clinical anaesthesia guidance

BILLING

ANAESTHESIA BILLING IN AUSTRALIA

RELATIVE VALUE GUIDE & BILLING UNITS
MEDICARE SCHEDULE FEE REBATE
PRIVATE HEALTH INSURANCE REBATES
PRIVATE HEALTH INSURANCE REBATE SHORTFALL (aka ‘THE GAP’)
BILLABLE ACTIVITIES & BILLING CODES

RELATIVE VALUE GUIDE & BILLING UNITS

Invoices for anaesthesia are based on the value of the anaesthesia service provided, taking into account anaesthesia procedures performed, surgical complexity, time taken, urgency, and patient health amongst others.
The Australian Medical Association (usually endorsed by the Australian Society of Anaesthetists) and the Government Medicare Benefits Scheme index these services into a series of codes that provide relative value to the anaesthesia service provided in the form of a number of billable units.
 
The resultant invoice fee is determined by multiplying the anaesthetist’s unit dollar value by the number of units associated with each of these codes.
By law anaesthetists are required to set their own unit dollar value individually to ensure free market forces are at play.
The AMA endorses a unit dollar value, which is considered a guide as to a reasonable maximum dollar value ($100/unit as of 2024).

MEDICARE SCHEDULE FEE REBATE

Australian citizens receive full cover for anaesthesia services in public hospitals.
 
Australian citizens are entitled to a Medicare rebate for eligible services provided in private hospitals, which amounts to 75% of the Medicare ‘Schedule Fee’, which is significantly lower than the AMA endorsed unit dollar value ($21.80/unit as of 2024)

PRIVATE HEALTH INSURANCE REBATES

Private health insurers provide rebates to patients above the 75% Medicare Schedule Fee rebate, however the magnitude of this rebate varies amongst health insurance companies. They are obligated to provided the remaining 25% of the Medicare Schedule Fee as a minimum.

For any given anaesthesia fee, the rebate provided to patients by their health insurance company will vary from insurer to insurer, around $32/unit and $40/unit.

PRIVATE HEALTH INSURANCE REBATE SHORTFALL (aka ‘THE GAP’)

The difference between the anaesthetist’s fee and the rebate the health insurer is willing to reimburse is the health insurance shortfall, commonly referred to as ‘the anaesthetist’s gap’.
This is an erroneous label, as the gap is not determined by the anaesthetist, but by the insurer.
The gap varies from insurer to insurer based on the rebate they are willing to provide to the patient for any given anaesthesia invoice.
 

Some health insurance companies propose a business agreement with individual anaesthetists in order to minimise or remove insurance shortfalls.

No gap
With a ‘no gap’ agreement the anaesthetist agrees to invoice the patient to a maximum amount determined by the insurer, the patient receives a rebate equal to this amount. There is no insurance shortfall as the insurer agrees to rebate the difference between the anaesthesia fee and the Medicare Schedule fee.

Known gap
With a ‘known gap’ agreement the anaesthetist agrees to not invoice the patient above a certain predicted shortfall, limiting the insurance shortfall. However, if the anaesthetist’s invoice is greater than this agreed amount, the health fund reduces any rebate for the patient back to the remaining 25% of the Medicare Schedule Fee rebate only, leaving the patient with a large shortfall.

BILLABLE ACTIVITIES & BILLING CODES

 
Attendances
Pre-anaesthesia consultation (<15min, 15-30min, 30-45min, >45min, labour regional, in-room, telehealth)
Post-anaesthesia consultation
Anaesthesia referred consultation (<15min, 15-30min, 30-45min, >45min) 
Pain consultation (initial, subsequent, subsequent minor)
Anaesthesia assistance (in-hours, after-hours, perfusion, elective)
Emergency attendances (1-2hrs, 2-3hrs, 3-4hrs, 4-5hrs, >5hrs, call-back, retrieval, intra-hospital)
 
Time
0-24 hours
 
Procedure
Positioning – prone

Surgical procedure

Modifiers
Physical status (ASA, obesity, pregnancy)
Age (<4y, >75y)
Emergency (in-hours, after-hours)
 
Regional
Perioperative neuraxial (for post-operative pain, with catheter)
Independent neuraxial (not in association with anaesthesia, labour, epidural blood patch, lumbar puncture)
Perioperative nerve blocks (proximal limb, complex eye block)
Independent nerve blocks
Intravenous nerve blockade (IVRA)
Regional infusion (subsequent management)
Ultrasound (ultrasound for nerve block)
 
Therapeutic-diagnostic
Airway management (intubation within ICU, outside of ICU, FOI, DLT/EBB)
Invasive access (neonatal, CVC/PICC, PAC, IAC)
Ultrasound (ultrasound for vascular access)
Monitoring (ABG, CVP/PAP/IABP/IC monitoring, TOE, depth of anaesthesia monitoring)
Blood management (blood collection, transfusion)
Cardiac/cardiopulmonary bypass/perfusion (cardioversion, intra-arterial infusion, limb perfusion, CPB, DHCA)
Allergy (allergy testing)
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