PCPA Billing Handbook

What is Medicare?

Medicare is the Australian government's publicly funded universal health insurance system, which provides access to a range of healthcare services, including consultations with medical specialists, hospital care, and other essential medical treatments. Established in 1984, Medicare aims to ensure that all Australians have access to affordable, high-quality healthcare, regardless of their income or location. The system operates under the principle of equity, making sure that essential health services are available to everyone, with particular emphasis on reducing financial barriers to access.

Intention of Medicare in Access to Specialist Medical Care

One of Medicare's core intentions is to provide equitable access to healthcare, including specialist medical care. The system helps make specialist consultations more affordable by subsidising the cost of medical services through a schedule of fees. This subsidy aims to reduce the financial burden on patients, particularly for those requiring ongoing or complex treatments. The system is designed to make sure that necessary medical services are available to all Australians, regardless of socioeconomic status, through subsidised fees for medical consultations, procedures, and hospital care.

However, Medicare was not intended to cover 100% of specialist medical fees. Medicare will pay for 85% of what it considers to be the appropriate fee for a particular service (the "schedule fee"), for services provided by non-GP specialists in the outpatient setting. Schedule fees undergo annual increases; however, these increases are not based on inflation and there is therefore an ever-increasing 'gap' between the rebate provided by Medicare, and the cost of providing that care. Medicare is intended to subsidise the cost of outpatient specialist care; not to pay for it in full.

What is a Schedule Fee?

The schedule fee is the amount that Medicare has determined to be the appropriate fee for a specific medical service or procedure. This fee is set by the Australian government and published in the Medicare Benefits Schedule (MBS). It is essentially a standard rate for each medical service covered under Medicare. The schedule fee does not necessarily reflect the actual fee charged by the medical practitioner, but rather it is a baseline for what the government considered an appropriate amount for the service provided. To attract the advertised rebate for that service, the item numbers and their descriptors often stipulate specifically what constitutes these item numbers and must be substantiated by the provider in the event of an audit.

Medicare's Payment Structure: 100%, 85%, and 75% of the Schedule Fee

Medicare reimburses a different percentage of the schedule fee depending on who provides the service, and where it is provided.

General Practitioners (GP Specialists)

• Out-of-Hospital Services: When GPs provide services outside of a hospital setting and offer to bulk bill the patient, Medicare will pay the GP 100% of the schedule fee. This means the patient incurs no out-of-pocket expenses. If the GP's fee exceeds the schedule fee, the patient must pay the fee in full, and the Medicare rebate is reimbursed to the patient.

Physicians (Non-GP Specialists)

• Out-of-Hospital Services: For services provided by non-GP medical specialists outside of a hospital setting, Medicare will pay directly to the doctor (if bulk billing), or rebate to the patient (if the fee exceeds the rebate amount) 85% of the schedule fee.
• In-Hospital Services: When non-GP medical specialists provide services within a private hospital, Medicare covers 75% of the schedule fee. The remaining amount may be covered by the private health insurer. Each private health insurer has its own list of benefits for each item number service. If there is still a gap between this amount and the fee charged by the provider, the patient is responsible for this gap. As an inpatient in a private hospital, the private health insurer is responsible for handling the processing of Medicare fees and passing them on to the provider, with the additional private health loading, so invoices only need to be submitted to the private health insurer, not to Medicare as well.
• Treatment of public patients in public hospitals: This is also funded by Medicare, but through a separate program, called the National Health Reform Agreement (NHRA). This is funded through Federal taxes and managed via State Governments to support individual hospitals.

Bulk Billing

Bulk billing occurs when a doctor obtains written consent from a patient to access their Medicare rebate and agrees to accept that rebate as full payment for the service provided. If a doctor chooses not to bulk bill, they may charge the patient a fee, which the patient must pay in full and then claim the Medicare rebate as reimbursement. This is often submitted on behalf of the patient by reception staff after receiving payment.

