FOR-OFFICIAL-USE-ONLY Medicare Benefits Schedule (MBS ... · FOR-OFFICIAL-USE-ONLY Medicare Benefits Schedule (MBS) Review Taskforce . 18 August 2015 Agenda Item No: 2A . ... (SLE)

FOR-OFFICIAL-USE-ONLY

Medicare Benefits Schedule (MBS) Review Taskforce 18 August 2015 Agenda Item No: 2A

Further information on Priority Review Items

Priority Review Topics – detailed information

Cardiology .................................................................................................................. 3

Cardiac Imaging...................................................................................................... 3

Cardiac Ultrasound, Stress cardiac imaging and Electrocardiography (ECGs) ... 3

Diagnostic Imaging ................................................................................................... 10

Bone Mineral Densitometry (BMD) - Dual-Energy X-ray Absorptiometry (DEXA Scanning ............................................................................................................... 10

Imaging (including computed tomography angiography) to exclude pulmonary embolism .............................................................................................................. 13

Imaging of the Knee, including: ............................................................................ 16

Ultrasound, X-ray and MRI, including GP requested MRI of knee .................... 16

Ankle imaging (ultrasound and x-ray) ................................................................... 20

Routine ultrasound for umbilical or inguinal hernias ............................................. 24

Use of computed tomography (CT) (and ultrasound for some) to diagnose appendicitis ........................................................................................................... 27

Brain CT ............................................................................................................... 30

Skull x-ray after head injury .................................................................................. 34

Use of chest x-ray for screening and preoperatively ............................................. 36

Duplex ultrasound for deep vein thrombosis ......................................................... 39

Use of plain tomography ....................................................................................... 41

Sinus CT for uncomplicated acute rhinosinusitis .................................................. 42

Ear, Nose & Throat................................................................................................... 44

Adenoidectomy and Tonsillectomy ....................................................................... 44

Grommets ............................................................................................................. 47

Endocrinology .......................................................................................................... 49

Thyroid disease investigations – pathology, imaging and surgery ........................ 49

Glycosylated hemoglobin (HbA1c) testing ............................................................ 51

Gastroenterology ...................................................................................................... 53

Use of colonoscopy .............................................................................................. 53

Upper GI tract investigations ................................................................................ 57

Capsule endoscopy in assessment of obscure gastrointestinal bleeding ............. 59

1 MBS Review Taskforce Meeting 2 – 18 August 2015 – Agenda Item 2A


FOR-OFFICIAL-USE-ONLY General Practice ...................................................................................................... 61

Health Assessments ............................................................................................. 61

Haematology ............................................................................................................ 65

Use of blood products/blood transfusion ............................................................... 65

Iron studies, including ferritin testing..................................................................... 71

Factor V Leiden testing ......................................................................................... 74

Groups of items claimed by haematologists 2013-14 ........................................... 77

Orthopaedics ............................................................................................................ 79

Knee arthroscopy.................................................................................................. 79

Obstetrics ................................................................................................................. 81

Routine prenatal testing (including screening for preterm labour, gestational diabetes, chlamydia, HepC, cholesterol, urinary protein for pre-eclampsia, thrombophilia) ....................................................................................................... 81

Assisted Reproductive Technologies .................................................................... 87

Pathology ................................................................................................................. 90

Use of urine microscopy and cultures in various patient groups, including asymptomatic patients .......................................................................................... 90

PSA testing in asymptomatic men with life expectancy less than seven years ..... 93

Coagulation studies .............................................................................................. 96

ANA screening without symptoms of systemic lupus erythematosus (SLE) or another connective tissue disease (CTD) ........................................................... 100

Respiratory ............................................................................................................. 102

Spirometry .......................................................................................................... 102

Sleep studies ...................................................................................................... 105

Surgical assistant ................................................................................................... 114

Urology ................................................................................................................... 116

The role of urodynamic testing in women prior to surgery for stress incontinence............................................................................................................................ 116

Vascular ................................................................................................................. 121

Interventions for carotid vessel disease .............................................................. 121

Regulations and rules ............................................................................................. 124

Co-claiming: routine claiming of subsequent attendances with procedures by some providers ............................................................................................................. 124

Items with general practitioners and specialist rebates for the same service ..... 126

Referrals ............................................................................................................. 127

