Private Health Insurance (PHI) Claims Descriptors

Frequently asked questions

When did the new physiotherapy codes come into effect?
Can I provide feedback on the new codes?
Who decides the rebates for each PHI claims item code?
Did the Healthpoint/HICAPS machine terminals update automatically with the new codes?
What if my Healthpoint/HICAPS machine terminal rejects a particular item code?
Do the new PHI claims codes have a different name?
Where can I find definitions for each PHI claims item code?
What happened to the descriptor Initial Consultation?
When do I code item number 500?
Can I code 505 Subsequent Consultation if I treat more than one patient at a time?
What is the difference between a group (code 560) and a subsequent (code 505) consultation?
What happened to the descriptor Standard Consultation?
What happened to the descriptor Long Consultation?
What happened to the descriptor Long Consultation – 2 Areas?
What happened to the Extended Consultation Codes (item numbers 514 and 515)?
What happened to item code 555 Hydrotherapy?
What code do I use for a Group or a Class?
What if there is no item code for a particular treatment intervention?
What does an item code 570 Lymphoedema involve?
Can I code item number 570 Lymphoedema straight away, or do I have to code 500 first?
Can item code 570 Lymphoedema be used only by titled and specialist APA members or physiotherapists who hold a Masters degree, or equivalent?
Will my patients receive a higher rebate for item code 570 Lymphoedema?
What does an item code 582 Neurological Rehabilitation involve?
Can I code item number 582 Neurological Rehabilitation straight away, or do I have to code 500 first?
Can item code 582 Neurological Rehabilitation be used only by titled and specialist APA members or physiotherapists who hold a Masters degree, or equivalent?
Will my patients receive a higher rebate for item code 582 Neurological Rehabilitation?
What does an item code 593 Pelvic Floor Physiotherapy involve?
Can item code 593 Pelvic Floor Physiotherapy be used only by titled and specialist APA members or physiotherapists who hold a Masters degree, or equivalent?
Will my patients receive a higher rebate for item code 593 Pelvic Floor Physiotherapy?
Can I use item code 593 to treat continence and women’s health conditions?
Can I use item code 593 to treat continence and men’s health conditions?
What happened to code 590 Splints legs or arms?
What does an item code 591 Custom made orthosis (upper limb) Consultation involve?
Does item code 591 Custom made orthosis (upper limb) cover off-the-shelf orthotics?
Does item code 591 Custom made orthosis (upper limb) include the actual cost of the orthosis?
What does an item code 592 Custom made orthosis (lower limb) Consultation involve?
Does item code 592 Custom made orthosis (lower limb) cover off-the-shelf orthotics?
Does item code 592 Custom made orthosis (lower limb) include the actual cost of the orthosis?
Can I claim item codes 591 and 592 straight away, or do I have to claim the 500 first?
What does an item code 595 Antenatal Exercise Class Consultation involve?
Can I claim item code 595 straight away, or do I have to claim the 500 first?
What does an item code 596 Postnatal Exercise Class Consultation involve?
Can I claim item code 596 straight away, or do I have to claim the 500 first?
Is the code for an Initial Hospital Consultation and Treatment the same as before?
Is the code for a Standard Hospital Treatment the same as before?
Is the code for an Initial Home Consultation the same as before?
Is the code for a Standard Home Visit the same as before?
What happened to code 580 Cardiac Rehabilitation?

 

When did the new physiotherapy codes come into effect?

New PHI claims physiotherapy codes came into effect on 1 April 2015.

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Can I provide feedback on the new codes?

The APA will monitor member feedback over the next 6 months and meet again with Private Healthcare Australia and the private health insurers to discuss if the new codes are working or if we need to tweak the codes. You can provide feedback by contacting the APA Hub on 1300 306 622.

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Who decides the rebates for each PHI Claims item code?

Private health insurance rebates to patients are commercial decisions made by individual health funds.

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Did the Healthpoint/HICAPS machine terminals update automatically with the new codes?