When a doctor bulk bills, they bill Medicare directly, and the patient does not need to pay anything out-of-pocket for the service.

Medicare rebates belong to patients. To bulk bill a patient without their expressed consent is theft. Patients may assign their rights to access their rebate to their doctor in the form of signing an Assignment of Benefits form, or other means such as pressing a button on the Medicare Easyclaim EFTPOS machine. During the COVID pandemic, temporary measures were approved to accept verbal agreements for telehealth items -- these measures are no longer valid and written or email agreement is required.

How Medicare's Schedule Fees Have Been Indexed Over Time

Medicare's schedule fees are subject to indexing, which means that they are regularly adjusted to account for inflation, the rising costs of healthcare, and changes in the economy. This indexing process is designed to ensure that the schedule fees remain relevant and reflective of the current cost of providing healthcare services.

Typically, Medicare's schedule fees are indexed annually, using a formula that considers factors such as the consumer price index (CPI), wage growth, and the cost of providing medical services. While the intention is to maintain the real value of the schedule fees, it's important to note that these increases are often modest and may not fully keep up with the rising costs of medical practice, including administrative expenses, staff salaries, and the cost of medical technology.

What is a Gap Fee?

A gap fee is the difference between the fee a medical practitioner charges for their service and the amount Medicare (or for private inpatients, the private health insurer) will reimburse for that service. Medicare, and for private inpatients, private health insurers, set a schedule fee for each medical service, which is the amount that they will pay for a service provided it meets all criteria listed in the item number descriptor. If a doctor charges more than either the Medicare rebate fee, or the amount covered by the private health insurer, the patient is responsible for paying the difference. This is known as the gap fee.

Example: If a Medicare schedule fee for a specialist consultation is $100, and the doctor charges $150 for the service, the gap would be $50. Patients must pay the full $150 and accept the $100 rebate -- you cannot bulk bill $100 and charge the patient $50.

Because Medicare's schedule fees are indexed at a relatively low rate, the gap between the schedule fee and what a doctor must charge to remain financially viable, will grow over time. As the costs of running a medical practice increase (for example, rising overhead costs or technological advancements), and the indexation of Medicare remains an issue, most doctors will need to charge more than the Medicare schedule fee to maintain financial viability. As a result, patients will be required to pay increasing gap fees over time.

As an example, from 1995 to 2002, Medicare's average indexation was 1.1%, compared to the consumer price index (CPI) of 2.4% and average weekly earnings (AWE) of 3.5%. This means that when accounting for inflation, the same rebate for a consultation in 2002 was worth less than the same consultation in 1995 (AMA, 2022). Just to earn the same as they did in 1995, a doctor in 2002 is forced to introduce a gap, and this isn't even accounting for the increased costs of medical practice management for the same period.

Medicare Safety Nets

Medicare Safety Nets have been introduced to increase Medicare assistance to patients who have high out-of-pocket medical costs for services provided out of hospital. They do not apply to services not listed on the MBS, or for MBS services provided within a hospital.

Once a patient's medical expenses reach a certain amount (in 2025, these amounts are $576 for the Original Medicare Safety Net (OMSN) and $2,615.50 for the Extended Medicare Safety Net (EMSN) for non-concession cardholders -- for concession cardholders, the EMSN threshold is $834.50), Medicare receives information about a patient's out-of-pocket costs when fees and rebates are processed.

When an individual has reached the OMSN threshold, the rebate amount provided by Medicare will increase from the usual 85% of the schedule fee, to 100% of the schedule fee for the rest of the financial year. When an individual reaches the EMSN threshold, they will receive 80% of further out-of-pocket costs for the financial year. EMSN benefits are capped; providers can't (and shouldn't!) charge a patient subject to the EMSN $10,000 for an appointment and expect Medicare to pay 80% of the gap fee, for example. Where EMSN benefits are applicable, they can be found in the MBSOnline listing underneath the usual benefit amount (for example, the EMSN Cap for item 132 in 2025 is $500.00). Note -- some services (eg. consults) are capped for EMSN but some are not.

