Ophthalmologists response to a restriction on claiming Medicare Benefits Schedule (MBS) attendance items with Surgical Operations that have an MBS fee of $300 or more

Page last updated: 19 February 2018

What do the changes involve?


In August 2017, the Government announced a number of changes to the MBS in response to recommendations from the MBS Reviews Taskforce. These include an amendment from 1 November 2017 that restricts the claiming of a specialist and consultant physician consultation item (items 105, 116, 119, 386, 2806, 2814, 3010, 3014, 6019, 6052, 16404) when performed on the same day with a procedure in Group T8 - Surgical Operations (including eye injections) that has an MBS fee of $300 or more.

Why is the Government making this change?


A planned MBS procedure with a fee of $300 or more should already capture a consultation component, and billing a full separate consultation is therefore not considered appropriate.

This change enforces the long standing Medicare principle of a 'complete medical service', whereby the most relevant item that captures the entire service should be claimed. The intent of the change was not for additional out of pocket costs to be passed onto patients, but rather, that practitioners would cease to bill the consultation items altogether. In most cases, charging a consultation item additional to the planned surgical procedure should be unnecessary.

Is there any way I can get a rebate for my attendance as well as my eye injection?


Three new attendance items have been introduced (111, 117, 120). These new items can be claimed on the same day as Group T8 items with schedule fees of $300 or more if the procedure is urgent and not able to be predicted prior to the commencement of the attendance. Generally, regular eye injection services are scheduled and these items are unlikely to apply unless your doctor consults you about an unrelated condition.

Regular eye injections are generally scheduled in advance (i.e. they are non-urgent and predicted). Any associated consultation is therefore considered to be part of that medical service.

The new attendance items could only apply to your eye injection if, for example, you have a consultation booked with your doctor about an unrelated matter, and they decide on that day you require an unscheduled or urgent eye injection. In this case one of the new consultation items may be claimed in conjunction with the eye injection.

Why am I still being billed for this service?


Some ophthalmologists may still consider it necessary to consult with you regarding your eye injection, and bill you a private service. Patients may be presented with two options to pay for this service:
1) attend a consultation and eye injection treatment on two separate days; or
2) receive a consultation on the same day and be ineligible for the Medicare rebate for the consultation item.
These options are not Government policy. A patient’s eye injection treatment and associated consultation should be covered under the fee for the eye injection. Patients should ask their ophthalmologist why a full separate consultation is necessary.

What options are available if I am having trouble paying the additional costs?


  • If you are having trouble paying for your treatment, you should consult your treating doctor about the fees they are charging. Some doctors adjust their fees in consideration of individual circumstances.
  • Be informed. Doctors should ensure that patients are fully informed of all costs involved in their treatment. Informed financial consent is especially important when there is likely to be a significant gap between the fees the doctor charges and the MBS rebate.
  • Exercise your consumer rights and shop around. There is often a considerable difference in the fees charged between doctors.
  • Macular Disease Foundation, Australia ph: 1800 111 709 is a valuable resource for patients and may be able to offer advice, or advocate on your behalf in certain circumstances.

Why am I now paying more for my optical coherence tomography (OCT) scan?


Some ophthalmology practices have advised patients the 1 November 2017 changes have affected the rebate they receive for performing an eye injection service, which may include an OCT scan. They also claim that if patients do not attend the consultation associated with their eye injection on a separate day (including the OCT scan), they must now pay for their OCT scan separately. This is incorrect. There is currently no MBS item or rebate for OCT scans for the purposes of monitoring treatment. The MBS item for OCT scans is limited to determining eligibility for initial treatment with Pharmaceutical Benefits Scheme medicines.

How much does the Government subsidise eye injections?


MBS item 42738 is the most commonly claimed eye injection item for treatment of macular degeneration and accounts for the highest amount of Medicare benefits in ophthalmology. In 2016/17 the Government paid over $118 million in Medicare benefits for more than 400,000 eye injections (item 42738) provided by Australia’s approximately 1,000 ophthalmologists. The Government contributes an average of $289.70 per service for item 42738.

In addition, the Government assists patients with their out-of-pocket expenses through a number of Medicare safety nets. The most significant is the Extended Medicare Safety Net which provides an increase in benefits once an annual threshold of out-of-pocket costs for MBS funded out-of-hospital services has been reached. The annual threshold for Commonwealth concession cardholders, including those with a Pensioner Concession Card, a Health Care Card or a Commonwealth Seniors Card is currently $656.30. For non-concession card holders the threshold is currently $2056.30

Where can I find more information?


The Macular Disease Foundation Australia can assist with information and guidance.

Common questions asked by consumers about this change:


I have been having regular eye injections for years – what has changed recently?


The Government made changes to the MBS from 1 November 2017, following recommendations from the MBS Reviews Taskforce. One change is a rule preventing doctors from co-claiming a standard subsequent consultation on the same day as performing a planned surgical procedure with a fee of $300 or more. The Government would not expect you to see any changes to the way your eye injection service is delivered.

Is this a reduction in Medicare rebates?


No. It is the Government’s position that doctors should not charge patients for a separate consultation when claimed in conjunction with a surgical procedure that has a fee of $300 or more.

Why do I have to have two appointments when it used to be done in one?


You should not need to attend a separate appointment. Please discuss this with your doctor. Your eye injection and the consultation that goes with it should be part of the same service, and is covered under the fee for the eye injection.
If you have a different, new or urgent issue you may need an unscheduled eye injection on the same day as a consultation. There are three new MBS items available to cover such circumstances. If one of these items is appropriate in your situation, you will be eligible for the applicable Medicare rebate.

Why am I paying more since this change took effect?


This is not Government policy, but a business decision by individual doctors to bill you.

What can I do?


  • If you are having trouble paying for your treatment, you should consult your treating doctor about the fees they are charging. Some doctors adjust their fees or offer other payment plans in consideration of individual circumstances.
  • Be informed. Doctors should ensure that patients are fully informed of all costs involved in their treatment. Informed financial consent is especially important when there is likely to be a significant gap between the fees the doctor charges and the MBS rebate.
  • Exercise your consumer rights and shop around.

Where can I get help or more information?


The Departments factsheet.

If you have questions further to this you would like answered by the Department you may email enquiries@health.gov.au.

The Macular Disease Foundation Australia is a valuable resource for patients and may be able to offer advice, or advocate on your behalf in certain circumstances.

Who can I complain to?


In the first instance you should discuss your situation with your treating doctor.

If you wish to raise a concern about a change in policy at a hospital or medical practice, guidance on how to go about this is available from the Australian Health Practitioner Regulation Agency.