Increasing the MBS Rebate for Selected Procedures ... · Medicare Benefits Schedule Fact Sheet: Increasing the MBS Rebate for Selected Procedures Performed by General Practitioners

Medicare Benefits Schedule Fact Sheet: Increasing the MBS Rebate for Selected Procedures Performed by General Practitioners (GPs) Page 1 of 3

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Increasing the MBS Rebate for Selected Procedures Performed by General Practitioners (GPs) Last updated: 22/08/2017

Effective 1 November 2017 (subject to the passage of legislation)

What do the changes involve?

The MBS items for some procedural services currently have different fees for GPs and specialists. This is depicted by ‘G’ (GP) and ‘S’ (specialist) items, whereby a lower fee is set for a procedural service performed by a GP than for the same service performed by a specialist. The current priced GP items will be removed and the specialist items will be amended to allow both GPs and specialists to claim the same fee for these services, set at the specialist rate. This change will see 43 MBS ‘S’ items amended and 31 current ‘G’ items deleted.

Why is the Government making this change?

This change acknowledges that minor procedures performed by specialists and GPs should be equally renumerated.

This change is based on a recommendation of the Medicare Benefits Schedule Review Taskforce.

What does this mean for MBS claiming?

The GP (lower fee) items will be removed from the MBS. GPs will be able to claim the higher fee items which were only available previously to specialists. There will be no change to the fees for MBS items claimed by specialists.

Change to item description/fees:

Items to be deleted from the MBS:

30009, 30013, 30041, 30048, 30067, 30074, 30102, 30106, 30110, 30266, 30282, 30620, 30634, 30638, 30675, 35512, 35516, 35526, 35617, 35639, 35676, 35683, 35687, 35712, 35716, 37622, 41665, 41788, 41792, 41796, 41800

Draft amendments to items in the MBS (final wording of items subject to finalisation and passage of legislation):

30010 Localised burns, dressing of, under general anaesthesia (not involving grafting) (S) (H) (Anaes.) Fee: $73.90 Benefit: 75% = $55.45

30014 Extensive burns, dressing of, under general anaesthesia (not involving grafting) (S) (H) (Anaes.) Fee: $155.40 Benefit: 75% = $116.55

http://www.mbsonline.gov.au/


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30042

Skin and subcutaneous tissue or mucous membrane, repair of wound of, other than wound closure at time of surgery, other than on face or neck, large (more than 7 cm long), involving deeper tissue, other than a service to which another item in Group T4 applies (S) (Anaes) Fee: $185.60 Benefit: 75% = $139.20 85% = $157.80

30049

Skin and subcutaneous tissue or mucous membrane, repair of wound of, other than wound closure at time of surgery, on face or neck, large (more than 7 cm long), involving deeper tissue (S) (Anaes.) Fee: $185.60 Benefit: 75% = $139.20 85% = $157.80

30068 Foreign body in muscle, tendon or other deep tissue, removal of, as an independent procedure (S) (Anaes.) (Assist.) Fee: $276.80 Benefit: 75% = $207.60 85% = $235.30

30075

Diagnostic biopsy of lymph gland, muscle or other deep tissue or organ, as an independent procedure, if the biopsy specimen is sent for pathological examination (S) (Anaes.) Fee: $149.75 Benefit: 75% = $112.35 85% = $127.30

30103 Sinus, excision of, involving muscle and deep tissue (S) (Anaes.) Fee: $183.90 Benefit: 75% = $137.95 85% = $156.35

30107 Ganglion or small bursa, excision of, other than a service associated with a service to which another item in this Group applies (S) (Anaes.) Fee: $219.95 Benefit: 75% = $165.00 85% = $187.00

30111 Bursa (large), including olecranon, calcaneum or patella, excision of (S) (Anaes.) (Assist.) Fee: $371.50 Benefit: 75% = $278.65 85% = $315.80

30266 Salivary gland, removal of calculus from duct or meatotomy or marsupialisation, one or more such procedures (S) (Anaes.) Fee: $149.75 Benefit: 75% = $112.35 85% = $127.30

