in the plan.

48 Meaning of contribution to a plan

(1) For items 726, 728 and 730, a contribution to a multidisciplinary community care plan, a multidisciplinary discharge care plan or a multidisciplinary care plan in a residential aged care facility must be at the request of the person (or residential aged care facility) who prepares the plan, and may include:

(a) preparation of a part of the plan that relates to the treatment, service or care that the medical practitioner will give to the patient; and

(b) giving advice to the person who prepares the plan.

(2) Contribution to a plan does not necessarily include preparation of the plan or part of the plan.

49 Meaning of multidisciplinary case conference

For the items mentioned in Subgroup 2 of Group A15, a multidisciplinary case conference is a process by which a multidisciplinary case conference team (see rule 52) carries out all of the following activities:

(a) discussing a patient’s history;

(b) identifying the patient’s multidisciplinary care needs;

(c) identifying outcomes to be achieved by members of the case conference team giving care and service to the patient;

(d) identifying tasks that need to be undertaken to achieve these outcomes, and allocating those tasks to members of the case conference team;

(e) assessing whether previously identified outcomes (if any) have been achieved.

50 Meaning of multidisciplinary discharge case conference

For items 746, 749, 757, 768, 771 and 773, a multidisciplinary discharge case conference is a multidisciplinary case conference carried out in relation to a patient before the patient is discharged from a hospital or day-hospital facility.

51 Meaning of multidisciplinary case conference in a residential aged care facility

For items 734, 736, 738, 775, 778 and 779, a multidisciplinary case conference in a residential aged care facility is a multidisciplinary case conference carried out in relation to a care recipient in a residential aged care facility.

52 Meaning of multidisciplinary case conference team

(1) For this table, a multidisciplinary case conference team:

(a) includes a medical practitioner; and

(b) includes at least 2 other members, each of whom provides a different kind of care or service to the patient and is not a family carer of the patient, and 1 of whom may be another medical practitioner; and

(c) may additionally include a family carer of the patient.

Examples of persons who, for paragraph (b), may be included in a team are:

Note: (a) allied health professionals such as:

 Aboriginal health care workers

 asthma educators

 audiologists

 dental therapists

 dentists

 diabetes educators

 dieticians

 mental health workers

 occupational therapists

 optometrists

 orthoptists

 orthotists or prosthetists

 pharmacists

 physiotherapists

 podiatrists

 psychologists

 registered nurses

 social workers

 speech pathologists; and

Note: (b) home and community service providers, or care organisers, such as:

 education providers

 ‘meals on wheels’ providers

 personal care workers

 probation officers.

(2) In subrule (1):

family carer includes a person who:

(a) is a relative or friend of the patient; and

(b) is providing care to the patient other than as a paid service.

53 Meaning of organise and co-ordinate in a multidisciplinary case conference and participation in a multidisciplinary case conference

(1) For items 734, 736, 738, 740, 742, 744, 746, 749 and 757, organise and co-ordinate a multidisciplinary case conference means undertaking all of the following activities in relation to a case conference:

(a) explaining to the patient the nature of a multidisciplinary case conference, and asking the patient whether the patient agrees to the conference taking place;

(b) recording the patient’s agreement to the conference;

(c) recording the day on which the conference was held, and the times at which the conference started and ended;

(d) recording the names of the participants;

(e) recording the matters mentioned in rule 49, and putting a copy of that record in the patient’s medical records;

(f) offering the patient and the patient’s carer (if any and if the practitioner considers appropriate and the patient agrees), and giving each other member of the team, a summary of the conference;

(g) discussing the outcomes of the conference with the patient and the patient’s carer (if any and if the practitioner considers appropriate and the patient agrees).

(2) For items 759, 762, 765, 768, 771, 773, 775, 778 and 779 participation in a multidisciplinary case conference must be at the request of the person who organises and co-ordinates the conference, and involves undertaking all of the following activities in relation to a case conference:

(a) explaining to the patient the nature of a multidisciplinary case conference, and asking the patient whether the patient agrees to the practitioner’s participation in the conference;

(b) recording the patient’s agreement to the practitioner’s participation;

(c) recording the day on which the conference was held, and the times at which the conference started and ended;

(d) recording the names of the participants;

(e) recording the matters mentioned in rule 49, and putting a copy of that record in the patient’s medical records.