Yes. Your HICAPS or Healthpoint machine terminal will be updated automatically between 1 April 2015 and 14 April 2015. Your terminal will still allow the new item numbers to be used, even if the new schedule has not been updated.

If your terminal has not been updated, please contact the HICAPS Helpdesk on 1300 650 852, or Healthpoint on 1300 301 692.

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What if my Healthpoint/HICAPS machine terminal rejects a particular item code?

If your Healthpoint or HICAPS terminal rejects a code:

  • The item code may have been repealed and no longer exists
  • The patient’s ancillary cover may not cover that particular item code
  • A specific insurer may not recognise that item code, (e.g. HCF does not recognise item code 561 for Class Consultation. Classes with HCF have to be claimed under HCF’s Health Management Program.)
  • Ensure you are using the correct item number
  • Check coverage with the insurance company
  • Check with the insurance company that they accept the code you are entering.

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Do the new PHI claims descriptors have a different name?

These codes are private health insurance industry codes and you can think of them as ‘PHI claims codes’.

Most patients claim any private health insurance funded subsidy for their physiotherapy care through an electronic payment system, either Healthpoint or HICAPS. This is facilitated by physiotherapy businesses using the PHI claims code for interventions provided to the patient.

Healthpoint has published the PHI claims codes in a document called the Physiotherapy Item Codes, which you can find here

Similarly, HICAPS has published the same list of PHI claims codes, called the Quick Reference Guide for Physiotherapists, which you can find here

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Where can I find definitions for each PHI claims descriptor?

You can find definitions for each item code under Resources on the APA website.

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What happened to the descriptor Initial Consultation?

Item number 500 is the same. The name has changed from ‘Initial Consultation’ to ‘Assessment Consultation’.

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When do I code item 500?

You need to code 500 Assessment Consultation if:

  • You see the patient for the first time, or
  • The patient presents to you for treatment of a new condition (so you can use the code 500 for the same patient more than once in the same year), or
  • There has been a lapse in treatment between visits, for the same condition.

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Can I code 505 Subsequent Consultation if I treat more than one patient at a time?

Yes. A physiotherapist might see, as a guide only, say 3 or 4 patients during the course of an hour. The Patients might attend in a staggered fashion, with each patient having an individual appointment time. Alternatively, three patients could all attend at the same time and leave at the same time, on the hour. Physiotherapists can treat patients concurrently and code 505 so long as each patient is individually assessed or reassessed, there is clear diagnostic formulation and goal setting specific to the patient’s clinical condition, each patient has an individual management plan, interventions are provided to meet the clinical goals of treatment and there is evidence of clinical recording noting patient progress against specific treatment goals.

We commonly get asked ‘how many patients can a physiotherapist treat in an hour?’ The number of patients is self-limiting because to provide a proper assessment or reassessment, intervention and clinical recording, the fewer participants the better. Around three participants an hour would be most common, or possibly four in the hour with each participant having received around 15 minutes of 1:1 time. You would be hard-pressed to clinically justify coding a 505 Subsequent Consultation if five or six patients (or more) attend in the hour – that should really be coded as a 560 Group.

In providing patient-centred care, the patients’ individual experience is significant. A patient should be able to walk away from a Subsequent Consultation feeling that they received a service provided to them individually, even if other patients were present in the rehabilitation setting at the time. Usually, patients will vote with their feet and move to another treatment provider if they feel that a physiotherapist is not spending enough time with them.

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What is the difference between a group (code 560) and a subsequent (code 505) consultation?

This is a common question. Our members ask the APA for advice: “If a physiotherapist sees say 3 or 4 patients in an hour, do I code a 505 or a 560 for a small group? What is the difference?” We can see where the confusion lies, essentially a small group of patients are treated concurrently and the lines seem to be blurred.

The key point of difference is this: some patients are not candidates for a group, and more patients require more intervention, supervision, goal setting etc.

