Level E consultation, in rooms

Intention of this service under item 135 and video equivalent item 92140

Items 135 or video equivalent item 92140 are intended for complex conditions, characterised by multi-domain cognitive and functional impairment. Patient eligibility is for neurodevelopmental disorders (NDD), which are assessed to be complex and mean that individuals require support across multiple domains.

The intention of this service is to provide access to treatment, through the development of a treatment and management plan by a paediatrician, for individuals diagnosed with a complex NDD. The development of the treatment and management plan follows a comprehensive medical assessment, and provides the opportunity to refer to eligible allied health practitioners for up to a total of 20 MBS treatment services per patient’s lifetime (items 82015, 82020, 82025, 82035, 93035, 93036, 93043 or 93044). This item is claimable once in a patient’s lifetime.

Eligibility:

In the context of item 135 (or 92140), the diagnosis of a complex NDD requires evidence of requiring support and showing impairment across two or more neurodevelopmental domains. Complexity is characterised by multi-domain cognitive and functional disabilities, delay or clinically significant impairment.

Neurodevelopmental domains include:

• Cognition
• Language
• Social-emotional development
• Motor skills
• Adaptive behaviour:  conceptual skills, practical skills, social skills or social communication skills

Age eligibility:

Whilst it is not expected that a paediatrician would routinely assess adult individuals (item 289 provides for assessments undertaken by a psychiatrist for patients aged over 18 years to under 25 years), item 135 provides an age ceiling which is consistent across all MBS items related to complex NDD and related allied health services. Where a paediatrician has been referred a patient (under 18 years of age) and the diagnostic formulation is not completed until after their 18th birthday, the higher age limit will allow the completion of the assessment by the paediatrician (as clinically appropriate).

Referral pathways:

Early identification of, and intervention for, individuals with complex NDD is important in promoting positive longer-term outcomes. Symptoms can cause clinically significant impairment in social, occupational or other important areas of functioning.

Where neurodevelopmental concerns have been identified and brought to the attention of the patient’s GP to initially assess these concerns and the GP considers there are persisting indications that require more specialised assessment, they are encouraged to refer to either a consultant paediatrician or psychiatrist for a comprehensive assessment.

Diagnostic Assessment:

The assessment and diagnosis of a complex NDD should be evaluated in the context of both a physical and developmental assessment. The paediatrician may require a number of separate attendances (through usual time-tiered or subsequent attendance items 110, 116, 119, 122, 128, 131 or video items 91824 to 91826) to complete a comprehensive accurate assessment and formulate a diagnosis, exclude other disorders or assess for co-occurring conditions.

Multi-disciplinary assistance with assessment and/or contribution to the treatment and management plan:

Depending on a range of factors, not limited to the patient’s age and nature of suspected complex NDD, the consultant physician may require a multi-disciplinary approach to complete a comprehensive accurate assessment and formulate a diagnosis.

Where the paediatrician determines the patient requires additional assessments to formulate a diagnosis, through the assistance of an allied health practitioner, they are able to refer the patient to an eligible allied health provider from standard attendance items (110 to 131 or telehealth (video or phone) items equivalent items).

Whilst Medicare benefits provide for a total of 8 allied health assessment services per patient per lifetime, an eligible allied health practitioner can only provide up to 4 services before the need for a review (the type of review can be specified in the referral to the eligible allied health professional) by the referring paediatrician, who must agree to the need for any additional allied health services prior to the delivery of the remaining 4 allied health assessment services.

Eligible allied health assessment practitioners include:

• Psychologist (MBS item 82000, 93032, 93040)
• Speech pathologist (MBS item 82005, 93033, 93041)
• Occupational therapist (MBS item 82010, 93033, 93041)
• Audiologist, dietitian, exercise physiologist, optometrist, orthoptist, physiotherapist (MBS item 82030, 93033, 93041)

Requirements of the referral to allied health practitioners

The paediatrician can refer to multiple eligible allied health practitioners concurrently, but a separate referral letter must be provided to each allied health practitioner. The referral should specify the intent of the assessment and if appropriate, specify the number of services to be provided. Where the number of sessions is not specified, each allied health practitioner can provide up to 4 assessment services without the need for review or agreement to provide further assessment services.

Review requirements following delivery of four (4) allied health assessment services

Where an eligible allied health practitioner has provided 4 assessment services (through items 82000, 82005, 82010, 82030, 93032, 93033, 93040 or 93041) and considers additional assessment services are required, they must ensure the referring paediatrician undertakes a review. If the type of review is not specified by the referring paediatrician an acceptable means of review includes: a case conference, phone call, written correspondence, secure online messaging exchange or attendance of the patient with the referring paediatrician.

