When invoicing particular items you may find that the DIMSR or MVUSSR buttons suddenly appear. These buttons relate to the Diagnostic Imaging Multiple Service Rule and Multiple Vascular Ultrasound Services Site Rule respectively. If you're wondering why your fees have all changed drastically after pressing one of these buttons - don't be alarmed! This article will give you a brief overview of these rules, and how they apply in Genie.
Before you begin
The below information has been gathered from Medicare Benefit Schedule Note IN.0.10.
For more information regarding these rules, please refer to the link above or contact Medicare directly.
Please Note: Any fees used in this article may not be up to date and are used as example figures only.
According to Medicare Benefit Schedule Note IN.0.10, there are several rules that may apply when calculating Medicare benefits payable when multiple diagnostic imaging services are provided to a patient at the same attendance (same day).
There are 5 rules which may be applied. Multiple rules may be applied to each invoice. If so, they are applied in the following order:
- Vascular Ultrasound Rule
- Rule A
- Rule B
- Rule C
- Bulk Billing Incentive
Definitions
Diagnostic Imaging Items: All items in MBS Category “I”
Vascular Ultrasound Items: All items beginning with “552xx” (subgroup of "I")
Consultation Items: All items in Category “A”
Non-consultation Items: All Items in Categories “D”, “C”, “O” and “T”
This rule applies to item numbers starting with “552xx”.
Where more than one vascular ultrasound service is provided to the same patient by the same practitioner on the same date of service, the following formula applies to the Schedule Fee for each service:
- 100% for the item with the greatest Schedule fee, and
- 60% for the item with the next greatest Schedule fee, and
- 50% for each other item.
When the Schedule Fee for some of the items are the same, the reduction is calculated in the following order:
- 100% for the item with the greatest Schedule fee and the lowest item number, and
- 60% for the item with the greatest Schedule fee and the second lowest item number, and
- 50% for each other item
Example:
Item 55238 and 55280 have the same Schedule Fee, so the sort order would be 55238, then 55280.
Before selecting DIMSRR (USS)
After selecting DIMSR (USS):
Please Note: Despite having the same fee in the first image, after selecting DIMSR (USS) the fee for 55280 has been reduced.
When calculating the benefit, it should be noted that despite the reduction, the collective items are treated as one service for the application of Rule A of the General Diagnostic Imaging Multiple Services rules and the patient gap. This means that if there are multiple vascular ultrasound items, then Rule A should only be applied to one of them.
When a medical practitioner renders two or more diagnostic imaging services to a patient on the same day, then: the diagnostic imaging service with the highest Schedule Fee has an unchanged Schedule Fee; and the Schedule fee for each additional diagnostic imaging service is reduced by $5.
Example:
55113 Schedule Fee $230.65
55238 Schedule Fee $169.50
The Schedule Fee for 55238 will be reduced to $164.50, and the rebate for it will be reduced to 85% of this, $139.85.
Before DIMSR (A) rule is applied:
After DIMSR (A) rule is applied:
Please Note: Both the Fee and Rebate for the 55238 have been reduced after selecting DIMSR (A).
When a medical practitioner renders at least one R-type diagnostic imaging service and at least one consultation to a patient on the same day, there is a deduction to the Schedule fee for the diagnostic imaging service with the highest Schedule fee as follows:
- If the Schedule fee for the consultation is $40 or more - by $35, or
- If the Schedule fee for the consultation is < $40 but > $15 - by $15, or
- If the Schedule fee for the consultation is < $15 - by the amount of that fee.
The deduction under Rule B is made once only. If there is more than one consultation, the consultation with the highest Schedule fee determines the deduction amount. There is no further deduction for additional consultations. A 'consultation' is a service rendered under an item from Category 1 of the Medicare Benefits Schedule (MBS), that is, items 1 to 10816 inclusive.
Example:
55113 Schedule Fee $230.65
110 Schedule Fee $153.15
Because the Schedule Fee for item 110 is greater than $40, $35 is deducted from the Schedule Fee for diagnostic item 55113, i.e. making it now $195.65
Before DIMSR (B) rule is applied
After DIMSR (B) rule is applied:
Please Note: The fee for 55113 has been reduced by $35 to $195.65.
When a medical practitioner renders an R-type diagnostic imaging service and at least one non-consultation service to the same patient on the same day, the Schedule fee for the diagnostic imaging service with the highest Schedule Fee is reduced by $5.
A deduction under Rule C is made once only. There is no further deduction for any additional medical services. For Rule C, a 'non-consultation' is defined as any following item from the MBS:
- Category 2, items 11000 to 12533;
- Category 3, items 13020 to 51318;
- Category 4, items 51700 to 53460;
- Cleft Lip and Palate services, items 75001 to 75854
Pathology services are not included in Rule C. When both Rules B and C apply, the sum of the deductions in the Schedule Fee for the diagnostic imaging service with the highest Schedule Fee is not to exceed that Schedule Fee.
Example:
55113 Schedule Fee $230.65 (Imaging Item)
110 Schedule Fee $153.15 (Consultation Item)
11712 Schedule Fee $152.15 (Non-Consultation Item)
In this case Rules B and C both apply. Rule B reduces the Schedule Fee for item 55113 to $195.65. Rule C takes another $5 off it, to now be $190.65.
Before DIMSR (B;C) rule is applied:
After DIMSR (B;C) rule is applied:
To provide an incentive to bulk-bill, for out of hospital services that are bulk billed the schedule fee is reduced by 5% and rebates paid at 100% of this revised fee (except for item 61369).
In the last example above under Rule C, after Rules B and C have been applied, the Schedule Fee for item 55113 is $190.65. If being bulk-billed the new schedule fee will be 95% of $190.65 = $181.15. The rebate will also be $181.15. This incentive also applies to the other two items 110 and 11712 on this invoice.