In fact, some patients will never join a small group because they are simply not well enough/mobile enough to join a small group setting. Also, some practices simply do not run groups or classes – that is just the way their business model is set up.

These patients will continue attending for months, or years at a time, and will always be invoiced as item code 505 for a Subsequent Consultation. There may well be two or three patients that attend during the space of an hour but still each patient is invoiced for item code 505 because each patient has a clinical need to continue attending for subsequent 1:1 sessions with the physiotherapist.

Alternatively, if three patients attend a physiotherapist and all three are assessed as being candidates for a group setting, then following the initial assessment (code 500 or 505), the patients would be slotted into a small group. You should then be invoicing the patients, from that point forward, for code 560 each time the patient attends the small group.

The important question to ask is: ‘is the patient an appropriate candidate for a group?’ Do they require a significant amount of supervision, re assessment, goal setting, therapist input? If so, code 560. If not, code 505.

Now, there is one other important point to mention. If you ordinarily have 6 participants attending for a 560 Group and only 3 participants turn up one week (say the other three are absent due to illness), you should not code 505 as a default on the basis of fewer attendees. If all participants are attending for a group and have been attending for a group in the past, then even if only 2 participants turn up one week, you still code a group 560 item code.

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What happened to the descriptor Standard Consultation?

Item number 505 is the same. The name has changed, from ‘Standard Consultation’ to ‘Subsequent Consultation’.

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What happened to the descriptor Long Consultation?

Item number 509 for a Long Consultation has been removed. You cannot use this code 509 any longer.

Now, if a physiotherapist is treating just one area of the body but needs a long consultation, physiotherapists now have to code a 505 Subsequent Consultation.

BUPA used to pay a higher rebate for item code 509, but only for BUPA Members’ Choice providers. We will discuss this with BUPA.

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What happened to the descriptor Long Consultation – 2 Areas?

Previously, the item descriptor ‘Long Consultation – 2 Areas’ was assigned item number 510. It is now item code 506 in a private practice setting, or 526 in a hospital or 536 in a private home or residential home setting. Item codes 506, 526 and 536 are now called ‘Long Subsequent Consult (2 Areas)’ and can only be used for a ‘Subsequent’ consultation for an assessment consultation code the 500.

You can only use theses code if treating 2 separate areas of the body. You cannot use this code if you need a Long Consultation for the one area; you must code that as a Subsequent 505.

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What happened to the Extended Consultation Codes (item numbers 514 and 515)?

You cannot use item codes 514 and 515 any longer.

Some physiotherapists who offer complex treatments may require longer than average treatment time, for example continence and women’s health physiotherapy or neurological physiotherapy, and so have been using Extended Consultation Codes. Codes 514 and 515 attracted a higher rebate than the rebate currently paid for the 582 Neurological Rehabilitation and code 593 Pelvic floor physiotherapy. We will be meeting with various insurance companies to address this matter and will keep members informed.

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What happened to item code 555 Hydrotherapy?

Item code 555 for Hydrotherapy has been removed.

Physiotherapists are advised to code 560 for small groups in which participants perform individually tailored exercises, or to code 561 for classes where all participants perform the same exercises.

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What code do I use for a Group or a Class?

Item code 560 is used for a group. That means, as a guide, 6 participants or less in a group. Each of the participants in a group setting must perform individually tailored exercises.

The code 561 is used for a Class. Everyone in a class does the same thing. The number of people in a class is not so significant.

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What if there is no item code for a particular treatment intervention?

Some treatment modalities, such as Pilates or now hydrotherapy, have no specific code. The physiotherapy codes cannot capture every treatment modality. The following codes capture any treatment modality not already included in the PHI industry descriptors:

  • 500 Assessment Consultation
  • 505 Subsequent Consultation
  • 560 Group Consultation
  • 561 Class Consultation

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What does an item code 570 Lymphoedema involve?