2

MBS Review Taskforce Meeting 2 – 18 August 2015 – Agenda Item 2A


FOR-OFFICIAL-USE-ONLY High level MBS statistics: Ultrasounds of the knee (note that there is already a restrictor in the items to note that ultrasound of the knee should only be used for meniscal and cruciate tears and assessment of chondral surfaces. Number of MBS items 4 Item numbers 55828, 55829, 55830, 55831 Services 2013/14 126,186 Benefits 2013/14 $12.7 million Growth 2011-12 to 2013-14 26.1%1 Number of patients 120,6772 Number of providers 3,0293 1 Growth rate is based on item numbers 55828 and 55830 only due to low service volumes for the other items. 2 note that the number of patients is the number of patients that received a service for all items added together. If a patient had a service for more than one item in the selected item group – they would be counted multiple times. 3 note that this is double counting practitioners as the same practitioners would be claiming more than 1 item. The item with the highest service count 5528 had a provider count of 1,702.

X-rays, which include imaging of the knee (note that there are no item specifically for radiographic examination of the knee – the items include foot, ankle, leg, knee or femur Number of MBS items 8 Item numbers 57518, 57521, 57524, 57527, 57535, 57536,

57538, 37539 Services 2013/14 2.1 million Benefits 2013/14 $84.2 million Growth 2011-12 to 2013-14 11.1% Number of patients 1.4 million1 Number of providers 10,1012 1 note that the number of patients is the number of patients that received a service for all items added together. If a patient had a service for more than one item in the selected item group – they would be counted multiple times. 2 note that this is double counting practitioners as the same practitioners would be claiming more than 1 item. The item with the highest service count 57521 had a provider count of 3,714

MRI of the knee (excluding MRI ordered by GP) Number of MBS items 2 Item numbers 63328, 63343 Services 2013/14 95,789 Benefits 2013/14 $36.6 million Growth 2011-12 to 2013-14 -2.0% Number of patients 85,5971 Number of providers 1,030 1 note that the number of patients is the number of patients that received a service for all items added together. If a patient had a service for more than one item in the selected item group – they would be counted multiple times.

GP MRI of the knee Number of MBS items 4 Item numbers 63513, 63514, 63560, 63561 Services 2013/14 85,345 Benefits 2013/14 $33.6 million Growth 2011-12 to 2013-14 Item introduced in November

2012/November 2013 Number of patients 82,057 Number of providers 2,004 1 note that the number of patients is the number of patients that received a service for all items added together. If a patient had a service for more than one item in the selected item group – they would be counted multiple times. 2 note that this is double counting practitioners as the same practitioners would be claiming more than 1 item. The item with the highest service count 63560 had a provider count of 1,096






FOR-OFFICIAL-USE-ONLY Table 1: Top pathology services by number of patients who have claimed a 20 week pregnancy ultrasound

Item number Item descriptor

Schedule fee

Number of patients

% of patients

Number of services Benefits paid EMSN

benefits

73928 Initiation of a patient episode by approved collection centre 5.95 240,182

91% 765,417

4,112,588

208,769

65096 Blood group testing 41.00 229,299

87% 360,049

12,589,941

89,026

65070 Full blood count 16.95 170,773

65% 313,828

4,555,038

71,065

69333 Urinalysis – protein, white cells 20.55 136,775

52% 225,893

3,967,539

26,952

73938 Initiation of a patient episode by treating practitioner 7.95 136,345

52% 251,177

1,780,800

80,915

69312 Swab at 36 weeks to test for Group B Streptococcus 33.75 117,181

44% 136,996

4,033,305

110,365

69415 Test for all 5: rubella, syphilis, Hep B, Hep C, HIV 69.10 115,111

44% 117,357

6,968,705

10,285

66596 Iron studies, including ferritin 32.55 92,407

35% 129,422

3,615,034

14,852

66750 12 week test for foetal abnormality (two of the tests) 39.75 91,439

35% 91,481

3,419,952

296,748

66548 Oral glucose tolerance test for diagnosis of gestational diabetes plus at least 3 measures of blood glucose

19.90 83,555

32% 91,661

1,584,402

30,747

73529 HGC quantitation for diagnosis of threatened abortion or follow up of abortion or diagnosis of ectopic pregnancy, including any services performed in item 73527 (HCG detection of serum or urine diagnosis of pregnancy)