30283 Ranula or mucous cyst of mouth, removal of (S) (Anaes.) Fee: $204.70 Benefit: 75% = $153.55 85% = $174.00

30621

Repair of symptomatic umbilical, epigastric or linea alba hernia requiring mesh or other formal repair of, in a person 10 years of age or over, other than a service to which item 30403 or 30405 applies (S) (H) (Anaes.) (Assist.) Fee: $407.50 Benefit: 75% = $305.65

30635

Varicocele, surgical correction of, other than a service associated with a service to which items 30638, 30641 and 30644 apply—one procedure (S) (H) (Anaes.) (Assist.) Fee: $291.80 Benefit: 75% = $218.85

30641 Orchidectomy, simple or subcapsular, unilateral with or without insertion of testicular prosthesis (S) (H) (Anaes.) (Assist.) Fee: $407.50 Benefit: 75% = $305.65

30676 Pilonidal sinus or cyst, or sacral sinus or cyst, excision of (S) (Anaes.) Fee: $379.05 Benefit: 75% = $284.30 85% = $322.20

35513 Bartholin’s cyst, excision of (S) (Anaes.) Fee: $221.70 Benefit: 75% = $166.30 85% = $188.45

35517 Bartholin’s cyst or gland, marsupialisation of (S) (Anaes.) Fee: $146.00 Benefit: 75% = $109.50 85% = $124.10

35527 Urethral caruncle, excision of (S) (Anaes.) Fee: $146.00 Benefit: 75% = $109.50 85% = $124.10

35618 Cervix, cone biopsy, amputation or repair of, other than a service to which item 35577 or 35578 applies (S) (Anaes.) Fee: $218.00 Benefit: 75% = $163.50 85% = $185.30



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35640

Uterus, curettage of, with or without dilatation (including curettage for incomplete miscarriage) under general anaesthesia or under epidural or spinal (intrathecal) nerve block, including procedures to which item 35626, 35627 or 35630 applies, if performed (S) (H) (Anaes.) Fee: $183.00 Benefit: 75% = $137.25

35677 Ectopic pregnancy, removal of (S) (H) (Anaes.) (Assist.) Fee: $ 536.00 Benefit: 75% = $402.00

35684 Uterus, suspension or fixation of, as an independent procedure (S) (H) (Anaes.) (Assist.) Fee: $ 471.15 Benefit: 75% = $353.40

35688

Sterilisation by transection or resection of fallopian tubes, via abdominal or vaginal routes or via laparoscopy using diathermy or another method (S) (H) (Anaes.) (Assist.) Fee: $397.25 Benefit: 75% = $297.95

35713

Laparotomy, involving oophorectomy, salpingectomy, salpingo-oophorectomy, removal of ovarian, parovarian, fimbrial or broad ligament cyst—one such procedure, other than a service associated with hysterectomy (S) (H) (Anaes.) (Assist.) Fee: $452.85 Benefit: 75% = $339.65

35717

Laparotomy, involving oophorectomy, salpingectomy, salpingo-oophorectomy, removal of ovarian, parovarian, fimbrial or broad ligament cyst—2 or more such procedures, unilateral or bilateral, other than a service associated with hysterectomy (S) (H) (Anaes.) (Assist.) Fee: $ 545.30 Benefit: 75% = $409.00

37623 Vasotomy or vasectomy, unilateral or bilateral (S) (Anaes.) Fee: $229.85 Benefit: 75% = $172.40 85% = $195.40

41668 Nasal polyp or polypi, removal of (S) (H) (Anaes.) Fee: $219.95 Benefit: 75% = $165.00

41789 Tonsils or tonsils and adenoids, removal of, in a person aged less than 12 years (S) (H) (Anaes.) Fee: $295.70 Benefit: 75% = $221.80

41793 Tonsils or tonsils and adenoids, removal of, in a person 12 years of age or over (S) (H) (Anaes.) Fee: $ 371.50 Benefit: 75% = $278.65

41797 Tonsils or tonsils and adenoids, arrest of haemorrhage requiring general anaesthesia, following removal of (S) (H) (Anaes.) Fee: $144.00 Benefit: 75% = $108.00

