Medicare item rules

Some Medicare item codes follow a rule which determines how the fee is calculated. For example, home visit items abide by an External Rule (Code X). This generally means that the doctor will be paid the same fee for the item as if it was performed in a medical centre plus a certain amount divided by the number of patients seen up to a maximum of six patients.

Click on Rule to select the type of surgical rule applied to the code.

The rule codes are Surgical, Anaethetic, eXternal, Radiology, Oncology, Time Base, Duration, Period, Quantity and W for Dummy (last)

Rule	Description
Surgical (S)	A multiple service rule is a rule that is applied to items that when billed more than once have their benefits halved for the 2nd item and halved again for 3rd item and every item after that. i.e. 1st item is paid at 100%, the 2nd item at 50% and 3rd+ item at 25%.
	Example : patient has in one 2 skin lesions perfomed (one on arm and one on leg)
	The dr would bill the patient 2 x 30032, item 30032 has a 100% fee of $76.20, this item also attracts the 85% fee :
	30032 = 76.20 x 100% x 85% = $64.80
	30032 = 76.20 x 50% 85% = $32.40
	Total Fee paid = $97.20
External (X)	An External Rule is derived from consultation items that are performed in locations other than the doctors practising rooms e.g. at the patients home, nursing home. The Medicare benefit is calculated by :
	Fee = Base Fee* + (Extra/#pats)
	*Base Fee is usually the fee for item 23
	Example : Item 35 where 2 patients were seen
	33.55 + (42.30/2) = $75.85
Anaesthetic (A)
Radiology (R)	When the schedule fee for some of the items are the same the reduction is applied in the following order.1.00 or 100% of the scheduled fee for the first item0.60 or 60% of the scheduled fee for the second item 0.5 or 50% of the scheduled fee for the third item 0.5 or 50% of the scheduled fee for the fourth item
Oncology (O)
Time-Based (T)
Duration (D)
Period (P)
Quantity (Q)
Multiple Service Type	A multiple service rule is a rule that is applied to items that when billed more than once have their benefits halved for the 2nd item and halved again for 3rd item and every item after that. i.e. 1st item is paid at 100%, the 2nd item at 50% and 3rd+ item at 25%.