How does Medicare count services for the 80/20 rule?

Question: Hi Paul,

I have a question and Medicare couldn’t give me a clear answer. 

With the 80/20 rule. 

If a doctor has multiple items in 1 claim, let’s say 3 items. 

Does that count as 1 or 3? 

Also if it’s counted per item does 10990 also get counted? 

Or is this item ignored because it’s an automatic incentive item?

Answer: Hi M.,

Thank you for your question.

Let me provide other readers with some context to your question.

There are Medicare rules of the ‘prescribed pattern of service’ for GPs.

The first is the 80/20 rule. A GP must not see more than 80 patients a day for any twenty days in 12 months period. 

The second is the 30/20 rule for Telehealth.

GPs face severe penalties if they breach those rules.

It does not surprise me that Medicare did not give you any clear answers.

The guidelines are not clear and allow Medicare to count the services both ways. 

Literally, they say: “The 80/20 rule is based on the number of professional attendance services per day, which may not be the same as the number of patients seen in a day”.(1) 

Based on the above, I would exercise caution and count both patients and services. Whichever is higher will make the total. This is just to be on the safe side.

Example of the breach 1. A GP sees 80 patients billing them all for item 23.  

Example of the breach 2. A GP sees 78 patients billing them for item 23. This doctor also sees 1 patient billing her for full Care Plan items 721 and 723. The total number of services is still 80 although there were only 79 patients on that day.

Item 10990 should not count in 80 services because it is an incentive rather than the service, I assume.

Reference:

Prescribed pattern of services – What you need to know. https://www.health.gov.au/resources/publications/prescribed-pattern-of-services-what-you-need-to-know . last accessed 22.10.22