41801 Adenoids, removal of (S) (H) (Anaes.) Fee: $162.95 Benefit: 75% = $122.25


Medicare Benefits Schedule Fact Sheet: Removal of Administrative Block to Allow Patients to Claim MBS Rebates for Consultations with General Practitioners (GPs) During the ‘Aftercare’ Period Page 1 of 1

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Removal of Administrative Block to Allow Patients to Claim MBS Rebates for Consultations with General Practitioners (GPs) During the ‘Aftercare’ Period Last updated: 22/08/2017

Effective from 1 November 2017 (subject to the passage of legislation)


It is a principle of the MBS that ‘aftercare’ services—that is, medical treatment directly related to a patient’s recovery from surgery—should be provided by the surgeon, and that the cost of these services should be covered by the fee for the original procedure. For these reasons, there is currently an administrative block on a patient claiming Medicare benefits for other MBS services provided to them in the aftercare period, the length of which varies depending on the type of procedure.

The current administrative block means that if a patient has an unrelated consultation with their GP following a procedure provided by a specialist, their claim may be automatically rejected by the Department of Human Services. As most of these claims are for MBS services unrelated to the operation, they are subsequently paid following a re-submission of the claim to the Department of Human Services. The current arrangements are cumbersome for patients and providers.


The changes to aftercare arrangements will allow patients access to MBS rebates for GP consultations during an aftercare period, where the operation was performed by another practitioner. This change is based on a recommendation of the Medicare Benefits Schedule Review Taskforce.


Under the new aftercare arrangements, practitioners, who perform the original procedure will still be required to provide normal aftercare services to their patients. However, patients will be able to claim MBS benefits for consultations with other GPs during the aftercare period of an operation, without having to resubmit the claim.

Please note that where the same GP provides the procedure and the consultation service, the aftercare rules will still apply. Where this is the case, the GP will need to advise if the consultation is not considered to be normal aftercare for the procedure in order for the consultation item to attract a Medicare benefit.

For patients who see a specialist during their aftercare period for a condition that is unrelated to their recent procedure, as per usual arrangements, the practitioner will need to advise that the consultation is 'not normal aftercare' when submitting their claim. The Department of Human Services website provides further information about aftercare periods for specialists.


Medicare Benefits Schedule Fact Sheet: Blocking claiming of MBS items for subsequent attendances with any item in group T8 (surgical operations) that has an MBS fee of $300 or more Page 1 of 2

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Blocking Claiming of MBS Items for Subsequent Attendances with Any Item in Group T8 (Surgical Operations) That Has an MBS Fee of $300 or More Last updated: 22/08/2017



The claiming of subsequent attendance items with any item in Group T8 (surgical operations) of the MBS will be restricted, if the Group T8 item has a schedule fee of equal to or greater than $300, and if the items are provided by the same practitioner on the same day.


This change is based on a recommendation of the Medicare Benefits Schedule Review Taskforce.

This change will ensure that patients receive the same MBS benefits for the same MBS benefits for the same service and improve consistency of practitioner billing practices.


Medical practitioners will no longer be able to claim MBS benefits for subsequent attendance items 105, 116, 119, 386, 2806, 2814, 3010, 3014, 6019, 6052, and 16404 if they are claiming any Group T8 items (30001-50952) with a schedule fee of equal to or greater than $300 on the same day.

Medical practitioners who are not claiming subsequent attendance items with Group T8 items will not be affected.

Three new subsequent attendance items will be introduced. These new items can be claimed on the same day as Group T8 items with schedule fees of equal to or greater than $300, if the procedure is urgent and not able to be predicted prior to the commencement of the attendance.

It is expected that these items would be rarely required.

New items:

(Draft wording of items subject to finalisation and passage of legislation):


Medicare Benefits Schedule Fact Sheet: Blocking claiming of MBS items for subsequent attendances with any item in group T8 (surgical operations) that has an MBS fee of $300 or more Page 2 of 2

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111

Professional attendance at consulting rooms or in hospital by a specialist in the practice of his or her specialty following referral of the patient to him or her by a referring practitioner—an attendance after the first attendance in a single course of treatment, if: (a) during the attendance, the specialist determines the need to perform an operation on the patient that had not otherwise been scheduled; and (b) the specialist subsequently performs an operation on the patient, on the same day; and (c) the operation is a service to which an item in Group T8 applies; and (d) the amount specified in the item in Group T8 as the fee for a service to which that item applies is $300 or more For any particular patient, once only on the same day.