(3) Participation in a multidisciplinary case conference does not include organising and co-ordinating a multidisciplinary case conference.

54 Meaning of living in a community setting in item 900

For item 900, a patient is living in a community setting if the patient:

(a) is not an in-patient of a hospital or day-hospital facility; and

(b) is not a care recipient in a residential aged care facility.

55 Meaning of amount under rule 55 in certain items

(1) In item 2503, amount under rule 55 means an amount equal to the sum of:

(a) the fee for item 2501; and

(i) if not more than 6 patients are attended at a single attendance — $20.60 divided by the number of patients attended; or

(2) In item 2506, amount under rule 55 means an amount equal to the sum of:

(a) the fee for item 2504; and

(i) if not more than 6 patients are attended at a single attendance — $20.60 divided by the number of patients attended; or

(3) In item 2509, amount under rule 55 means an amount equal to the sum of:

(a) the fee for item 2507; and

(i) if not more than 6 patients are attended at a single attendance — $20.60 divided by the number of patients attended; or

(4) In item 2518, amount under rule 55 means an amount equal to the sum of:

(a) the fee for item 2517; and

(i) if not more than 6 patients are attended at a single attendance — $20.60 divided by the number of patients attended; or

(5) In item 2522, amount under rule 55 means an amount equal to the sum of:

(a) the fee for item 2521; and

(i) if not more than 6 patients are attended at a single attendance — $20.60 divided by the number of patients attended; or

(6) In item 2526, amount under rule 55 means an amount equal to the sum of:

(a) the fee for item 2525; and

(i) if not more than 6 patients are attended at a single attendance — $20.60 divided by the number of patients attended; or

(7) In item 2547, amount under rule 55 means an amount equal to the sum of:

(a) the fee for item 2546; and

(i) if not more than 6 patients are attended at a single attendance — $20.60 divided by the number of patients attended; or

(8) In item 2553, amount under rule 55 means an amount equal to the sum of:

(a) the fee for item 2552; and

(i) if not more than 6 patients are attended at a single attendance — $20.60 divided by the number of patients attended; or

(9) In item 2559, amount under rule 55 means an amount equal to the sum of:

(a) the fee for item 2558; and

(i) if not more than 6 patients are attended at a single attendance — $20.60 divided by the number of patients attended; or

(10) In item 2575, amount under rule 55 means an amount equal to the sum of:

(a) the fee for item 2574; and

(i) if not more than 6 patients are attended at a single attendance — $20.60 divided by the number of patients attended; or

(11) In item 2578, amount under rule 55 means an amount equal to the sum of:

(a) the fee for item 2577; and

(i) if not more than 6 patients are attended at a single attendance — $20.60 divided by the number of patients attended; or

(12) In item 2723, amount under rule 55 means an amount equal to the sum of:

(a) the fee for item 2721; and

(i) if not more than 6 patients are attended at a single attendance — $20.60 divided by the number of patients attended; or

(13) In item 2727, amount under rule 55 means an amount equal to the sum of:

(a) the fee for item 2725; and

(i) if not more than 6 patients are attended at a single attendance — $20.60 divided by the number of patients attended; or

56 Application of Subgroup 2 of Group A18 and Subgroup 2 of Group A19

(1) An item in Subgroup 2 of Group A18 or Subgroup 2 of Group A19 does not apply to a service that is provided to a patient who has already been provided, in the previous 12 months, with another service to which an item in either of those Subgroups applies.

(2) For an item in Subgroup 2 of Group A18 or Subgroup 2 of Group A19, a professional attendance completes the minimum requirements for an annual cycle of care of a patient with established diabetes mellitus if the attendance completes a series of attendances that involve, over 12 months (the current cycle), the following:

(a) at least 1 assessment of the patient’s diabetes control, by measuring the patient’s HbA1c;

(b) if the patient has not had a comprehensive eye examination in the 12 months immediately before the current cycle — at least 1 comprehensive eye examination;

(c) measurement of the patient’s weight and height, and calculation of the patient’s BMI;

(d) further measurement of the patient’s weight at least once every 6 months;

(e) measurement of the patient’s blood pressure at least once every 6 months;

(f) examination of the patient’s feet at least once every 6 months;

(g) at least 1 measurement of the patient’s total cholesterol, triglycerides and HDL cholesterol;

(h) at least 1 test of the patient’s microalbuminuria;

(i) provision to the patient of self-management education regarding diabetes;

(j) a review of the patient’s diet, and provision to the patient of information about appropriate dietary choices;

(k) a review of the patient’s level of physical activity, and provision to the patient of information about the appropriate level of physical activity;

(l) checking the patient’s tobacco smoking activity, and, if relevant, encouraging the patient to stop smoking;

(m) a review of the patient’s medication.