How Does DVA Work?

The Department of Veterans Affairs (DVA) provides services and supports for veterans, current and former Australian Defense Force members, Australian Federal Police, and their families. Eligible service people are given a White or Gold card (or Orange for service in World War II!), which grants access to medical treatments.

DVA White Cardholders

DVA White cardholders are covered by DVA for service-related conditions, including treatment in hospitals or day procedure facilities, allied health, GP and non-GP specialist care, dental, optical, community nursing, and pathology and medical imaging. DVA White cardholders who develop cancer, even if unrelated to their service, may be eligible for cancer treatment cover under Non-Liability Health Care (NLHC), if they have engaged in certain forms of active duty. A DVA White cardholder can apply to DVA using the Application for Health Care for Cancer (Malignant Neoplasm) and Tuberculosis form available on the DVA website (form ID D9215). A veteran will be able to show you on their MyService account whether their condition has been approved for cover by DVA.

DVA Gold Cardholders

DVA Gold cardholders are covered by DVA for all medical conditions.

DVA has its own list of item numbers and an accompanying fee schedule. There is less of a difference between inpatient and outpatient fees provided by DVA than when the service is covered by Medicare. Charges to DVA do not act like a Medicare rebate; to access DVA payments, the DVA fee must be accepted as full payment for the service and although usually higher than the respective MBS rebate, DVA rebates remain lower than industry standard for many craft groups. Doctors can choose to not treat DVA cardholders, however many have a personal or group policy to accept DVA payments.

DVA may also cover certain non-MBS (including non-PBS) investigations and treatments, however application for prior approval is needed, and must include:

• The name and DVA number of the veteran
• The treatment entitlement of the veteran (ie White or Gold card)
• The provider number of the requesting health care provider
• The provider number of the referrer (where applicable)
• The date of the referral (where applicable)
• The service requiring prior approval
• Clinical justification for the requested service
• Summary of cost

How to Set Your Fees

A fee is how much you feel your time and care is worth. Many clinicians base this on a time-based model ("I need to earn $X per hour and I see 3 reviews per hour, so my review fee is $(X/3)"), or based on the Medicare schedule fee for a given item number, or even on the AMA Fee Schedule. Fees are set by individual clinicians.

Rebates are what a patient gets back as a subsidy for your consultation with them. Sometimes, patients may be charged a fee, but not be eligible for the associated rebate -- we will go into individual item numbers later, but an example here might be that if a patient undergoes a Complex Review (that would normally incur a rebate under item number 133), but they may have already had the two Complex Reviews that they are entitled to, or their Complex New (132) item number was billed to Medicare over 12 months ago -- this means they are not eligible for a 133 rebate, even if a Complex Review appointment or service has been rendered. A doctor is still entitled to charge their fee for a Complex Review, but the patient may only be eligible for a Simple Review (116) item number rebate. The distinction between fees and rebates is important in the private sector.

What is the AMA Fees List?

The Australian Medical Association (AMA) Fees List is a separate and independent schedule of recommended fees for medical services that are used by many doctors as a guideline for their charges. The AMA Fees List reflects the costs associated with providing medical care, including overheads, staff salaries, equipment, and other practice expenses.

While Medicare uses the schedule fee as the standard for reimbursement, the AMA Fees List provides a recommended rate for services provided by private practitioners. These fees are often much higher than the Medicare schedule fees and are typically used for private billing. It is important to note that the AMA Fees List is not a government-approved fee schedule and is not binding on medical practitioners, however can be a useful guide in determining fee structure.

How Private Health Insurance Works

Private health insurance in Australia is an optional, additional form of coverage that complements Medicare. While Medicare provides universal health care to all Australian citizens and permanent residents, private health insurance offers individuals more choice and flexibility in their healthcare, including faster access to medical services, treatment in private hospitals, and coverage for services not fully covered by Medicare.