Lymphoedema management is provided to the individual client by a physiotherapist in person. It includes but is not limited to:

  • Subjective and objective assessment or re-assessment
  • Diagnostic formulation
  • Goal setting
  • Management plan
  • Intervention
  • Clinical recording

Lymphoedema management is conducted by a physiotherapist who is expected to demonstrate skills in the assessment and management of clients with lymphoedema.

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Can I code item number 570 Lymphoedema straight away, or do I have to code 500 first?

The APA advises that you code item code 500 Assessment Consultation for the assessment consultation and code 570 for each subsequent consultation.

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Can item code 570 Lymphoedema be used only by titled and specialist APA members or physiotherapists who hold a Masters degree, or equivalent?

No. Item code 570 can be used by any physiotherapist. The only requirement the APA has stipulated for use of this complex code is that lymphoedema treatment should be conducted by a physiotherapist who is expected to demonstrate skills in the assessment and management of clients with lymphoedema.

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Will my patients receive a higher rebate for item code 570 Lymphoedema?

Each individual health fund sets its own fee structures and decides what rebates to offer their members.

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What does an item code 582 Neurological Rehabilitation involve?

Neurological rehabilitation is conducted by a physiotherapist who demonstrates skills in the assessment and management of impairments and activity limitations arising from a neurological disorder. This activity is conducted in a variety of land and water based environments. This service is provided to the client individually and in person. It includes but is not limited to:

  • Subjective and objective assessment or re-assessment
  • Diagnostic formulation
  • Goal setting
  • Management plan
  • Intervention
  • Clinical recording

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Can I code item number 582 Neurological Rehabilitation straight away, or do I have to code 500 first?

The APA advises that you code item code 500 Assessment Consultation for the assessment consultation and code 582 for each subsequent consultation.

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Can item code 582 Neurological Rehabilitation be used only by titled and specialist APA members or physiotherapists who hold a Masters degree, or equivalent?

No. Item code 582 can be used by any physiotherapist. The only requirement the APA has stipulated for use of this complex code is that neurological rehabilitation should be conducted by a physiotherapist who is expected to demonstrate skills in the assessment and management of clients with a neurological condition.

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Will my patients receive a higher rebate for item code 582 Neurological Rehabilitation?

Each individual health fund sets its own fee structures and decides what rebates to offer their members.

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What does an item code 593 Pelvic Floor Physiotherapy involve?

Pelvic floor physiotherapy is an activity performed by a physiotherapist.

This service is provided to the client individually and in person. It includes but is not limited to:

  • Subjective and objective assessment or re-assessment
  • Diagnostic formulation
  • Goal setting
  • Management plan
  • Intervention
  • Measurement of outcomes
  • Clinical recording

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Can item code 593 Pelvic Floor Physiotherapy be used only by titled and specialist APA members or physiotherapists who hold a Masters degree, or equivalent?

No. Item code 593 can be used by any physiotherapist. The only requirement the APA has stipulated for use of this complex code is that Pelvic Floor physiotherapy should be conducted by a physiotherapist who is expected to demonstrate skills in the assessment and management of clients with a pelvic floor condition.

HBF requires physiotherapists to have a Masters degree or equivalent to use item code 593. The APA will discuss this issue with HBF and will keep members informed.

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Will my patients receive a higher rebate for item code 593 Pelvic Floor Physiotherapy?

Each individual health fund sets its own fee structures and decides what rebates to offer their members.

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Can I use item code 593 to treat continence and women’s health conditions?

Yes. You can use this code for any women’s health issues related to the pelvic area, for example for pregnancy-related musculoskeletal conditions, or pelvic area osteoporosis.

Some women’s health conditions, such as breastfeeding conditions, may not be covered.

The APA will monitor member feedback over the next 6 months and meet again with Private Healthcare Australia and the private health insurers to discuss how the new codes are working. You can provide feedback by contacting the APA Hub on 1300 306 622.

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Can I use item code 593 to treat continence and men’s health conditions?

Yes.

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What happened to code 590 Splints legs or arms?

Code 590 Splints legs or arms has now been split into two codes, code 591 Custom made orthosis (upper limb) Consultation and code 592 Custom made orthosis (lower limb) Consultation.