57 Application of Subgroup 3 of Group A18 and Subgroup 3 of Group A19

(1) An item in Subgroup 3 of Group A18 or Subgroup 3 of Group A19 does not apply to a service that:

(a) is provided to a patient who has already been provided, in the previous 12 months, with another service to which an item in either of those Subgroups applies; and

(b) is not clinically indicated.

(2) For an item in Subgroup 3 of Group A18 or Subgroup 3 of Group A19, a professional attendance completes the minimum requirements of the Asthma 3+ Visit Plan if the attendance completes a series of attendances that involve:

(a) documented diagnosis and documented assessment of severity; and

(b) at least 3 asthma‑related consultations (at least 2 of which are consultations that have been planned at any of the earlier asthma‑related consultations), over a period of not less than 4 weeks and not more than 4 months, that involve the following, for a patient with moderate to severe asthma:

(i) a review of the patient’s use of asthma‑related medication;

(ii) either:

(A) provision to the patient of a written asthma action plan; or

(B) if the patient is unable to use a written asthma action plan — discussion with the patient about an alternative method of providing an asthma action plan, and documentation of the discussion in the patient’s medical records;

(iii) provision to the patient of self-management education regarding asthma;

(iv) a review of the patient’s asthma action plan.

58 Meaning of approved site in items 15338 and 37220

For items 15338 and 37220, approved site, in relation to radiation oncology, means a site at which radiation oncology may be performed lawfully under the law of the State or Territory in which the site is located.

59 Group T10 applies only in connection with certain services

(1) Each of items 20100 to 21990 (other than item 21965), 22060, 23010 to 24136, 25200 and 25205 applies to a service only if the service is provided in connection with a service that:

(a) is a professional service within the meaning of subsection 3 (1) of the Act; and

(b) is specified in an item that includes, in its description, ‘(Anaes.)’.

(2) Each of items 22900 and 22905 applies to a service only if the service is provided in connection with a dental service (other than a dental service that is a prescribed medical service under paragraph (b) of the definition of professional service in subsection 3 (1) of the Act).

60 Services specified in Subgroups 21 to 25 of Group T10

In Subgroups 21 to 25 of Group T10:

(a) a reference to anaesthesia is a reference to administration of anaesthesia performed in association with a service to which any of items 20100 to 21997, 22900 and 22905 applies; and

(b) a reference to perfusion is a reference to perfusion to which item 22060 applies; and

(c) a reference to assistance is a reference to assistance:

(i) in the administration of anaesthesia; and

(ii) to which item 25200 or 25205 applies.

61 Meaning of service time in Subgroups 21, 24, 25 and 26 of Group T10

In Subgroups 21, 24, 25 and 26 of Group T10:

service time means:

(a) in relation to administration of anaesthesia on a patient by an anaesthetist — the period that:

(i) begins when the anaesthetist commences exclusive and continuous care of the patient for anaesthesia; and

(ii) ends when the anaesthetist places the patient safely under the supervision of other personnel; and

(b) in relation to perfusion performed on a patient under anaesthesia — the period that:

(i) begins when the anaesthetic commences; and

(ii) ends with the closure of the chest of the patient; and

(c) in relation to assistance given by an assistant anaesthetist in the administration of anaesthesia performed on a patient — the period when the assistant anaesthetist is actively attending on the patient.

62 Application of Subgroup 21 of Group T10

(1) An item in the range 23010 to 24136 applies to perfusion in addition to any other item that applies to the perfusion.

(2) An item in the range 23010 to 24136 applies to assistance only as a component of item 25200 or 25205 and for the purpose of calculating the amount of fee for that item.

63 Application of Subgroups 22 and 23 of Group T10

(1) An item in the range 25000 to 25020 applies to anaesthesia in addition to any other item that applies to the anaesthesia.

(2) An item in the range 25000 to 25020 applies to perfusion in addition to any other item that applies to the perfusion.