Private health insurance can be divided into two main categories: hospital cover and extras cover.

Hospital Cover

Hospital cover provides insurance for treatment in private hospitals or for services that may not be fully covered under Medicare. This cover typically includes:

• Treatment in private hospitals: This means patients can choose their doctor, be treated in a private room (if available), and avoid waiting lists for elective surgery.
• Private rooms: Some policies may offer additional benefits, such as private rooms in hospitals or additional comfort and services.
• Out-of-pocket costs: Private insurance can help reduce or cover the "gap" between what the doctor charges for inpatient treatment, or the supervision thereof, and what Medicare reimburses as well as what the private hospital or day chemotherapy unit charges in accommodation fees, allowing patients to avoid substantial out-of-pocket expenses.
• Choice of specialists: Patients with private health insurance can choose their specialist or surgeon for treatments, unlike with Medicare, where the choice might be limited to specialists available in public hospitals.

Hospital cover is often divided into tiers, ranging from basic hospital cover to comprehensive policies that offer the widest range of benefits.

Extras Cover (also known as General Treatment Cover)

Extras cover provides insurance for specific services that are often not covered by Medicare, such as:

• Dental care: Regular checkups, fillings, root canals, and other dental treatments.
• Optical: Coverage for eye exams, glasses, and contact lenses.
• Physiotherapy, chiropractic, and osteopathy: Coverage for services such as physiotherapy, massage, and osteopathy.
• Podiatry: Treatment for feet and lower limb concerns.
• Psychology and other allied health: Includes consultations with mental health professionals, dietitians, speech pathologists, and more.
• Pharmacy: Drugs prescribed by a medical practitioner which are TGA registered but not otherwise covered by the Pharmaceutical Benefits Scheme. These may include cancer medications prescribed on a private script. Different health funds have different policies regarding financial support for these kinds of medications.

Extras cover can vary significantly depending on the insurer and the level of coverage selected. Patients often use this type of insurance for routine or non-emergency treatments that are not covered by Medicare.

Referrals

Patients require a referral to be eligible for Medicare rebates for specialist care, and to provide the referred specialist with the necessary background on the patient to contribute to their management.

• Referrals from GP-specialists (GPs): Valid for 12 months
• Referrals from non-GP specialists: Valid for three months -- this ensures that in that time, the patient should return to see and update their GP as the central hub of their medical care to determine if ongoing care by the non-GP specialist is needed, and to issue a new referral.

The duration of validity of the referral is not from the date of referral but from the date that the patient is first seen by the specialist to whom the referral is written.

GPs may choose to issue an indefinite referral; however, this is purely at the discretion of the GP. There are many reasons why GPs may choose to not provide an indefinite referral, including to force us into writing a letter to them and updating them on the patient's care!

Referrals received for admitted patients in private hospitals are valid until the date of discharge -- a new referral is required for the patient for the patient to be eligible for a rebate to continue care with the specialist after discharge.

Locum Tenens Arrangements

Covering for another doctor, commonly referred to as "locumming", includes weekend cover arrangements, and is a common area of confusion with regards to billing rights. Most importantly, it is important to have clear agreement between the usual doctor and the locum regarding how billing is to proceed during the period of cover.

Important aspects of locum arrangements include:

• New referral not required: A new referral is not required to the doctor performing the locum, provided the referral to the usual doctor is valid.
• Limited item numbers: A locum may only bill item numbers that the usual doctor would have had the right to bill if they were continuing care. Specifically, the first time a locum meets a patient on behalf of their usual doctor, it is not an "initial consultation".
• Duration rules: If covering for less than two weeks, the locum can bill their services through their existing provider number at another location. If the period of cover is to be either greater than two weeks or is expected to occur on a regular basis within those two weeks, the locum should apply for their own provider number for that location.
• Provider number restriction: A service provided by one practitioner cannot be billed under another practitioner's provider number, even during short-term locum cover.

