Information guide

In the example above, item number H300 is an acute psychiatric accommodation item with step-downs on days 22 and 43. Consequently, the primary rate would be billed for the first 21 days (row 1 – 01/03/2017 to 21/3/2017). The stepdown rate would be billed for the next 6 days (days 22-27, row 2 – 22/3/2017 to 28/3/2017). The day of discharge is not payable.

How to claim a Continuation claim

In the example below, a veteran was admitted on 1 March, 2017 for surgery for Intracranial Haemorrhage.

Date of Service		No of Days	Item No	Total Claimed		Theatre Date	Total Claimed	Procedure Item No
From	To
01/03/17	14/03/17	14	H255	$7,000.00		01/03/17	$500.00	39603

In the continuation claim example, the person has not been discharged on the 14th day. Therefore, the FROM date in the subsequent claim would be 15/03/17. In this instance the box should be ticked to indicate an interim account and “S” placed in the separation code box.

Is this account interim or final? Interim Final  Is this a readmission within 7 days? Yes  No 

Separation Code: S

How to claim a Continuation claim with leave day:

In the example below, a veteran was admitted on 1 March, 2017 for surgery and on the 6 March had a leave day returning to hospital on the 7 March 2017.

Date of Service		No of Days	Item No	Total Claimed		Theatre Date	Total Claimed	Procedure Item No
From	To
01/03/17	05/03/17	5	H266	$1250.00
06/03/17	06/03/17	1	H999
07/03/17	12/03/17	5	H266	$1250.00

In this example, the hospital is required to show the leave period by entering item H999.
How to claim theatre fees for multiple procedures:

DVA will pay theatre fees which include the cost of pre-operative purgative preparations, imprest medications and pharmaceutical products, dressings and consumable items in Table 4 of Part C, Schedule G: Hospital Services Fee Tables.

When multiple procedures are involved in an operation, the theatre fee will be payable as follows:

1. 
   the first procedure will be paid at 100% of the applicable fee; and
   
2. 
   the second, third and subsequent procedures will be paid at the percentages indicated in Table 4 of Part C, Schedule G: Hospital Services Fee Tables.
   

How to claim a case payment for Short Stay MBS Packages

Case payments for Short Stay MBS packages include all theatre fees and expenses, including consumables, together with same day or overnight accommodation not exceeding two days. For 3 nights or longer, or where critical care is administered, the package does not apply and the provider must claim per Diem (unbundling) and the relevant procedure fee.

In the example below, a veteran undergoes a Colonoscopy (MBS item 32090) on 1 March, 2017.

Date of Service		No. of Days	Item No	Total Claimed		Theatre Date	Item No	Total Claimed	Procedure Item No
From	To
01/03/17	02/03/17	1	H292	$1500		01/03/17			32090

In this example H292 is the DVA item number for the complete case payment as per Table 1 in Schedule 1 of your Agreement. The procedure item number should still be noted in the “Theatre” section. Additional theatre fees for multiple procedures can be billed at the relevant multiple discount rate according to your Agreement, if a case payment is claimed.

How to claim per Diem (unbundling) for Short Stay MBS Procedures

Date of Service		No. of Days	Item No	Total Claimed		Theatre Date	Total Claimed	Procedure Item No
From	To
01/03/17	02/03/17	1	H257	$800.00		01/03/17	$800.00	32090
03/03/17	05/03/17	3	H257	$1500.00

In the above example, a patient undergoes a Colonoscopy (MBS item 32090) however ultimately has an inpatient stay of four days. As the total admission exceeds two days this episode needs to be ignored and the accommodation according to the principal procedure applies together with the theatre fee as banded in the Group Accommodation and Theatre Banding (GATB) Schedule. To determine the appropriate accommodation and theatre rate payable refer to the GATB schedule and search for the relevant MBS item number. In this example, the accommodation banding for item 32090 is Surgical Group 1 and the theatre band is Band 2. Consequently, the prime accommodation rate at Surgical Group 1 (H257) is claimed for one day, the second stepdown claimed for 3 days plus the agreed rate for Theatre Band 2.