Fee: $43.00 Benefit: 75% = $32.25 85% = $36.55

117

Professional attendance at consulting rooms or in hospital, by consultant physician in the practice of his or her specialty (other than psychiatry) following referral of the patient to him or her by a referring practitioner—an attendance after the first attendance in a single course of treatment, if: (a) the attendance is not a minor attendance; and (b) during the attendance, the consultant physician determines the need to perform an operation on the patient that had not otherwise been scheduled; and (c) the consultant physician subsequently performs an operation on the patient, on the same day; and (d) the operation is a service to which an item in Group T8 applies; and (e) the amount specified in the item in Group T8 as the fee for a service to which that item applies is $300 or more For any particular patient, once only on the same day. Fee: $75.50 Benefit: 75% = $56.60 85% = $48.45

120

Professional attendance at consulting rooms or in hospital by a consultant physician in the practice of his or her specialty (other than psychiatry) following referral of the patient to him or her by a referring practitioner—an attendance after the first attendance in a single course of treatment, if: (a) the attendance is a minor attendance; and (b) during the attendance, the consultant physician determines the need to perform an operation on the patient that had not otherwise been scheduled; and (c) the consultant physician subsequently performs an operation on the patient, on the same day; and (d) the operation is a service to which an item in Group T8 applies; and (e) the amount specified in the item in Group T8 as the fee for a service to which that item applies is $300 or more For any particular patient, once only on the same day. Fee: $43.00 Benefit: 75% = $32.25 85% = $36.55


Medicare Benefits Schedule Fact Sheet: Changes to Gastroenterology Services (not including Colonoscopy) Page 1 of 4

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Changes to Gastroenterology Services (not including Colonoscopy) Last updated: 22/08/2017



Changes will be made to a number of items for gastroenterology, as follows:

1 - Capsule endoscopy

Item 11820 will be amended to better describe the service and eligible patient population.

2 – Upper gastrointestinal services

Item 30478 will be amended to allow services currently provided under 30476 to be claimed. Item 30476 will be deleted from the schedule.

Item 30479 will be amended to remove Argon Plasma Coagulation (APC) from the item descriptor. The item descriptor for 30478 will be amended to allow APC to be claimed.

Claiming restrictions will prevent MBS item 30479, 30473 and 30478 from being claimed together on the same day, for the same patient, by the same provider.

Item 30478 will be amended to allow for the claiming of push enteroscopy services currently claimed under item 30487. Item 30487 has been deleted. Item 32095 is available for endoscopic examination of the small bowel via a stoma.

3 - Endoscopic upper gastrointestinal stricture services

Item 30475 will be amended to allow for the claiming of services currently provided under items 41819 and 41820 to be claimed. Items 41819 and 41820 have been deleted.

The MBS fee for item 30475 will be the MBS fee for item 41819 of $348.95 which is higher than the current fee for item 30475.

Item 41831 will be amended to indicate this service is specific to the treatment of achalasia.

4 - Sigmoidoscopy/colonoscopy

The item descriptors for 32084 and 32087 will be amended to better define the extent of the examinations covered under these items to ‘does not reach the caecum’ and to remove reference to ‘fibreoptic’ as these days scopes are digital.

The item descriptor for 32087 will also be amended to remove specific reference to APC to enable other therapies to be used.

Introduce claiming restrictions to prevent MBS items 32084 and 32087 from being claimed with other colonoscopy items 32090 and 32093 on the same day, same patient, same provider, unless the subsequent service has been provided under a second episode of sedation/anaesthesia.

5 - Endoscopic ultrasound services

Items 30688, 30690, 30692, 30694 will be amended to remove the current restrictions on the claiming of certain other items during the same episode of care.



