WorkSafe shoulder surgery billing position statement

Introduction

WorkSafe Victoria (WorkSafe) can pay the reasonable costs of medical services provided by a medical practitioner to an injured worker where required as a result of a work-related injury or illness.

WorkSafe adopts the Medicare Benefits Schedule (MBS) item numbers, explanations, definitions, rules and conditions as a basis for billing by medical practitioners. However WorkSafe sets its own fees for each MBS item to ensure that WorkSafe fees reflect the reasonable cost of service. When invoicing for medical services, medical practitioners are expected to adhere to these MBS explanations, definitions, rules and conditions unless otherwise specified by WorkSafe in this publication or its medical policies.

This publication outlines WorkSafe's position for appropriate item number usage for elective shoulder surgery and has been updated to align with changes to Medicare funded orthopaedic surgery services from 1 July 2021.

This publication will be reviewed and updated regularly in line with MBS updates and must be read in conjunction with:

In general, the 'explanations, definition, rules and conditions' associated with MBS items for shoulder surgery will apply, unless otherwise specified by WorkSafe in this publication.

Where there are differing interpretations of the MBS rules pertaining to item number usage (or the MBS rules are insufficiently clear), this document acts to clarify WorkSafe's position on what it considers is appropriate item number use and what WorkSafe can and cannot pay for in relation to a number of specific MBS item combinations.

WorkSafe will continue to periodically audit payments made for surgical services to ensure that they are appropriate and made in accordance with WorkSafe policies, fee schedules and with MBS rules and guidelines.  When appropriate, WorkSafe will provide practical and constructive advice to surgeons about how to comply with any relevant policy or billing rule. Surgeons may be asked to reimburse any incorrect / inappropriate payments that are identified through these reviews.

WorkSafe encourages providers to regularly review their billing practices relating to WorkSafe claims. If at any time you discover billing errors in relation to services provided, the relevant WorkSafe Agent will work with you to address any issues and provide advice on how errors can be rectified.

Guidelines for billing of item 48415 in conjunction with shoulder codes (items 48900 – 48960) funded by WorkSafe (Victoria)

No benefit is payable for item 48415 when billed in combination with any shoulder surgery code (items 48900 – 48960). WorkSafe will review any billing of item 48415 in conjunction with items 48900 – 48960 and consider payment for this item in exceptional circumstances whereby detailed reasoning is supported by documentation (such as the operation report or other information) that indicates the procedure performed meets the criteria of the MBS descriptor for this item.

Note: Items 30111 and 50405 have been deleted from the MBS as of 1 July 2021.

Guidelines for the billing of more than five MBS items for a single shoulder surgery funded by WorkSafe

Where more than five MBS items are billed for single shoulder surgery, the surgeon will be asked to submit detailed reasoning supported by documentation for consideration by the relevant WorkSafe Agent. Documentation should include a contemporaneous legible operation note and any routinely performed imaging on CD/DVD. Submitted imaging should consist of unedited pre-operative and routine post-operative imaging.

Contact information

Contact WorkSafe's Provider Support team by email at [email protected].