Psychiatric Consultation MBS Documentation: A Practitioner Guide

The three groups

Group A — Item 291 (assessment and management plan)

Item 291 is a standalone item with a distinctive structure:

• More than 45 minutes face-to-face at consulting rooms.
• Comprehensive diagnostic assessment.
• Mandatory written report containing both the diagnostic assessment and a management plan, sent to the referring practitioner within 2 weeks of the attendance.
• Claimable once per patient per 12-month period (combined with the telehealth equivalent 92435).
• Higher schedule fee than 296 — the fee differential reflects the management-plan-letter requirement.

The management-plan letter is the defining feature. PSR auditors who see a 291 claim look for the letter on file. Without it, the claim is rejected and the difference between 291 and 296 becomes a recoverable amount.

Group B — Items 296 / 297 / 299 (new-patient comprehensive consultation)

This three-item family applies when the patient is new to this psychiatrist OR has not received an attendance from this psychiatrist in the preceding 24 months. The items differ only by location:

• 296 — consulting rooms.
• 297 — hospital.
• 299 — other location (typically home).

All three require more than 45 minutes face-to-face and a comprehensive new-patient assessment. The notes-must-show pattern matches 291 closely, except the management-plan-letter mechanism does not apply (a referrer letter is good practice but not the schedule-mandated requirement that defines 291).

The 24-month re-attendance rule is strict: if this psychiatrist has billed any of items 296/297/299/300/302/304/306/308 (or their telehealth equivalents) for this patient in the preceding 24 months, the duration-tier follow-up items apply instead — not the new-patient family.

Group C — Items 300 / 302 / 304 / 306 / 308 (duration-tier follow-up)

The 300-series is a five-item family at consulting rooms, differing only in duration:

• 300 — up to 15 minutes.
• 302 — more than 15 to up to 30 minutes.
• 304 — more than 30 to up to 45 minutes.
• 306 — more than 45 to up to 75 minutes.
• 308 — more than 75 minutes.

All five share a single 50-attendances-per-calendar-year combined cap, counted across items 296/297/299/300/302/304/306/308 and their telehealth equivalents (91827–91831, 91837–91839, 92437). Practices billing high volumes need to track the cap across the calendar year — exceeding it triggers a Medicare review.

The time band documented must match the item claimed. This is the single most common audit finding in psychiatry — billing 306 (>45 min) when the recorded duration is 38 minutes.

Group A documentation — Item 291

A defensible 291 note covers:

• Date, start time, end time, and total face-to-face duration (>45 min).
• Referral details — referrer name and profession (medical practitioner / nurse practitioner / specialist / consultant physician), referral date, validity period.
• Presenting concern — in the patient's words, plus the referrer's framing.
• History of presenting complaint — onset, course, triggers, severity, prior interventions and response.
• Past psychiatric history — admissions, prior diagnoses, medications, response, side effects, treatment continuity gaps.
• Past medical history, current medications, allergies, family psychiatric history.
• Social history — relationships, work, finances, accommodation, substance use, legal, supports.
• Developmental history where relevant.
• Mental state examination — appearance and behaviour, speech, mood and affect, thought form and content, perception, cognition, insight, judgement.
• Risk assessment — suicide, self-harm, harm to others, vulnerability, capacity. Static and dynamic factors, safety-plan elements.
• Diagnosis or differential — DSM-5-TR or ICD-11 framing with reasoning and rule-outs.
• Biopsychosocial formulation — predisposing, precipitating, perpetuating, and protective factors.
• Management plan — pharmacological reasoning, non-pharmacological modalities, monitoring, psychoeducation, and review interval.
• Confirmation that a written report containing both the diagnostic assessment and the management plan has been provided to the referring practitioner within 2 weeks. Record the date the letter was sent.
• Confirmation that no prior 291 (or telehealth equivalent 92435) service has been provided to this patient in the preceding 12 months.

The defining elements of 291 — distinguishing it from 296 — are the mandatory written report inside 2 weeks and the 12-month-per-patient claim limit.

Group B documentation — Items 296 / 297 / 299

A defensible new-patient comprehensive-consultation note covers everything in the 291 list above, minus the management-plan-letter requirement, and plus:

• Location of attendance (consulting rooms / hospital / home / other) — must match the item billed.
• Confirmation the patient is new to this psychiatrist OR no prior attendance by this psychiatrist in the preceding 24 months. This is the threshold test for the family.