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What does an item code 591 Custom made orthosis (upper limb) Consultation involve?

Fitting of custom made orthosis (upper limb) is an activity carried out by a physiotherapist. It includes but is not limited to:

  • Assessment of the injury or condition
  • Measurement of the affected limb
  • Moulding, fitting and modification of the materials to create an orthosis.

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Does item code 591 Custom made orthosis (upper limb) cover off-the-shelf orthotics?

No. This item code does not cover the fitting or moulding of off-the-shelf orthotics

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Does item code 591 Custom made orthosis (upper limb) include the actual cost of the orthosis?

No. It covers the cost of the physiotherapy consultation but not the cost of the actual orthotic item.

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What does an item code 592 Custom made orthosis (lower limb) Consultation involve?

Fitting of custom made orthosis (lower limb) is an activity carried out by a physiotherapist that includes but is not limited to:

  • Assessment of the injury or condition
  • Measurement of the affected limb
  • Moulding, fitting and modification of the materials to create an orthosis.

NB: This item does not include the cost of any orthosis.

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Does item code 592 Custom made orthosis (lower limb) cover off-the-shelf orthotics?

No. This item code does not cover the fitting or moulding of off-the-shelf orthotics.

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Does item code 592 Custom made orthosis (lower limb) include the actual cost of the orthosis?

No. It covers the cost of the physiotherapy consultation but not the cost of the actual orthotic item.

 

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Can I claim item codes 591 and 592 straight away, or do I have to claim the 500 first?

Physiotherapists can claim the code 591 and 592 straight away, without first claiming for item 500 Assessment Consultation.

For auditing purposes, we advise members to code the 500 Assessment first.

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What does an item code 595 Antenatal Exercise Class Consultation involve?

An Antenatal Exercise Class is an activity by a physiotherapist in which common interventions are provided simultaneously to a number of pregnant clients. These exercises/activities may be land or water based. A class consultation usually follows an assessment consultation or thorough screening for factors that may contraindicate exercise/activity or require modification of the exercise/activity. Appropriate clinical records must be kept for each person in the class. Antenatal classes are conducted by a physiotherapist who is expected to demonstrate skills in the assessment and management of antenatal clients. Management of this complex condition may require longer than average treatment time.

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Can I claim item code 595 straight away, or do I have to claim the 500 first?

You must claim item number 500 first.

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What does an item code 596 Postnatal Exercise Class Consultation involve?

A Postnatal Exercise Class is an activity by a physiotherapist in which common interventions are provided simultaneously to a number of post-natal clients. These exercises/activities may be land or water based. A class consultation usually follows an assessment consultation or thorough screening for factors that may contraindicate exercise/activity or require modification of the exercise/activity. Appropriate clinical records must be kept for each person in the class.

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Can I claim item code 596 straight away, or do I have to claim the 500 first?

You must claim item number 500 first.

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Is the code for an Initial Hospital Consultation and Treatment the same as before?

Yes. It is now under a separate heading ‘Hospital’, and item number 520 has a new name ‘Assessment Consultation’.

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Is the code for a Standard Hospital Treatment the same as before?

Yes. The item number is 525. Previously, this item was named ‘Standard Hospital Treatment’. It is now under a separate heading ‘Hospital’ and item number 525 has a new name ‘Subsequent Consultation’.

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Is the code for an Initial Home Consultation the same as before?

Yes. The item number is exactly the same, 530. Previously, this item was named ‘Initial Home Consultation’. It is now under a separate heading ‘Home’ and item number 530 has a new name ‘Assessment Consultation’.

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Is the code for a Standard Home Visit the same as before?

Yes. The item number is exactly the same, 535. Previously, this item was named ‘Standard Home Visit’. It is now under a separate heading ‘Home’ and item number 535 has a new name ‘Subsequent Consultation’.

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What happened to code 580 Cardiac Rehabilitation?

This code has been removed.

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