Overseas work note: It is not permissible to bill for services that occur whilst a doctor is overseas. This is a particular issue for Medical Oncologists and Haematologists as it relates to billing for supervised treatments (eg item numbers 13950), since the physician may have signed the chemotherapy treatment prior to leaving Australia. Patients receiving treatment can only be billed by a physician who is in Australia and "supervising" the treatment on that particular day.

Medicare Compliance

The Department of Health and Aged Care ("the Department") is responsible for ensuring compliant claiming under the Medicare Benefits Scheme (MBS) and Pharmaceutical Benefits Scheme (PBS), as well as the Child Dental Benefits Schedule (CDBS -- outside the scope of this document). The Department monitors claiming data and uses other means to identify non-compliance that is divided into five themes relevant to Medical Oncology and Haematology practice:

1. Incorrect claiming from the MBS
2. Incorrect prescribing from the PBS
3. Business arrangements that seek to inappropriately maximise payment of benefits
4. Possible inappropriate practice, including:
   • Unacceptable conduct
   • Prescribed pattern of services (80/20 rule, 30/20 rule)
   • Causing or permitting inappropriate practice
5. Fraud -- Dishonestly obtaining benefits by deception

Targeted Compliance Letters

Communication from the Department to a health care provider to let them know that their billing practices may not be consistent with their peers, and to encourage the provider to review item number descriptors. An opportunity for the provider to voluntarily acknowledge (a no-fault process) and repay incorrectly billed amounts. If a targeted compliance letter is received by a PCPA member, discuss with your medical indemnity provider.

Practitioner Review Program (PRP)

The PRP reviews servicing behaviour to determine whether identified concerns regarding billing practices require review by the Director of the Professional Services Review (PSR) under the PSR Scheme. Referral to the Director of the PSR is the most serious form of review. PRP reviews may involve an interview that provides an opportunity to provide an explanation for variances in billing practices, a six-month review to evaluate changes made in billing practices. Depending on the information provided and the severity of concerns raised, alongside the outcome of the PRP interview with/without the six-month review, the PRP may refer cases to a delegate of the Chief Executive Medicare.

Delegate Assessment

Health Professional Advisers and senior staff of the Department will be referred cases that can't be resolved through the PRP. A delegate will review all relevant information pertaining to the case and decide whether a matter can be closed or requires referral to the Director of the PSR. Delegates are required by law to refer all cases of breaching the 80/20 rule and the 30/20 rule to the Director of the PSR.

Review by the Director of the PSR

The Director of the PSR will review cases referred to them by delegates of the Chief Executive Medicare. They cannot initiate their own reviews. The Director will review all information available and decide on one of three outcomes:

• No further action
• Negotiation of an agreement, which requires the practitioner to acknowledge their inappropriate practices and may include specified actions, such as repayment of benefits claimed or partial or full disqualification from providing MBS services for a specified period
• Referral to a Committee of peers for further investigation

Item Numbers

An item number is how Medicare codes the rebates that patients are entitled to for medical services. Some medical procedures (particularly novel procedures) or encounters don't have an item number associated with them, meaning there is no rebate associated for these services and fees are paid in full by the patient with no reimbursement. To satisfy criteria to be entitled to a specific item number's rebate, Medicare may require certain aspects of that item number that must be satisfied (time spent with the patient, for example). The website mbsonline.org.au is a good resource for the specific wording of item numbers and their required criteria, however it is worth noting that the wording of item numbers on this website can change from time to time without notice -- it is important that physicians update themselves about the requirements of item numbers. Other ways of staying on top of current issues is to join the Private Cancer Physicians of Australia (PCPA) and attend our Annual Scientific Meetings (ASMs)!

