The last few weeks, medical social media has been ablaze with discussions around the ‘nudge’ letters from The Department of Human Services. If you have missed the uproar and have no idea what it’s all about, it’s basically the government sending letters to 341 GPs asking them to ‘review’ their co-billing of mental health consultation items with physical health items.

These letters appear to be an experiment from the government, one which doctors are rightly angry about, but this latest round of ‘nudges’ from Medicare seems to have caused a real outrage.

If a consultation is for the purpose of a GP Mental Health Treatment Plan, Review or Consultation item, a separate and additional consultation should not be undertaken in conjunction with the mental health consultation, unless it is clinically indicated that a separate problem must be treated immediately.

MBS item 2713

There’s been much discussion on social media platforms about this, and the RACGP President Dr Harry Nespolon, along with the RACGP, have been doing a great job publicising the issue.

What are doctors saying?

Some doctors are railing against this and are being very vocal, tweeting, lobbying, campaigning. Indeed some, such as Dr Gillian Riley, have started a petition on change.org which is gaining traction, and please consider signing it you haven’t already.

Others have been saying that they didn’t even realise they could co-bill and have decided they are going to start doing it, giving patients better rebates.

Others have decided it’s time to stop co-billing altogether. They feel that it’s too complicated and too hard to stick to the rules when the rules seem so arbitrary and can be changed on a whim by the PSR. I’ve actually been relatively vocal on some of my social media groups as well, offering my own personal perspective, which is similar.

As I was writing another of many responses last night about my reluctance to co-bill, it suddenly dawned on me. I actually do co-bill and have no hesitation in doing so. I do it a lot. But not mental health.

Procedural vs Cognitive Medicine

I realised I co-bill a lot. If I had to guess, I’d estimate around 50% of my work is skin cancer medicine. I regularly co-bill when doing this work. I don’t do a biopsy every time I do a skin check, but it’s often. I’d wager far more often than those who received nudge letters co-bill a physical health item with a mental health item. I also occasionally co-bill a physical consult (e.g. item 23) when doing a skin cancer excision. Not for the excision, but for something unrelated. The patient usually wants a prescription, or something else needs doing.

Indeed many of us do this with our physical health consultations as well. We add on items such as an ECG, spirometry, pregnancy test etc.

I have absolutely no hesitation doing this, and simply annotate the billing ‘not related to procedure’.

So why do I do this quite happily, yet advise others against doing this for mental health consults?

Well, it’s down to the Medicare descriptors. You can see above the wording on the mental health consults (2713). It specifically excludes co-billing any other type of consultation with a mental health consultation, unless it is ‘immediately necessary’. That is unless they come for the physical item first then it turns in to a mental health consultation afterwards.

To my knowledge, there are no such restrictions for almost any physical health Medicare item number, save for burns, which I’m sure are far less common than mental health conditions.

What does ‘Treated Immediately’ mean?

Well, that’s part of the problem, nobody really knows. Some feel it means they need to be in a life and death situation. That would certainly fit the bill. But what about those who can’t afford to travel back to the clinic? What about those rural patients who live 500 miles away? That would appear to most rational people to be necessary for that day and not ask the patient to return.

Or are they in fact meant to simply come back the next day because it’s convenient for Medicare despite the obvious inconvenience for the patient?

Some feel it means something which could wait but would be best to treat there and then. For example, somebody concerned about a breast lump. It could wait until the next day, but is that really fair to the patient that’s terrified she has cancer?

Why the dichotomy between physical and mental health?

The obvious difference is the word ‘consultation’. Surgical excisions, ECGs, other physical health items aren’t considered consultations to Medicare, but that does not mean that they should disadvantage those with mental health conditions.

We don’t know why the Government wants it this way, and that’s the main issue. They are, as expected, remaining quiet on this, but it’s obvious that they do not want mental health items being co-billed. For some reason though they seem quite happy for other physical health items to be co-billed with no such qualifiers required.

So, for the time being, I will continue to co-bill these items whilst it seems that Medicare is happy to let me do, but I am starting to wonder whether I really am as protected as I think I am. Even though it seems totally legitimate, I wonder when my ‘nudge’ letter will be coming.

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