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Interventional items 30484, 30485, 30491, 30494 will be eligible for an MBS payment on the same day, same patient, same provider as an endoscopic ultrasound service.

6 – Biliary manometry

Item 30493 will be removed from the schedule as the service is obsolete.


The changes to MBS items for gastroenterology are intended to align MBS items with clinical best practice, better describe/prescribe indications and ensure appropriate claiming of MBS items:

These changes are based on recommendations of the Medicare Benefits Schedule Review Taskforce.


All practitioners that perform these services will continue to be able to claim the relevant MBS items, provided the services reflect the updated descriptions.



30487, 41819, 41820, 30493, 30476


11820 Capsule endoscopy to investigate an episode of obscure gastrointestinal bleeding, using a

capsule endoscopy device (including administration of the capsule, associated endoscopy procedure if required for placement, imaging, image reading and interpretation, and all attendances for providing the service on the day the capsule is administered) if:

(a) the patient to whom the service is provided:

(i) has recurrent or persistent gastrointestinal bleeding, and

(ii) has iron deficiency anaemia that is not due to coeliac disease; and

(iii) menorrhagia if present has been considered and managed; and

(iv) is anaemic or has overt active gastrointestinal bleeding; and

(b) an upper gastrointestinal endoscopy and a colonoscopy have been performed on the patient and have not identified the cause of the bleeding; and

(c) the service has not been provided to the same patient on more than 2 occasions in the preceding 12 months; and

(d) the service is performed by a specialist or consultant physician with endoscopic training that is recognised by The Conjoint Committee for Recognition of Training in Gastrointestinal Endoscopy; and

(e) the service is not associated with balloon enteroscopy items 30680, 30682, 30684, 30686

Fee: $2,039.20 Benefit: 75% = $1,529.40 85% = $1,959.00 30473 OESOPHAGOSCOPY (not being a service to which item 41816 or 41822 applies)

GASTROSCOPY, DUODENOSCOPY or PANENDOSCOPY (one or more such procedures), with or without biopsy, not being a service associated with a service to which item 30476 or 30478 or 30479, applies (Anaes.)



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Fee: $177.10

30478 OESOPHAGOSCOPY (not being a service to which item 41816, 41822 or 41825 applies), GASTROSCOPY, DUODENOSCOPY, PANENDOSCOPY or PUSH ENTEROSCOPY (one or more such procedures), with one or more of the following endoscopic procedures:

i Polypectomy ii Sclerosing or adrenalin injections iii Banding iv Endoscopic clips, v Haemostatic powders vi Diathermy vii Argon plasma coagulation viii Heater probe or laser coagulation

For the treatment of: a) Upper gastrointestinal tract bleeding b) Polyps c) Foreign body (removal), d) Oesophageal or gastric varices e) Peptic ulcers f) Neoplasia g) Benign vascular lesions h) Strictures of the gastrointestinal tract i) Tumorous overgrowth through or over oesophageal stents

not being a services associated with a service to which item 30473 or 30476 30479 applies, (Anaes.)

Fee: $245.55 Benefit: 75% = $184.20 85% = $208.75 30479 ENDOSCOPY with LASER THERAPY or ARGON PLASMA COAGULATION, for the

treatment of: a) Neoplasia b) Benign vascular lesions c) Strictures of the gastrointestinal tract d) Tumorous overgrowth through or over oesophageal stents e) Peptic ulcers f) Angiodysplasia g) Gastric antral vascular ectasia (GAVE) h) Post-polypectomy bleeding

one or more of, not being a service associated with a service to which item 30473 or

30478 applies (Anaes.)

Fee: $476.10 Benefit: 75% = $357.10 85% = $404.70 30475 ENDOSCOPY with balloon dilatation of gastric or gastroduodenal stricture ENDOSCOPIC

DILATATION OF STRICTURE OF UPPER GASTRO-INTESTINAL TRACT including the use of imaging intensification where clinically indicated Multiple Services Rule (Anaes.)