Explanatory Notes

The astute medical practitioner reviewing the MBSOnline descriptors will note below the listed Fee and Benefit rates for many item numbers, reference is made to paragraphs of explanatory notes, termed general explanatory notes (GNs), associated explanatory notes (ANs), or therapeutic explanatory notes (TNs). These are additional stipulations or considerations for the use of item numbers that may pertain to the item number one is reviewing. These might refer to multiple attendances on the same day or relevant equivalent Telehealth item numbers. It is important not only to be aware of the item number descriptor, but aspects of the explanatory notes that often clarify the appropriateness of the item number in certain situations.

AN.0.7 - Multiple Attendances on the Same Day

• Payment of multiple benefits on the same day may be made, provided the subsequent attendances are not a continuation of the initial or earlier attendance, however there should be a reasonable lapse of time between such attendances before they can be regarded as separate attendances.
• An example of when multiple attendance item numbers may be required include when an admitted patient is seen on ward rounds in the morning and then develops a complication during the day and requires a separate review. This is clearly not a continuation of the previous attendance as there has been a clinical change that requires separate attention. Of note, management of infusion reactions may be expected to be included in the supervision of parenteral anticancer therapy item number, and it therefore may not be considered appropriate to bill separate attendance item numbers for this.
• They may be a need to review a sick or unstable inpatient more than once in a day. Each consultation can be billed separately if the time of each of the consultations are submitted with the claim for service and the visits are documented in the case records.

AN.40.1 - Specialist and Consultant Physician MBS Telehealth

• This explanatory note provides a reference table for the equivalent to Face-to-Face item numbers when consultations are conducted over either Video-based, or Telephone-based media.
• Of note, there is no longer a 'New' consultation item number for use over telephone.
• Any practitioner utilising Telehealth as part of their business model should familiarise themselves with the Technical Requirements and requirements to ensure privacy and confidentiality listed under this explanatory note, as well as ensuring that all relevant cybersecurity requirements are met by the platform through which they conduct these appointments.

AN.0.23 - Referred Patient Consultant Physician Treatment and Management Plan (Items 132 and 133)

• Item 132 should include the development of options for discussion with the patient, and family members, if present, including the exploration of treatment modalities and the development of a comprehensive consultant physician treatment and management plan, with discussion of recommendations for services by other health providers as appropriate.
• Item 133 is available in instances where a review of the consultant physician treatment and management plan provided under item 132 is required, up to a maximum of two claims for this item in a 12-month period. Should further reviews of the consultant management plan be required, the appropriate item for such service/s is 116.
• If appropriate, a written copy of the consultant physician treatment and management plan should be provided to the patient.
• A written copy of the consultant physician treatment and management plan should be provided to the referring practitioner, usually within two weeks of the consultant physician consultation.

AN.0.21 - Minor Attendance by a Consultant Physician

• A minor consultation is regarded as being a consultation in which the assessment of the patient does not require the physical examination of the patient and does not involve a substantial alteration to the patient's treatment
• Examples provided:
  • Hospital visits where a physical examination does not result, or where only a limited examination is performed.
  • Hospital visits where a significant alteration to the therapy or overall management plan does not ensue.
  • Brief consultations or hospital visits not involving subsequent discussions regarding patient's progress with a specialist colleague or the referring practitioner.

TN1.27 - Appropriate Billing of Item 13950

This explanatory note is discussed in more detail below under the 13950 item number discussion.

GN.12.31 - Services Rendered on Behalf of Medical Practitioners

• Services subject to GN.12.31 (including 13950, 13706, and 14221, but not including 14206) can be provided on behalf of a medical practitioner and still attract a rebate payable to that medical practitioner for the supervision of that service.
• Important points to this are that:
  • The practitioner must accept full responsibility for the service
  • The practitioner maintains adequate and contemporaneous records
  • All elements of the service must be performed in accordance with accepted medical practice
  • The supervision does not occur from outside Australia
  • The supervision does not need to be present for the entire service, but they must have direct involvement in at least part of the service

Individual Item Numbers (Current as of July 2025)

Item 110 - Simple New

MBS Description: Professional attendance at a consulting rooms or hospital, by a consultant physician in the practice of the consultant physician's specialty (other than psychiatry) following referral of the patient to the consultant physician by a referring practitioner -- initial attendance in a single course of treatment.