Inter-disciplinary allied health referral

Eligible allied health practitioners are also able to make inter-disciplinary referrals to other eligible allied health practitioners as clinically necessary to assist with the formulation of the diagnosis or contribute to the treatment and management plan. Inter-disciplinary referrals must be undertaken in consultation and agreement with the referring paediatrician. Whilst they do not require the need for an attendance with the patient (face-to-face/video/phone) by the referring paediatrician, they do require an agreement from the referring paediatrician. This can be undertaken (but is not limited to) an exchange by phone, written communication or secure online messaging.

Contribution to the Treatment and Management Plan through allied health referral

In addition to referring to allied health practitioners for assistance with formulating a diagnosis, once a paediatrician makes a complex NDD diagnosis, the paediatrician may require the contribution of an eligible allied health practitioner to assist with the development of the Treatment and Management plan (before billing item 135 or 92140).

MBS items 82000, 82005, 82010, 82030, 93032, 93033, 93040 or 93041 provide a dual function for this purpose. It is important to note that the service limit of a total of 8 services per patient per lifetime apply regardless of whether the items are used for assistance with diagnosis or contribution to the treatment and management plan, and the referring paediatrician should be mindful of this when referring to eligible allied health practitioners.

Development of the Treatment and Management Plan

Once the paediatrician has made a diagnosis of a complex NDD, to complete the item requirements of item 135 or 92140 they must develop a treatment and management plan which includes:

Written documentation of the patient’s confirmed diagnosis of a complex NDD, including any findings of assessments performed (which assisted with the formulation of the diagnosis or contributed to the treatment and management plan)

• A risk assessment which means assessment of:
  • the risk to the patient of a contributing co‑morbidity and
  • environmental, physical, social and emotional risk factors that may apply to the patient or to another individual.
• Treatment options which include:
  • Recommendations using a biopsychosocial model
  • Identifying major treatment goals and important milestones and objectives
  • Recommendation/s and referral for treatment services provided by eligible allied health practitioners (where relevant) and who should provide this, specifying number of treatments recommended (to a maximum of 20 treatment services)
  • Indications for review or episodes requiring escalation of treatment strategies
• Documenting the Treatment and Management plan and providing a copy to the referring medical practitioner and relevant allied health practitioner/s.

Referral for allied health treatment services

Once a treatment and management plan is in place (under item 135 or 92140) the paediatrician can refer the individual to eligible allied health practitioners for the provision of treatment services. Treatment services address the functional impairments identified through the comprehensive medical assessment which are outlined in the treatment and management plan. Treatment services focus on interventions to address developmental delays/disabilities or impairments.

Eligible allied health treatment practitioners include:

• Psychologist (MBS items 82015, 93035, 93043)
• Speech pathologist (MBS items 82020, 93036, 93044)
• Occupational therapist (MBS items 82025, 93036, 93044)
• Audiologist, dietitian, exercise physiologist, optometrist, orthoptist, physiotherapist (MBS items 82035, 93036, 93044)

A total of 20 allied health treatment services per patient per lifetime are available through the MBS, which may consist of any combination of items 82015, 82020, 82025 or 82035 or equivalent video or phone items. Whilst the paediatrician can refer to multiple eligible allied health practitioners concurrently, a separate referral letter must be provided to each allied health practitioner.

The referral should specify the goals of the treatment and if appropriate, specify the number of services to be provided. It is the responsibility of the referring paediatrician to allocate the number of treatment services (up to a maximum of 10 services per course of treatment) in keeping with the individual’s treatment and management plan.

It is important to note, that a benefit will not be paid for the MBS allied health treatment services unless the pre-requisite items (135 or 92140) have been processed through the Medicare claiming system.

On the completion of a “course of treatment” (specified by the referring paediatrician, up to maximum of 10 services), the eligible allied health practitioner must provide a written report to the referring paediatrician, which should include information on the treatment provided, recommendations on future management of the individual’s disorder and any advice to caregivers (such as parents, carers, school teachers). This written report will inform the referring paediatrician’s decision to refer for further treatment services. Where subsequent courses of treatment are required after the initial 10 services (up to a maximum of 20 services per patient per lifetime) a new referral is required.

Inconclusive assessment:

Where a patient does not meet the diagnostic threshold of a complex NDD and where ongoing medical management is required, patients can be managed through subsequent attendance items (such as 116 or 91825) or where at least two separate diagnoses are made through item 132 or 92422.

Examples include where:

• Neurodevelopmental assessment is incomplete or inconclusive
• Neurodevelopmental impairment is present in fewer than two domains
• Neurodevelopmental impairment is present in two or more domains, but individuals do not require sufficient support to meet criteria
• Comprehensive, age-appropriate neurodevelopmental assessment is impossible or unavailable (e.g. in infants or young children- particularly those under 6 years of age)

These individuals may be considered “at risk of a complex NDD” and require follow-up and reassessment in the future.