How to claim for Dual Banded items

MBS items numbers involved in the dual banding 40300, 40301, 40303 and 40306, 40309 and 40312. The dual banding means that a basic laminectomy is a band 6. However, if the procedure involves one or more of the indicators of high cost or complexity listed on the complexity certificate then a band 9 benefit is payable. Where payment for the higher band is claimed, complexity certificates should be completed and kept with the patient’s medical record.

How to claim an ECT as a day Patient

In the example below, a veteran was admitted 01/03/2017 as a Day Patient for ECT.

Date of Service		No. of Days	Item No	Total Claimed		Theatre Date	Total Claimed	Procedure Item No
From	To
01/03/17	02/03/17	1	H468	$500.00

For this example, item H468 is the item number for ECT as a Day Patient. No theatre is claimed because the H468 includes both Accommodation and Theatre.

Certain MBS Coronary Angiography items

When the (6) coronary angiography items (in the grey-shaded column below) were added to the MBS schedule, the National Theatre Banding Committee (NPBC) was unable to assign appropriate theatre bands to them and the items were not added to the GATB schedule. As these items were rollups/combinations of other existing MBS items, they could only be successfully processed by claiming the combinations of items which they were replacing. At that time the NPBC recommended that the accommodation group for each of the 6 items would be S2. Subsequently, a workaround has been agreed and implemented; these same 6 items have been added to the GATB schedule and should be claimed directly, but for full payment to occur ALL the items must be claimed from the relevant row of the 2^nd column in the table. (The multiple procedure discount rules will then apply as per clause 17.11.2 of your Agreement.)

Rolled-up MBS Item No.	MBS/Theatre Band combination to be claimed by hospitals (multiple procedure rules apply)	Surgical Accommodation Group
38225	38225 + 38220	S2
38228	38228 + 38222	S2
38231	38231 + 38222 + 38220	S2
38234	38234 + 38220	S2
38237	38237 + 38222	S2
38240	38240 + 38222 + 38220	S2

How to claim Overnight Dental

Date of Service		No. of Days	Item No	Total Claimed		Theatre Date	Total Claimed	Procedure Item No
From	To
01/03/16	02/03/16	1	H257	$400.00

Miscellaneous

M036

Where a patient is admitted for a dental procedure requiring an overnight admission item M036 is payable in relation to the theatre fees and item H257 (Surgical Group 1 accommodation) is payable in relation to the accommodation component of the admission. Package fees in Table 10 of your Agreement are not relevant. You should not include ICD or MBS on your claim for overnight dental admissions.

Admitted Same Day Rehabilitation Services

Admitted Same Day Rehabilitation Services must comply with the Guidelines for Recognition of Private Hospital-Based Rehabilitation Services, as amended from time to time. Programmes for the delivery of same day rehabilitation services must be approved by DVA, and should be billed using the item numbers in Table 13 of the Agreement.

Any changes to an admitted same day rehabilitation programme must be approved by DVA, for example change to the length and frequency of the programme, the number of treatment hours, or the admission criteria.

Non-admitted Sessional Rehabilitation Services

Where a hospital has agreed non-admitted Sessional Rehabilitation Services (under Clause 4.26 of the Hospital Services Agreement) Hospitals should use the item numbers outlined in the table below:

DESCRIPTION	Item No.
Aquatic Physiotherapy (hydrotherapy) session – supervised individual	HX021
Aquatic Physiotherapy (hydrotherapy) session – supervised group	HX022
Outpatient – Exercise Physiology	HX058
Outpatient – Physiotherapy	HX027
Outpatient – Occupational Therapy	HX028
Outpatient – Dietetics	HX029
Outpatient – Psychology	HX030
Outpatient – Speech therapy	HX031
Outpatient – Diabetes educator	HX065
Lymphoedema treatment inclusive of measurement and fitting of garments 1 set bandages – First Session (exclusive of the supply of the garments)	HX001
Lymphoedema Maintenance (Subsequent session)	HX002

Non-admitted Sessional Rehabilitation Services may only be delivered to Entitled Persons who have previously undertaken an inpatient rehabilitation programme or same day rehabilitation programme as part of the treatment of that condition or the same episode of care.