(3) An item in the range 25000 to 25020 applies to assistance only as a component of item 25200 or 25205 and for the purpose of calculating the amount of fee for that item.

64 Meaning of amount under rule 64 in items 25025, 25030 and 25050

(1) For item 25025 amount under rule 64 means the amount that is equal to 50% of the sum of:

(a) the fee specified in any of items 20100 to 21997 and 22900 for the initiation of management of anaesthesia in association with which the anaesthesia is performed; and

(b) the fee specified in the item in the range 23010 to 24136 that applies to the anaesthesia; and

(c) if any of items 25000 to 25015 applies to the anaesthesia — the fee specified in that item; and

(d) if a service specified in an item in the range 22001 to 22050 is performed in association with the anaesthesia — the fee specified in that item.

(2) For item 25030 amount under rule 64 means the amount that is equal to 50% of the sum of:

(a) $82.50; and

(b) the fee specified in the item in the range 23010 to 24136 that applies to the assistance; and

(c) if any of items 25000 to 25015 applies to the assistance — the fee specified in that item; and

(d) if a service specified in an item in the range 22001 to 22050 is performed in association with the assistance — the fee specified in that item.

(3) For item 25050 amount under rule 64 means the amount that is equal to 50% of the sum of:

(a) $330.00; and

(b) the fee specified in the item in the range 23010 to 24136 that applies to the perfusion; and

(c) if any of items 25000 to 25015 applies to the perfusion — the fee specified in that item; and

(d) if a service specified in an item in the range 22001 to 22050 is performed in association with the perfusion — the fee specified in that item.

65 Application of Subgroups 24 and 25 of Group T10

An item in the range 25025 to 25050 applies to the anaesthesia, assistance or perfusion in addition to any other item that applies to the service.

66 Meaning of complex paediatric case in item 25205

For item 25205, a complex paediatric case involves 1 or more of the following services:

(a) invasive monitoring, either intravascular or transoesophageal;

(b) organ transplantation;

(c) craniofacial surgery;

(d) major tumour resection;

(e) separation of conjoint twins.

67 Meaning of amount under rule 67 in items 25200 and 25205

For each of items 25200 and 25205, amount under rule 67, means the sum of:

(a) $82.50; and

(b) the fee specified in the item in the range 23010 to 24136 that applies to the assistance; and

(c) if any of items 25000 to 25020 applies to the assistance — the fee specified in that item.

68 Restriction of telepsychiatry consultations to rural and remote areas

Each of items 353 to 358 applies only to a consultation that is provided:

(a) by a consultant physician located in a Statistical Local Area that is a M1, M2 or R1 area within the meaning of the Rural, Remote and Metropolitan Areas Classification; and

(b) to a patient located in a different Statistical Local Area that is a R1, R2, R3, Rem1 or Rem2 area within the meaning of the Rural, Remote and Metropolitan Areas Classification.

69 Meaning of recognised emergency department and problem focussed history in Group A21

(1) In Group A21, recognised emergency department, of a private hospital, means a department of the hospital that is licensed, under a law of the State or Territory in which the hospital is located, to operate as an emergency department.

(2) In items 501, 503 and 507, problem focussed history means a history focussing on the medical condition of the patient that necessitates the patient presenting for emergency attention.

70 Prolonged attendances by emergency physicians

In items 519 to 536, an attendance for emergency evaluation of a critically ill patient with an immediately life threatening problem means an attendance that requires:

(a) immediate and rapid assessment; and

(b) initiation of resuscitation and electronic monitoring of vital signs; and

(c) taking a comprehensive history and evaluation while undertaking resuscitative measures; and

(d) ordering and evaluation of appropriate investigations; and

(e) transitional evaluation and monitoring; and

(f) formulation and documentation of a diagnosis and management plan in relation to 1 or more problems; and

(g) initiation of appropriate treatment interventions; and

(h) liaison with relevant health care professionals and discussion with, as appropriate, the patient or the patient’s relatives or agent.

71 Application of Subgroup 4 of Group A18 and Subgroup 4 of Group A19

(1) An item in Subgroup 4 of Group A18 or Subgroup 4 of Group A19 applies only to a service that is provided by a medical practitioner:

(a) whose name is entered in the register maintained by the Commission under regulation 3T of the Health Insurance Commission Regulations 1975; and

(b) who meets any training and skills requirements, as determined by the General Practice Mental Health Standards Collaboration, for providing services to which those Subgroups apply.

