Medicare Complex Neurodevelopmental Disorders and Eligible Disability Guide

Posted on 2 September 2023

These should be viewed as two separate schemes due to the referral requirements:

• For clients with or suspected of having a complex neurodevelopmental disorder (such as autism), the items require referral from a paediatrician or psychiatrist.
• Clients suspected of having an eligible disability can be referred by a GP or a specialist such as a paediatrician or psychiatrist.

What are Complex Neurodevelopmental disorders?

These disorders are not clearly specified within the MBS.  They are “intended for complex conditions characterised by multi-domain cognitive and functional impairment.  Patient eligibility is for neurodevelopmental disorders, which are assessed to be complex and mean that individuals require support across multiple domains.”

The diagnosis of a complex neurodevelopmental disorder requires evidence of requiring support and showing impairment across two or more neurodevelopmental domains. Complexity is characterised by multi-domain cognitive and functional disabilities, delay, or clinically significant impairment.

Neurodevelopmental domains include:

• Cognition
• Language
• Social-emotional development
• Motor skills
• Adaptive behaviour:  conceptual skills, practical skills, social skills, or social communication skills

The defined conditions are thus quite broad and guided by the referring specialist (paediatrician or psychiatrist). There are several diagnoses that would easily meet these criteria, such as Autism, ADHD, learning disabilities, and intellectual disability.

What are “Eligible Disabilities?”

'Eligible disabilities' for the purpose of these items include the following conditions: 

(a)        sight impairment that results in vision of less than or equal to 6/18 vision or equivalent field loss in the better eye, with correction.

(b)        hearing impairment that results in:

- a hearing loss of 40 decibels or greater in the better ear, across 4 frequencies; or

- permanent conductive hearing loss and auditory neuropathy.

(c)        deafblindness

(d)        cerebral palsy

(e)        Down syndrome

(f)         Fragile X syndrome

(g)        Prader-Willi syndrome

(h)        Williams syndrome

(i)         Angelman syndrome

(j)         Kabuki syndrome

(k)        Smith-Magenis syndrome

(l)         CHARGE syndrome

(m)       Cri du Chat syndrome

(n)        Cornelia de Lange syndrome

(o)        microcephaly if a patient has:

- a head circumference less than the third percentile for age and sex; and

- a functional level at or below 2 standard deviations below the mean for age on a standard developmental test, or an IQ score of less than 70 on a standardised test of intelligence.

(p)        Rett's disorder

(q)        Fetal Alcohol Spectrum Disorder (FASD)

(r)         Lesch-Nyhan syndrome 

(s)         22q deletion syndrome

What is covered by these items

8 assessment items can be used in a lifetime but must be used in blocks of four, with additional approval if more than four are required by an allied health practitioner. Up to 4 services can be provided to the same patient on the same day. Allied health practitioners can also refer to other disciplines with the agreement of the referring eligible medical practitioner. Agreement can be gained by (but is not limited to) an exchange by phone, written communication, or secure online messaging.

Once a treatment and management plan is in place (written by the referring practitioner), the client can be referred to a psychologist for treatment services. Treatment services address the functional impairments identified through the assessment, which are outlined in the treatment and management plan. A total of 20 Allied Health Treatment services per patient per lifetime are available through the MBS, which may consist of any combination of practitioners using in-person, telephone, or telehealth items.  Whilst the paediatrician can refer to multiple eligible Allied Health practitioners concurrently, a separate referral letter must be provided to each Allied Health practitioner.

The referral should specify the goals of the treatment and, if appropriate, specify the number of services to be provided. It is the responsibility of the referring practitioner to allocate the number of treatment services (up to a maximum of 10 services per course of treatment) in keeping with the individual’s treatment and management plan. On the completion of a “course of treatment” (specified by the referring practitioner, up to a maximum of 10 services), the psychologist must provide a written report to the referrer, which should include information on the treatment provided, recommendations on the future management of the individual’s disorder and any advice to caregivers (such as parents, carers, school teachers). This written report will inform the referrer's decision to refer for further treatment services. Where subsequent courses of treatment are required after the initial 10 services (up to a maximum of 20 services per patient per lifetime), a new referral is required.

Psychologist Assessment items (MBS item 82000, 93032, 93040)

Psychologist Treatment items (MBS items 82015, 93035, 93043)

Case Conferencing

Both have accompanying case conferencing items that need to be organised by different parties.  These, unfortunately, can only be used if the client is under 13 years old.

The item numbers differ for each scheme, as does the health professional who is required to coordinate these case conferences. These items are all able to be done in person, via telephone and via video conferencing using the same item code specific to the scheme you are seeing the client under. All clients must have a referral in place that allows them to receive rebates for either Better Access, Eating Disorder Treatment and Management, Chronic Disease Management, and Complex Neurodevelopmental Disorder and Eligible Disability schemes. All case conferences must have a minimum of three health or allied health professionals in attendance.

The items for participation in a case conference are time-tiered and can be used once every 3 months were clinically relevant. They can be provided more frequently in exceptional circumstances, defined as “a significant change in the patient's clinical condition or care requirements that necessitates the performance of the service for the patient.”

Psychologists can only claim rebates to participate in case conferences, not organise them. They need to be organised by the referring practitioner. 

The client can attend the case conference as well if the health professionals think that this is appropriate.  They can also have a support person present such as a family member or carer. The client, family member or carer is not counted in the minimum number of health professionals that must attend a case conference. If they do not want to attend the case conference, this is also allowed if they have provided informed consent and you have recorded this consent in their file.

More information can be found on MBS online here.

You can also refer to this resource on the Services Australia website, this flow chart, and this brief online module.

Download this as a PDF.