Welcome to the first instalment of our Navigating the Maze series – your guide to understanding the complexities of ICU billing in Australia. At ClaimLogic, we believe that empowering intensivists and hospital billing teams with practical knowledge is key to streamlining claims, reducing rejections, and ensuring fair remuneration for critical care.
The Medicare Benefits Schedule (MBS) can often feel like a maze, with layers of item numbers, billing restrictions, and interdependencies that are easy to overlook. This series will walk you through the major categories of item numbers relevant to intensive care, providing clarity on how they function, how they interact, and how to use each MBS item number compliantly and effectively.
In this introductory article, we provide an overview of the main groups of ICU-related MBS item numbers. Each of these groups will be explored in more detail in subsequent articles.
1. Daily Management and Monitoring (Critical Care) Items
These are the cornerstone of ICU billing. They cover the daily ongoing care provided to critically ill patients and are generally claimable once per calendar day per patient.
Key features:
- Item numbers such as 13870, 13873, 13876, 13882, etc., relate to management and monitoring.
- Many have “first day” and “subsequent day” variants, recognising the higher intensity of care and setup on initial admission or initiation of treatment.
- These MBS item numbers often include bundled services (e.g., ECGs, blood gases), making understanding inclusions and exclusions essential.
Correct usage is crucial, especially when co-claiming with procedures or other consults.
2. Procedural MBS Item Numbers
These cover specific interventions frequently performed in the ICU, such as:
- Vascular access (e.g., CVC, arterial lines – items 13815, 13842),
- Intubation, Cardioversion, insertion of intra-aortic balloon pumps, and more.
Key considerations:
- These MBS item numbers are typically claimable in addition to daily management items, provided the service is distinct and documented.
- Some procedures have time or complexity-based restrictions.
- Proper documentation in patient notes and consent is often essential to support claims.
Procedural items are commonly audited, so accuracy matters.
3. Consultation and Attendance MBS Item Numbers
These include specialist and standard physician attendance items:
- Initial and subsequent consultations, including emergency attendances (104, 105, 110, 116, 160, etc.)
- They may apply when the ICU specialist is acting outside their intensive care role (e.g., as a general physician or in a consulting specialist capacity).
Billing tips:
- These items should not be claimed in conjunction with ICU daily care items for the same clinical service.
- They can, however, apply in scenarios such as emergencies, clinically necessary ward follow-up post-ICU discharge, inter-hospital consultations, or pre-ICU assessments.
4. Diagnostic Imaging (Ultrasound) Items
Ultrasound is a powerful tool in the ICU, used for vascular access, pleural assessments, echocardiography, and more.
Key points:
- MBS item numbers such as 55054, 55036, 55129 and others fall under this category.
- A major billing challenge has arisen from the 2020 MBS amendment, which removed ultrasound as a co-claimable item alongside certain intensive care procedures (e.g., 13815, 13832, 13842, 13840).
- As a result, standalone ultrasound billing often results in rejection unless documented and submitted with appropriate overrides under an eligible scenario.
We’ll cover the implications of these rules – and how ClaimLogic helps you navigate them – in a future post.
5. Anaesthesia Items
While not traditionally thought of as part of ICU billing, anaesthesia MBS item numbers are relevant when:
- ICU specialists assist or perform procedures requiring sedation or anaesthetic monitoring,
- Particularly in the context of Tracheostomies, Bronchoscopies, Transoesophageal Echocardiography or transport services.
Anaesthesia item numbers include complex calculation rules involving time units, modifiers, and ASA scores. Understanding when and how they apply in ICU contexts is essential to ensure you’re not missing revenue or overstepping compliance bounds.
What’s Next?
In upcoming articles, we’ll break down each of these categories in depth, highlighting:
- Common mistakes,
- Co-claiming rules,
- Documentation tips,
- Real-world examples,
- How ClaimLogic automates compliance checks and billing logic behind the scenes.
At ClaimLogic, we’re here to help you navigate the complexity so you can focus on patient care – not paperwork. Our platform, launching this September, is designed from the ground up for intensive care, offering intuitive claim creation, real-time validation, and significant time and cost savings.
Stay tuned for Part 2 of Navigating the Maze, where we dive into the daily ICU management and monitoring item numbers in detail.
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Disclaimer
This blog is provided for educational and general informational purposes only and does not constitute legal, medical, or financial advice. While every effort has been made to ensure accuracy, billing requirements under the Medicare Benefits Schedule (MBS) are complex and subject to change. Clinicians should always consult the official MBS, relevant hospital policies, or seek independent professional advice before making billing decisions. While we use reasonable effort to ensure that our overview articles are accurate, current and complete, we do not represent, warrant, or guarantee (to the maximum extent permitted by law) their accuracy, currency, or completeness or imply that they are applicable to your individual situation. ClaimLogic accepts no liability arising from for actions taken based on the content of this article.