(2) An item in Subgroup 4 of Group A18 or Subgroup 4 of Group A19 does not apply to a service that:

(a) is provided to a patient who has already been provided, in the previous 12 months, with another service to which an item in either of those Subgroups applies; and

(b) is not clinically indicated.

(3) A reference in an item in Subgroup 4 of Group A18 or Subgroup 4 of Group A19 to the minimum requirements of the 3 Step Mental Health Process is a reference to the following procedures in relation to the patient concerned:

(a) at least 3 consultations related to a mental health disorder:

(i) at least 2 of which are consultations that have been planned at a previous consultation; and

(ii) each of which is of at least 20 minutes duration;

(b) assessment of the mental health disorder, including administration of an outcome measurement tool (except if considered clinically inappropriate);

(c) formulation or diagnosis or both formulation and diagnosis of the mental health disorder;

(d) supplying the patient or, if the patient agrees, the patient’s carer with:

(i) a written mental health plan; and

(ii) suitable education about the mental health disorder;

(e) at least 4 weeks, but no later than 6 months, after the consultation at which the written mental health plan was prepared:

(i) a review of the patient’s progress against the goals recorded in that plan; and

(ii) if necessary, adjustment of that plan; and

(iii) administration of the outcome measurement tool used in the assessment mentioned in paragraph (b) (except if considered clinically inappropriate).

(4) In this rule:

mental health disorder means a significant impairment of any or all of an individual’s cognitive, affective and relational abilities that:

(a) may require medical intervention; and

(b) may be a recognised, medically diagnosable illness or disorder; and

(c) is not dementia, delirium, tobacco use disorder or mental retardation.

Note In relation to this definition, practitioners should be aware of the Diagnostic and Management Guidelines for Mental Health Disorders in Primary Care (ICD-10, Chapter 5, Primary Care Version), developed by the World Health Organisation and published in 1996.

outcome measurement tool means a tool used to monitor changes in a patient’s health that occur in response to treatment received by the patient.

written mental health plan means a written plan that:

(a) is prepared in consultation with a patient or, if the patient agrees, a patient’s carer; and

(b) describes arrangements for:

(i) treatment of the mental health disorder or disorders; and

(ii) crisis intervention; and

(iii) relapse prevention.

72 Focussed psychological strategies

(1) An item in Group A20 applies only to a service that:

(a) is clinically indicated under the 3 Step Mental Health Process; and

(b) is provided by a medical practitioner:

(i) whose name is entered in the register maintained by the Commission under regulation 3T of the Health Insurance Commission Regulations 1975; and

(ii) who is identified in the register as a practitioner who can provide services to which Group A20 applies; and

(iii) who meets any training and skills requirements, as determined by the General Practice Mental Health Standards Collaboration, for providing services to which Group A20 applies; and

(c) is provided in a general practice that participates in the Practice Incentives Program or is an accredited general practice that is not participating in the Program.

(2) An item in Group A20 does not apply to:

(a) a service that:

(i) is provided to a patient who has already been provided, in the previous 12 months, with 6 other services to which any of the items in that Group applies; and

(ii) is provided before the medical practitioner managing the 3 Step Mental Health Process has conducted a review and has noted in the patient’s records a recommendation that the patient have more than 6 sessions of psychological strategies in 12 months; or

(b) a service that is provided to a patient who has already been provided, in the previous 12 months, with 12 other services to which any of items in that Group applies.

(3) In Group A20, a reference to focussed psychological strategies is a reference to any of the following mental health care management strategies, being a strategy that has been derived from evidence-based psychological therapies:

(a) psycho-education;

(b) cognitive-behavioural therapy that involves cognitive or behavioural interventions;

(c) relaxation strategies;

(d) skills training;

(e) interpersonal therapy.

(4) In this rule:

general practice means a business, consisting of 1 or more medical practitioners, that provides a general practice of medical services.

73 Meaning of qualified surgeon in items 31539 and 31545

For items 31539 and 31545, a medical practitioner is a qualified surgeon if:

(a) he or she is a specialist in the practice of his or her specialty of surgery; and

(b) the Commission has received a written notice from the Royal Australasian College of Surgeons stating that the person meets the skills requirements for providing services to which the items apply.