Fee: $348.95 Benefit: 75% = 261.70 85% = 296.60

41831 OESOPHAGUS, endoscopic pneumatic dilatation for treatment of achalasia Multiple Services Rule (Anaes.)

Fee: $357.00 Benefit: 75% = $267.75 85% = $303.45 30688 ENDOSCOPIC ULTRASOUND (endoscopy with ultrasound imaging), with or without

biopsy, for the staging of one or more of oesophageal, gastric or pancreatic cancer, not in association with another item in this Subgroup (with the exception of item 30484 or 30485 or 30491 or 30494) and not being a service associated with the routine monitoring of chronic pancreatitis. (Anaes.)

Fee: $364.90 Benefit: 75% = $273.70 85% = $310.20



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30690 ENDOSCOPIC ULTRASOUND (endoscopy with ultrasound imaging), with or without biopsy, WITH FINE NEEDLE ASPIRATION, including aspiration of the locoregional lymph nodes if performed, for the staging of one or more of oesophageal, gastric or pancreatic cancer, not in association with another item in this Subgroup (with the exception of item 30484 or 30485 or 30491 or 30494) and not being a service associated with the routine monitoring of chronic pancreatitis. (Anaes.)


biopsy, for the diagnosis of one or more of pancreatic, biliary or gastric submucosal

tumours, not in association with another item in this Subgroup (with the exception of item

30484 or 30485 or 30491 or 30494) and not being a service associated with the routine

monitoring of chronic pancreatitis. (Anaes.)


biopsy, WITH FINE NEEDLE ASPIRATION for the diagnosis of one or more of pancreatic, biliary or gastric submucosal tumours, not in association with another item in this Subgroup (with the exception of item 30484 or 30485 or 30491 or 30494) and not being a service associated with the routine monitoring of chronic pancreatitis. (Anaes.)

Fee: $563.30 Benefit: 75% = $422.50 85% = $483.10 32084 Endoscopic examination of the colon which does not reach the caecum by FLEXIBLE

FIBREOPTIC SIGMOIDOSCOPY or FIBREOPTIC COLONOSCOPY, up to the hepatic flexure, WITH or WITHOUT BIOPSY, not being as service associated with a service to which items 32087, 32222 to 32241 applies (Anaes.)

Fee: $111.35 Benefit: 75% = $83.55 85% = $94.65 32087 Endoscopic examination of the colon up to the hepatic flexure which does not reach the

caecum by FLEXIBLE FIBREOPTIC SIGMOIDOSCOPY or FIBREOPTIC COLONOSCOPY for the REMOVAL OF ONE OR MORE POLYPS or the treatment of radiation proctitis, angiodysplasia or post-polypectomy bleeding by ARGON PLASMA COAGULATION, one or more of, not being a service associated with a service to which items 32084, 32222 to 32241 applies (Anaes.)

Fee: $204.70 Benefit: 75% = $153.55 85% = $174.00


Medicare Benefits Schedule Fact Sheet: Changes to MBS Items for Obstetrics Services Page 1 of 5

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Changes to MBS Items for Obstetrics Services Last updated: 22/08/2017



The changes will amend a number of MBS obstetrics items, and introduce six new items to align MBS obstetrics items with clinical best practice.


The changes support the Government’s priority of ensuring that Medicare funded services are safe, clinically effective and cost-effective.

These changes are based on recommendations of the Medicare Benefits Schedule Review Taskforce.



Service Item Reason for deletion Procedures on multiple pregnancies

16633 and 16636

Items 16633 and 16636 will be deleted. Instead two or more services will attract MBS rebates when a procedure is performed on a second or subsequent fetus.

Management of second trimester labour

16525 Item 16525 will be deleted and two new items will be introduced for the management of pregnancy loss, between 14 and 15.6 weeks gestation, and 16 and 22.6 weeks gestation (see below).