The Simple New item number requires a referral from a medical or nursing practitioner and is used where any of the required criteria for billing of a 132 (Complex New) is not satisfied. Examples of this might include:

• A 63-year-old man with no comorbidities for initial consultation regarding their new diagnosis of rectal cancer.
• A 74-year-old patient known to you for metastatic lung cancer, who is referred via the Emergency Department for their new issue of a community-acquired pneumonia.
• An 88-year-old man with a new diagnosis of pancreatic cancer on the background of hypertension, type II diabetes, but for whom the consultation only lasted 40 minutes as they didn't want further investigation or treatment.

Item 132 - Complex New

MBS Description: Professional attendance by a consultant physician in the practice of the consultant physician's specialty (other than psychiatry) of at least 45 minutes for an initial assessment of a patient with at least 2 morbidities (which may include complex congenital, development and behavioural disorders) following referral of the patient to the consultant physician by a referring practitioner...

Item 133 - Complex Review

MBS Description: Professional attendance by a consultant physician in the practice of the consultant physician's specialty (other than psychiatry) lasting at least 20 minutes after the first attendance in a single course of treatment for a review of a patient with at least 2 morbidities...

Discussion points:

• The patient is only eligible for a 133 rebate if their initial consultation was eligible for, and claimed as, a 132 (ie unlike in the medical world, simple cases cannot become complex)
• Item 133 is available up to a maximum of two claims for this item in a 12-month period
• Worth highlighting, the 133 item number descriptor requires that at least 20 minutes to the patient is required to satisfy this rebate. Appointments scheduled for 15-minute intervals may require documentation of start and stop times.

Item 116 - Standard Review

MBS Description: Professional attendance at consulting rooms or hospital, by a consultant physician in the practice of the consultant physician's specialty (other than psychiatry) following referral of the patient to the consultant physician by a referring practitioner -- each attendance (other than a service to which item 119 applies) after the first in a single course of treatment.

For most physicians, this will likely be their most-billed item number. There are few additional stipulations on the requirements of satisfying this item number, however consideration should be given to whether a review attendance may be more appropriate for item number 119.

Item 119 - Minor Review

MBS Description: Professional attendance at consulting rooms or hospital, by a consultant physician in the practice of the consultant physician's specialty (other than psychiatry) following referral of the patient to the consultant physician by a referring practitioner -- each minor attendance after the first in a single course of treatment.

Consultations where a minor attendance item number may be more appropriate are outlined in the associated note AN.0.21, discussed in the Explanatory Notes section above.

Item 13950 - Parenteral Anticancer Treatment

MBS Description: Parenteral administration of one or more antineoplastic agents, including agents used in cytotoxic chemotherapy or monoclonal antibody therapy but not agents used in anti-resorptive bone therapy or hormonal therapy, by or on behalf of a specialist or consultant physician -- attendance for one or more episodes of administration.

TN.1.27 - Appropriate Billing of Item 13950

• Parenteral routes: Include intravenous, intramuscular, subcutaneous, intrathecal, and intracavitatory (eg. intravesical or intraperitoneal) treatment
• Duration: Commences with establishment of parenteral route, ends with disconnection, regardless of time expired
• Single billing per day: Item 13950 can only be billed once each time the patient presents for treatment, irrespective of the number of antineoplastic agents administered
• CVAD access: Item number 13950 includes payment for the accessing of a CVAD; items 13950 and 14221 cannot be billed during the same service
• Pump loading: Loading of pumps, reservoirs, or ambulatory drug delivery devices can be billed under item 13950 -- however, Item 13950 cannot be claimed where the patient is receiving the infusion at home via a pre-loaded pump or ambulatory delivery device (eg day 2 of a 3-day 5FU infusion - 13950 applies to day 1 only)
• Hormonal therapy: Item 13950 cannot be claimed for administration of hormonal therapy (such as fulvestrant injections)
• Remote supervision: Remote supervision is allowed so long as the practitioner is satisfied that administration is being performed with generally accepted professional supervision levels. Both practitioner and patient must be in Australia.