74 Meaning of qualified radiologist in item 31542

For item 31542, a medical practitioner is a qualified radiologist if:

(a) he or she is a specialist in the practice of his or her specialty of radiology; and

(b) the Commission has received a written notice from the Royal Australian and New Zealand College of Radiologists stating that the person meets the skills requirements for providing services to which the item applies.

75 Injection of botulinum toxin

Each of items 18350 to 18370 applies only to a service provided by a medical practitioner who is registered by the Commission to participate in the arrangements made, under paragraph 100 (1) (b) of the National Health Act 1953, for the purpose of providing an adequate pharmaceutical service for persons requiring treatment with botulinum toxin.

76 Meaning of qualified medical acupuncturist in items 193, 195, 197 and 199

For items 193, 195, 197 and 199, a person is a qualified medical acupuncturist if:

(a) the person is a general practitioner; and

(b) the Commission has received a written notice from the Royal Australian College of General Practitioners stating that the person meets the skills requirements for providing services to which the items apply.

77 Application of items 10990 and 10991

(1) If the medical service described in item 10991 is provided to a person, either that item or 10990, but not both those items, applies to the service.

(1A) If item 10990 or 10991 applies to a medical service, the fee specified in that item applies in addition to the fee specified in any other item in this table that applies to the service.

(2) For items 10990 and 10991:

bulk-billed, in relation to a medical service, means:

(a) a medicare benefit is payable to a person in respect of the service; and

(b) under an agreement entered into under section 20A of the Act:

(i) the person assigns to the medical practitioner by whom, or on whose behalf, the service is provided, his or her right to the payment of the medicare benefit; and

(ii) the medical practitioner accepts the assignment in full payment of his or her fee for the service provided.

Commonwealth concession card holder means a person who is a concessional beneficiary within the meaning given by subsection 84 (1) of the National Health Act 1953.

unreferred service means a medical service provided to a person by, or on behalf of, a medical practitioner, being a service that has not been referred to that practitioner by another medical practitioner or person with referring rights.

(3) For item 10991:

ASGC means the document titled Australian Standard Geographical Classification (ASGC) 2002, published by the Australian Bureau of Statistics, as in force on 1 July 2002.

practice location, in relation to the provision of a medical service, means the place of practice in respect of which the medical practitioner by whom, or on whose behalf, the service is provided, has been allocated a provider number by the Commission.

regional, rural or remote area means an area classified as RRMAs 3-7 under the Rural, Remote and Metropolitan Areas Classification.

Rural, Remote and Metropolitan Areas Classification has the meaning given by subrule 3 (1) of Part 2 of Schedule 1 to this table.

SLA means a Statistical Local Area specified in the ASGC.

SSD means a Statistical Subdivision specified in the ASGC.

78 Application of item 10993

(1) For item 10993:

enrolled nurse means a person who:

(a) holds a current practising certificate as a nurse issued by a State or Territory regulatory authority; and

(b) is licensed to provide nursing care under the supervision of a registered nurse.

general practice means a business, consisting of 1 or more medical practitioners, that provides a general practice of medical services.

immunisation means the administration of a registered vaccine to a person for any purpose other than as part of a mass immunisation of persons.

practice nurse means a registered nurse or an enrolled nurse who is employed by, or whose services are otherwise retained by, a general practice.

registered vaccine means a vaccine that is included in the part of the Australian Register of Therapeutic Goods for registered goods, being the Register maintained under section 9A of the Therapeutic Goods Act 1989.

(2) Item 10993 applies to an immunisation provided to a person by a practice nurse only if:

(a) the practice nurse is appropriately qualified and trained to provide immunisations to persons; and

(b) the medical practitioner under whose supervision the immunisation is provided retains responsibility for the health, safety and clinical outcomes of the person.

79 Application of item 10996

(1) For item 10996:

enrolled nurse has the meaning given by subrule 78 (1).

general practice has the meaning given by subrule 78 (1).

practice nurse has the meaning given by subrule 78 (1).

(2) Item 10996 applies to the treatment of a person’s wound (other than normal aftercare) provided by a practice nurse only if:

(a) the practice nurse is appropriately qualified and trained to treat wounds; and

(b) the medical practitioner under whose supervision the treatment is provided has conducted an initial assessment of the person; and

(c) the practice nurse has been instructed by the medical practitioner in relation to the treatment of the wound; and

(d) the medical practitioner retains responsibility for the health, safety and clinical outcomes of the person.