Summary of amendments to obstetric MBS items (subject to finalisation and passage of legislation):

Service Item/s Description of change

Complex birth item 16522 Amendments will include detailed clinical requirements to provide greater specificity and clarity to providers (final wording is subject to finalisation and passage of legislation). Management of labour and birth, or birth alone, (including caesarean section), on or after 23 weeks gestation, if in the course of antenatal supervision or intrapartum management one or more of the following conditions is present, including postnatal care for 7 days: (a) fetal loss; (b) multiple pregnancy; (c) antepartum haemorrhage that is: (i) of greater than 200 ml; or (ii) associated with disseminated intravascular coagulation; (d) placenta praevia on ultrasound in the third trimester with the placenta within 2 cm of the internal cervical os;



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(e) baby with a birth weight less than or equal to 2,500 g; (f) trial of vaginal birth in a patient with uterine scar where there has been a planned vaginal birth after caesarean section; (g) trial of vaginal breech birth where there has been a planned vaginal breech birth; (h) prolonged labour greater than 12 hours with partogram evidence of abnormal cervimetric progress as evidenced by cervical dilatation at less than 1 cm/hr in the active phase of labour (after 3 cm cervical dilatation and effacement until full dilatation of the cervix); (i) acute fetal compromise evidenced by: (i) scalp pH less than 7.15; or (ii) scalp lactate greater than 4.0; (j) acute fetal compromise evidenced by at least one of the following significant cardiotocograph abnormalities: (i) prolonged bradycardia (less than 100 bpm for more than 2 minutes); (ii) absent baseline variability (less than 3 bpm); (iii) sinusoidal pattern; (iv) complicated variable decelerations with reduced (3 to 5 bpm) or absent baseline variability; (v) late decelerations; (k) pregnancy induced hypertension of at least 140/90 mm Hg associated with: (i) at least 2+ proteinuria on urinalysis; or (ii) protein-creatinine ratio greater than 30 mg/mmol; or (iii) platelet count less than 150 x 109/L; or (iv) uric acid greater than 0.36 mmol/L; (l) gestational diabetes mellitus requiring at least daily blood glucose monitoring; (m) mental health disorder (whether arising prior to pregnancy, during pregnancy or postpartum) that is demonstrated by: (i) the patient requiring hospitalisation; or (ii) the patient receiving ongoing care by a psychologist or psychiatrist to treat the symptoms of a mental health disorder; or (iii) the patient having a GP mental health treatment plan; or (iv) the patient having a management plan prepared in accordance with item 291; (n) disclosure or evidence of domestic violence; (o) any of the following conditions either diagnosed pre-pregnancy or evident at the first antenatal visit before 20 weeks gestation: (i) pre-existing hypertension requiring antihypertensive medication prior to pregnancy; (ii) cardiac disease (co-managed with a specialist physician and with echocardiographic evidence of myocardial dysfunction); (iii) previous renal or liver transplant; (iv) renal dialysis;



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(v) chronic liver disease with documented oesophageal varices; (vi) renal insufficiency in early pregnancy (serum creatinine greater than 110 mmol/L); (vii) neurological disorder that confines the patient to a wheelchair throughout pregnancy; (viii) maternal height of less than 148 cm; (ix) a body mass index greater than or equal to 40; (x) pre-existing diabetes mellitus on medication prior to pregnancy; (xi) thyrotoxicosis requiring medication; (xii) previous thrombosis or thromboembolism requiring anticoagulant therapy through pregnancy and the early puerperium; (xiii) thrombocytopenia with platelet count of less than 100,000 prior to 20 weeks gestation; (xiv) HIV, hepatitis B or hepatitis C carrier status positive; (xv) red cell or platelet iso-immunisation; (xvi) cancer with metastatic disease; (xvii) illicit drug misuse during pregnancy (H) (Anaes.)

Fee: $1,629.35 Benefit: 75%=$1,222.05

Planning and management of a pregnancy where the doctor intends to attend the birth

16590 Item 16590 will be amended so that it can only be claimed from 28 weeks gestation. The item will also include a requirement for a mental health assessment of the patient to be performed, including screening for drug and alcohol use and domestic violence. Doctors are to be continuously available to the patient during pregnancy and will be required to have privileges for intrapartum care in a hospital or birth centre. A patient cannot claim item 16590 and 16591 for the same pregnancy. The fee for item 16590 will be increased by 15 per cent. Fee: $372.75 Benefit: 75%=$279.60 85%=$316.85

Planning and management of a pregnancy where the doctor does not intend to attend the birth

