Medicare Referral Validity: A summary for practice staff

Medicare Referral Validity: A summary for practice staff

Do you know how long an indefinite referral lasts? Do you know the rules about if and when you can bill another initial consult item on a new referral? Practice staff are encouraged to learn the Medicare rules regarding Referrals. Responsibility for the accuracy of medical billing ultimately lies with the servicing provider, however a savvy receptionist can be instrumental in identifying potential billing errors before they even occur, simply by knowing the rules and gently advising the practice manager or the doctor if you believe there is reason to bill differently.

Here are the basic essentials:

  • GP referrals last 12 months (unless clearly marked as “indefinite”) from the date of the first appointment using the new referral. An Indefinite referral can often fail via electronic transmission if it is greater than five years old.
  • Specialist referrals last 3 months from the date of the first appointment using the new referral.
  • A new consultation item can only be billed with a new referral if the patient has not been seen for the same condition within the last nine months.
  • Referrals must be signed and dated BEFORE the appointment date, and cannot be back-dated.
  • No referral = no medicare payment

This information is just a general summary. To get everything you need to know for your practice, read these articles:

  1. Medicare Referrals and Requests
  2. Referrals, initial consultations and Medicare compliance by Michael Wade, Avant Special Counsel – Medicare

Be the billing watchdog for your practice –  reduce lost income for the practice, and improve your Medicare compliance.

Here is another great article on Referrals –

Medicare Audits – The rules for initial consultations

Medicare Audits – The rules for initial consultations

Are you one of the many medical practices that have received an audit request from Medicare? You aren’t alone. Medicare has ramped up its review processes because of the many mistakes made with medical billing in both general and specialist practice.

Today I want to talk about the INITIAL CONSULT. These are typically items 104 for specialists and 110/132 for consultant physicians. The initial items in the MBS contain similar key words, Here is the 104 MBS Item description with two key phrases highlighted in red:

“Professional attendance at consulting rooms or hospital by a specialist in the practice of his or her specialty after referral of the patient to him or her—each attendance, other than a second or subsequent attendance, in a single course of treatment, other than a service to which item 106, 109 or 16401 applies”

‘Referral’ means that this service can only be supplied with the presentation of a valid referral.

A ‘single course of treatment’  is an initial attendance plus any subsequent attendances for the continuing management of the condition until the patient is referred back to the referring practitioner. That means that a new referral for the same condition does not mean you can automatically bill another initial consult item.

Another initial attendance item can be billed only if the referring doctor decides the patient’s condition needs to be reviewed and provides a new referral, and the last referral has expired, and the patient was last seen by the specialist or consultant physician more than 9 months earlier for that condition. That is a lot of ‘ands’. But, in short, it means that you cannot bill another initial consult item within 9 months of a previous visit unless the referral is for a different condition altogether.

Take a note of that: Even with a new referral, you cannot claim for another initial attendance if it has been less than 9 months since you last saw them for that same condition.

If you have received an urgent action request from Medicare to justify the 110, 132 or 104 items billed within 9 months of each other, you will need to show that they were for different conditions. If you cannot, then they need to be corrected to subsequent consult items and the monies repaid to Medicare.

If you need assistance with Medicare Audit reviews, or if you would like to get your staff billing compliantly before an audit request hits you, get in touch. We can help with review, corrective action, and training.


Welcome to Practice Management Plus

Welcome to Practice Management Plus

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