A letter to the referrer is best practice but not the schedule-mandated mechanism that 291 imposes.

Group C documentation — Items 300 / 302 / 304 / 306 / 308

Follow-up attendance notes have a different shape — they are structured, comparative, and decision-focussed:

• Date, start time, end time, and total face-to-face duration. This single field determines which item is correctly claimed.
• Item number anticipated against the documented duration (e.g. "Item 304 — 38-minute consultation"). Recording the intended item alongside the duration closes the most common audit gap.
• Interval since last consultation and any changes reported by the patient or third parties.
• Patient self-report — symptoms, functional changes, medication adherence and tolerability, life events, treatment engagement.
• Mental state examination — focussed update against the previous MSE, specifically noting changes.
• Risk update — current risk level, any new risk factors, any safety-plan deployment since last review.
• Investigations — results of bloods, ECG, BP, weight, side-effect monitoring (e.g. AIMS for tardive screening) where indicated.
• Psychometric reassessment where the practitioner uses an instrument longitudinally (e.g. PHQ-9, MADRS, YMRS, BPRS, HAM-D).
• Treatment-plan changes — medication adjustments with reasoning (per the medication-change documentation framework), psychotherapy adjustments, investigations ordered.
• Communication plan — letter to referrer where indicated; private-practice psychiatrists typically update the referring GP after each significant decision rather than every visit.
• Review interval — when the next consultation is scheduled and which item is anticipated.

Tracking the 50-attendances-per-calendar-year cap

The 296/297/299/300/302/304/306/308 cluster (and their telehealth equivalents 91827–91831, 91837–91839, 92437) share a single 50-attendances-per-calendar-year cap per patient per psychiatrist. Practices billing high volumes need to surface a running attendance count for each patient — once a patient is approaching 50 attendances in a calendar year, the next attendance triggers a Medicare review.

PSR audit failure modes (psychiatry)

The Professional Services Review schemes that examine psychiatric MBS billing have published recurring patterns:

• Time-band mismatch — the most common single finding. Note records "30-minute review" but the item billed is 306 (which requires more than 45 minutes). Always document start-time and end-time, then check that the recorded duration matches the item.
• 291 claimed without the management-plan letter — the highest-risk error in psychiatry billing. The differential between 291 and 296 is recoverable when the letter is missing.
• New-patient item billed where the 24-month re-attendance rule fails — billing 296/297/299 for a patient seen by this psychiatrist in the preceding 24 months. The duration-tier follow-up items apply instead.
• Item-location mismatch — billing 296 for a home visit, or 297 for a private-rooms attendance.
• No documented MSE — narrative-only notes that summarise the conversation without an explicit MSE.
• No risk assessment — psychiatry notes without a documented current risk position fail the threshold test for "comprehensive consultation".
• 50-attendances-per-year cap breach — particularly for high-volume private practices with frequent-attender patients. Track the cap across the calendar year per patient per psychiatrist.
• Telehealth confusion — 291 and the 296/300-series are not telehealth items; the telehealth equivalents are separately numbered (e.g. 92435 for telehealth 291, 92437 in the 296/300 cap). Billing the wrong limb is an item-rule breach.

Practical workflow

Most defensible psychiatric documentation follows the same workflow regardless of item:

1. Capture start time and end time at the moment of the consultation. AI-assisted documentation that timestamps recording start/stop is more defensible than retrospective time estimation.
2. Document the MSE in a structured field — having a fixed MSE template reduces the risk of an MSE being skipped during a busy session.
3. Maintain a longitudinal psychometric record — the same instrument, scored each session, gives auditors and reviewers a clean trajectory.
4. Record the intended billing item against the duration — this single line ("Item 304 — 38-minute consultation") closes the most common audit gap.
5. Send the referrer letter promptly — same-week is the audit-defensive default. Save a copy in the file.

Documentation tools

Grounded Scribe ships psychiatric consultation note templates that capture the structure above — initial-consultation comprehensive notes, follow-up review notes, medication-change framework, risk re-assessment. The platform also tracks consultation duration automatically and surfaces the corresponding MBS attendance item.

Related reading

• Documenting Medication Changes During Psychiatric Reviews
• Mental Health Tribunal & Medico-Legal Report Writing for Psychiatrists
• Medicare Audit-Ready Documentation: A GP's Guide to MBS Item Number Compliance
• Better Access Progress Reports for Psychologists