Item 13706 - Blood Transfusion

MBS Description: Transfusion of blood or bone marrow - already collected

• Subject to the supervision rule (ie billable by a supervising specialist or consultant physician)
• Applies for the supervision of transfusion of blood, platelets, white blood cells, bone marrow, or gamma globulins (not payable for intramuscular gamma globulins)
• Billable once daily, regardless of the number of units transfused, unless a separate assessment and transfusion process is documented

Item 14221 - CVAD Access

MBS Description: Long-term implanted device for delivery of therapeutic agents, accessing of, not being a service associated with a service to which item 13950 applies.

This rebate is available for the supervision of accessing of central venous access devices (ports/PICCs) for reasons other than the delivery of antineoplastic agents. This can include for regular access and flushing, accessing for disconnections of infusion pumps, for blood tests, transfusing blood products or for delivery of other intravenous treatments, such as antibiotics or bisphosphonates. This service is subject to the Medicare supervision rule (GN.12.31).

Item 871 - Multidisciplinary Team (Presentation)

MBS Description: Attendance by a general practitioner, specialist or consultant physician as a member of a case conference, to lead and coordinate a multidisciplinary case conference on a patient with cancer...

Item 872 - Multidisciplinary Team (Attendance)

MBS Description: Attendance by a general practitioner, specialist or consultant physician as a member of a case conference, to participate in a multidisciplinary case conference on a patient with cancer...

Discussion points (for items 871 and 872):

• Only one practitioner is eligible to claim item 871 for each patient during a case conference
• Only patients with a malignancy of a solid organ or tissue, or a systemic cancer are covered
• The billing practitioner must be a treating doctor of the patient discussed
• Participants must be in communication throughout the case conference, either face-to-face, or by telephone or video link
• In general, no more than two case conferences per patient per year will be billed by a practitioner

Item 14206 - Hormone Implantation

MBS Description: Hormone or living tissue implantation by cannula

• Billable for the injection of hormonal treatments (such as fulvestrant)
• NOT subject to the Medicare supervision rule -- this item number is only applicable if performed by the specialist or consultant physician personally

Telehealth Item Numbers

From 1 November 2025, additional item numbers were added to the MBS for specialist consultation over telephone. All telehealth (both video and telephone-based) are available as outpatient services only. Providers are expected to obtain informed financial consent from patients prior to providing the service, including details related to fees and out-of-pocket costs to the patient.

Important Notes About Telehealth Item Numbers

• Telehealth consultations can be provided from anywhere, and not at the location where their provider number is registered -- the provider number at the most appropriate practice for the patient's care should be used.
• Both the patient and the medical practitioner must be located in Australia at the time that the service is provided.
• All Telehealth item numbers still require a valid referral to be eligible for the respective rebate, but do not require their own separate referral.
• The 30/20 rule applies -- any practitioner who provides more than 30 telehealth services per day on 20 or more days in a 12-month period will automatically be referred to the Professional Services Review (PSR).
• All telehealth and telephone item numbers require that the attendance was greater than 5 mins.
• Only the time taken in consultation with the patient counts towards the time of consultation.
• Telehealth item numbers are also subject to the multiple attendance rule -- a patient would not be eligible for two rebates if a telephone appointment was held in the morning, followed by a face-to-face appointment later in the day if it were deemed to be a continuation of the same attendance.
• Video attendance requirements: Video attendance item numbers require the maintenance of a visual and audio link with the patient throughout the period of service.
• Clinical appropriateness: All Telehealth and Telephone item numbers require that the medical practitioner is satisfied that it is clinically appropriate to provide the service to the patient over either video telehealth or telephone.

Telehealth Item Numbers Comparison Table