28.65 82,209

31% 119,189

2,938,971

28,877

66512 Biochemical screen 17.70 78,247

30% 150,789

2,249,633

24,334

66545 Oral glucose challenge test for diagnosis of gesta ional diabetes plus 1 or 2 measures of blood glucose

15.80 75,096

28% 76,979

1,074,353

38,898

65111 Antibodies in blood 23.20 66,072

25% 81,578

1,648,366

36,486

66716 TSH quantitation 25.05 60,183

23% 74,493

1,602,148

10,632

73806 Pregnancy test by 1 or more immunochemical methods 10.15 58,044

22% 63,497

550,434

1,241

66593 Ferritin - quantitation, except if requested as part of iron studies 18.00 45,147

17% 61,552

974,216

32,612

66751 12 week test for foetal abnormality (three or more of tests) 55.25 43,527

16% 43,549

2,126,284

56,204

66542 Oral glucose challenge test for diagnosis of gesta ional diabetes plus at least 2 measures of blood glucose

18.95 40,696

15% 44,633

723,802

2,783

69413 Test for 4 of following: rubella, syphilis, Hep B, Hep C, HIV 55.70 37,043

14% 37,614

1,799,018

3,912

69494 Detection of a virus or microbial antigen or microbial nucleic acid (not elsewhere specified) 1 test 28.65 33,041

13% 34,260

855,484

16,847

66719 Thyroid function test 34.8 31,875

12% 71,785

2,143,323

17,390

69478 Test for 2 of following: Hep A, Hep B, Hep C or Hep D 29.25 28,570

11% 29,231

734,158

1,714



FOR-OFFICIAL-USE-ONLY AMDA – The Society for Post-Acute and Long-Term Care Medicine






FOR-OFFICIAL-USE-ONLY Coagulation studies

Current MBS items for coagulation studies

Item Description Schedule Fee

65120 Prothrombin time (including INR where appropriate), activated partial thromboplastin time, thrombin time (including test for the presence of heparin), test for factor XIII deficiency (qualitative), Echis test, Stypven test, reptilase time, fibrinogen, or 1 of fibrinogen degradation products, fibrin monomer or D-dimer - 1 test 13.70

65123 2 tests described in item 65120 20.35

65126 3 tests described in item 65120 27.85

65129 4 or more tests described in item 65120 35.50

High level MBS statistics: MBS data do not capture the services provided in Emergency Departments of public hospitals. 1 test Item number 65120 Services 2013/14 3,647,103 Benefits 2013/14 $42.1 million Growth in benefits (2011-12 to 2013-14) -7.5% Number of patients 2013/14 346,391 2 tests Item number 65123 Services 2013/14 382,872 Benefits 2013/14 $6.1 million Growth in benefits (2011-12 to 2013-14) 1.7%



FOR-OFFICIAL-USE-ONLY Comments by Choosing Wisely et al




Respiratory Spirometry

High level MBS statistics: Diagnostic respiratory function tests Number of MBS items 5 Item numbers 11500, 11503, 11506, 11509, 11512 Services 2013/14 597,947 Benefits 2013/14 $38.5 million Growth 2011-12 to 2013-14 23.1% Number of patients 95,374 Number of providers 18,901 1 note that the number of patients is the number of patients that received a service for all items added together. If a patient had a service for more than one item in the selected item group – they would be counted multiple times. 2 note that this is double counting practitioners as the same practitioners would be claiming more than 1 item. The item with the highest service count 11506 had a provider count of 17,257.






FOR-OFFICIAL-USE-ONLY Sleep studies

High level MBS statistics: Number of MBS items 7 Item numbers 12203, 12207, 12210, 12213, 12215, 12217,

12250 Services 2013/14 164,670 Benefits 2013/14 $69.1 million Growth 2011-12 to 2013-14 22.4% Number of patients 145,540 Number of providers 673 1 note that the number of patients is the number of patients that received a service for all items added together. If a patient had a service for more than one item in the selected item group – they would be counted multiple times. 2 note that this is double counting practitioners as the same practitioners would be claiming more than 1 item. The item with the highest service count 12203 had a provider count of 279






FOR-OFFICIAL-USE-ONLY • Furthermore, about 29,220 patients (72%) did not receive an item 110 and/or 116 within the

twelve months (before or after) the study. Of the patients who did receive an item 110 and/or 116, 11,283 patients (56%) received the consultation service from the same respiratory and sleep specialist who billed item 12250.

• Given the majority of patients do not have a specialist consultation with a respiratory and sleep specialist prior to the investigation, this raises a potential issue around whether the necessity for the investigation is being appropriately assessed by the sleep provider prior to the test (in line with the descriptor requirement that:

“…the investigation takes place after the qualified adult sleep medicine practitioner has: (i) confirmed the necessity for the investigation”.