Prior approval for the delivery of non-admitted sessional rehabilitation services is not required, except for treatment in excess of four weeks, or where the treatment is not otherwise covered by a programme agreed between the parties.

Accident and Emergency

Accident and Emergency item HX013 may be included in The Agreement where fees for these items have been negotiated with DVA. Item HX013 cannot be claimed if the patient is subsequently admitted to the Hospital for a related condition within the next 24 hours.

High Cost Medical Devices

DVA will meet the costs associated with the use of High Cost Medical Devices (HCMD) where it is considered not reasonably included in the theatre fees. As a guide, items valued at $250 or less would generally not be considered high cost. As all disposable and consumable items are considered to be included in the theatre fee payable for the procedure, the item should only be used in exceptional circumstances.

HCMD claims should only be used when a theatre or surgical package item is claimed. Claims for HCMD do not require prior approval. Claims are to be itemised (i.e. multiple items are not to be added together) and based on invoice price from the supplier. No handling charge is payable for the items. DVA has implemented a post payment monitoring regime to examine the nature and type of items claimed and reserves the right to view the relevant supplier invoices.

High Cost Robotic Consumables

DVA will meet the cost of the specific consumables associated with the use of robotic technology, on the basis of invoice fee from the supplier, pro-rated for multi-use items. When raising a charge for the robotic consumables the Contracting Entity must quote DVA Item number M201 for each item claimed. No additional high cost medical consumable claims under M152 will be paid when M201 is claimed. As a guide, items valued at $250 or less would generally not be considered high costs.

Calculating the day count

During some admissions there are circumstances where a patient might need to be reclassified, and as a result, the day count needs to be restarted. For example:

If an Entitled Person in the same hospital…	Then……
is discharged and readmitted within 7 days for a condition that continues to be described by the ICD describing the first condition	the day count continues
is discharged and readmitted within 7 days for a condition that is not described by the ICD describing the first condition	the day count starts again
has a second more complex procedure	the day count starts again at the higher classification
has a second less complex procedure	the day count continues at the previous classification
is interrupted during a rehabilitation program for either surgical or medical treatment and then returns to the rehabilitation program	the day count starts again for the continuation of the rehabilitation program
If an Entitled Person in a different hospital is	Then……
transferred to another hospital for a more complex procedure	the day count starts again at the receiving hospital
transferred to another hospital for the same condition	the day count continues at the receiving hospital
transferred to another hospital where classification has changed e.g. to rehabilitation	the day count starts again at the receiving hospital

z)Certificates and Certification

There are a range of certificates available for hospitals to use:

• 
  D9076 – Acute Care Certificate (PDF 212 KB)
  
• 
  D6345 – Coronary Care Patient Certificate (PDF 169 KB)
  
• 
  D6346 – Intensive Care Patient Certificate (PDF 174 KB)
  
• 
  Rehabilitation Program Certificate
  

Acute Care Certificates

These certificates are required for acute care patients once they have been admitted for 35 days. Leave days and periods between hospitalisation do not count towards the 35 day period. Hospitals should note:

• 
  If claiming an acute rate for a period beyond 35 days, an Acute Care Certificate must be completed by the treating Medical Practitioner and forwarded to DHS with the account for that period of stay.
  
• 
  If hospitals are using electronic billing, the Acute Care Certificate information can be submitted electronically, however, a hard copy must be retained on the Entitled Person’s Clinical Record.
  
• 
  Hospitals can either use the DVA Acute Care Certificate or a similar form. Please do not send Acute Care certificates to DVA.
  
• 
  Where DHS receives a claim for an admission longer than 35 days without an accompanying Acute Care Certificate, the period up to 35 days will be paid at the rate claimed by the hospital and the period over 35 days will be rejected. This allows the hospital to either resubmit the claim accompanied with an Acute Care Certificate or alter the claim to indicate the appropriate non-acute NHTP rate.
  

Please Note: DVA will pay the basic daily care fee patient contribution for ex-Prisoner of War (ex-POWs) and entitled veterans awarded the Victoria Cross who are classified as receiving Nursing Home Type care in hospital.