Surgical assistant Assist at operations including funding model and assessment of items for appropriateness of assistant

- 1,981 items currently have (assist) in the item descriptor.

High level MBS statistics: Number of MBS items 7 Item numbers 51300, 51303, 51306, 51309, 513012,

51315, 51318 Services 2013/14 478,312 Benefits 2013/14 $75.1 million Growth 2011-12 to 2013-14 12.0% Number of patients 446,235 Number of providers 7,844 1 note that the number of patients is the number of patients that received a service for all items added together. If a patient had a service for more than one item in the selected item group – they would be counted multiple times. 2 note that this is the number of practitioners that claimed item 51303 – the assistant items with the highest claim volume.







Vascular Interventions for carotid vessel disease Including:

- investigation and role of surgery/stenting in carotid disease - open vs endovascular approaches to vascular disease including carotid vessel

disease - endartertomies or stenting in high risk asymptomatic patients with limited life

expectancy

High level MBS statistics: Note that the data below only account for those items specified for use in treating carotid disease. There other items that are often claimed for this treatment, however the items are not specific to this treatment and therefore have not been captured by this report. These items include 32760, 33500, 33548, 33551, 33554, and 35307). Number of MBS items 4 Item numbers 32700, 32703,33500, 35307 Services 2013/14 1,366 Benefits 2013/14 $1.1 million Growth 2011-12 to 2013-14 1.5% Number of patients 1,3011 Number of providers 2832 1 note that the number of patients is the number of patients that received a service for all items added together. If a patient had a service for more than one item in the selected item group – they would be counted multiple times. 2 note that this is double counting practitioners as the same practitioners would be claiming more than 1 item. The item with the highest service count 33500 had a provider count of 166.







Regulations and rules

Co-claiming: routine claiming of subsequent attendances with procedures by some providers

High level MBS statistics:

• In 2013-14, there were more than 1.2 million occasions where a subsequent attendance (including a 105, 116 or 133) was provided by the same practitioner on the same day as a therapeutic procedure with a schedule fee of more than $100 (groups T1 and T8).

• This equates to around 20 per cent of procedures. • Using a conservative methodology, assuming that on all 1.2 million episodes an item

105 was claimed (in-hospital rebate of $32.25), this would equate to around $38.8 million in benefits paid for the consultation services.

• The practice is more common with some procedures than others. • For example, for item 42738 (injection into the eye for the treatment of macular

degeneration), a subsequent attendance is also claimed 79% of the time. • For item 38218, coronary angiography, a subsequent attendance is claimed on the

same day 60% of the time. • For item 47288, laser capsulotomy, a subsequent attendance is claimed on the same

day more than 50% of the time. • For item 30473, Oesophagoscopy with or without biopsy, a subsequent attendance is

claimed on the same day more than 18% of the time. • For item 32090, Colonoscopy with or without biopsy, a subsequent attendance is

claimed on the same day more than 17% of the time.



FOR-OFFICIAL-USE-ONLY • In the next step of data analysis further information will be sort on the number of

practitioners charged a subsequent attendance on the same day as the procedure for each item to determine if the practice is widespread among certain specialties with certain procedures or whether the practice is concentrated in a small number of providers.



FOR-OFFICIAL-USE-ONLY Items with general practitioners and specialist rebates for the same service

• High level MBS data:

• In 2014-15 around 158,000 were provided under the ‘G & S’ items. • 18 per cent of these services were claimed by GPs.

List of G & S items Item numbers 30009, 30010, 30013, 30014, 30041, 30042, 30048, 30049, 30067, 30068, 30074, 30075, 30102, 30103, 30106, 30107, 30110, 30111, 30265, 30266, 30282, 30283, 30612, 30614, 30616, 30617, 30620, 30621, 30634, 30365, 30638, 30641, 30659, 30659, 30660, 30675, 30676, 35512, 35513, 35516, 35526, 35527, 35617, 35618, 35639, 35640, 35676, 35677, 35683, 35688, 35712, 35716, 37622, 37623, 41665, 41668, 41788, 41789, 41792, 41793, 41796, 41797, 41800, 41801



FOR-OFFICIAL-USE-ONLY Referrals



Documents

FOR-OFFICIAL-USE-ONLY Medicare Benefits Schedule (MBS ... · FOR-OFFICIAL-USE-ONLY Medicare Benefits Schedule (MBS) Review Taskforce . 18 August 2015 Agenda Item No: 2A . ... (SLE)