16591 Item 16591 will be amended so that it can only be claimed from 28 weeks gestation. The item will also include a requirement for a mental health assessment of the patient to be performed, including screening for drug and alcohol use and domestic violence. A patient cannot claim item 16590 and 16591 for the same pregnancy. Fee: $142.65 Benefit: 75%=$107.00 85%=$121.30

Management of second trimester labour

Two new items (16530 and 16531)

The current item for management of second trimester labour will be split into two, with management of pregnancy loss between 14 and 15.6 weeks gestation retaining the current fee ($384.35), and the management of pregnancy loss between 16 and 22.6 weeks gestation attracting a higher fee ($768.70). The management of pregnancy loss from 23 weeks should be claimed under the complex birth item (16522). 16530 – pregnancy loss between 14 and 15.6 weeks Fee: $384.35 Benefit: 75%=$288.30 85%=$326.70



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16531 - pregnancy loss between 16 and 22.6 weeks Fee: $768.70 Benefit: 75%=$576.55

Delivery where the patient is transferred by another medical practitioner

16515 and 16520

The schedule fees for items 16515 and 16520 will be amended to align with the principal birth item (16519) which does not distinguish between a vaginal and operative birth. There will also be minor changes to update terminology from 'delivery' to 'birth' in both items. 16515 Fee: $630.85 Benefit: 75%=$473.15 85%=$536.25 16520 Fee: $630.85 Benefit: 75%=$473.15 85%=$536.25

Delivery where the patient is transferred by a participating midwife

16527 and 16528

The schedule fees for items 16527 and 16528 will be amended to align with the principal birth item (16519) which does not distinguish between a vaginal and operative birth. There will also be minor changes to update terminology from 'delivery' to 'birth' in both items. 16527 Fee: $630.85 Benefit: 75%=$473.15 85%=$536.25 16528 Fee: $630.85 Benefit: 75%=$473.15 85%=$536.25

Consultations of more than 40 minutes for pregnancy complications

Two new items (16533 and 16534)

Two new items will be introduced for consultations lasting at least 40 minutes for specific pregnancy complications. The new items will be equivalent to items 16508 and 16509 and will be restricted to in-hospital services only. Each item can be claimed up to 3 times for each pregnancy. Fee: $105.55 Benefit: 75%=$79.20

Postnatal consultation

New item (16407)

A new item will be introduced for a postnatal attendance lasting at least 20 minutes between 4 and 8 weeks after birth. The item will also include a requirement for a mental health assessment of the patient to be performed, including screening for drug and alcohol use and domestic violence. This item can only be claimed once per pregnancy. Fee: $71.70 Benefit: 75%=$53.80 85%=$60.95

Postnatal home visit

New item (16408)

A consultation at the patient’s home between 1 and 4 weeks after birth, by an obstetrician, GP or registered midwife (if midwife, it will be on behalf of, and under the supervision of the medical practitioner who attended the birth). This item can only be claimed once per pregnancy. Fee: $53.40 Benefit: 85%=$45.40

Obstetrics consultation when patient is referred by a participating midwife

16406 Item 16406 will be amended so it can be claimed at any time during the pregnancy, if clinically appropriate. Fee: $133.95 Benefit: 75%=$100.50 85%=$113.90

Minor changes to 16508; Minor amendments to change terms such as ‘delivery’ to



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update terminology 16509; 16515;

16518; 16519; 16606; 20855; 20946; 20958;

51306; 51309

‘birth’; and ‘foetus’ to ‘fetus’. The current schedule fees for items 16508; 16509; 16518; 16519; 16606; 20855; 20946; 20958;51306; and 51309 will be retained.

Minor amendments for consultations

16401 and 16404

Minor amendments to item 16401 and 16404, to make it clearer when these items should be claimed. The current schedule fee for 16401 and 16404 will be retained.


Medicare Benefits Schedule Fact Sheet: Changes to Ear, Nose and Throat Items 41674, 41789, 41793 and 41801 Page 1 of 2

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Changes to Ear, Nose and Throat Items 41674, 41789, 41793 and 41801 Last updated: 22/08/2017



The changes to Medicare Benefits Schedule items 41674, 41789, 41793 and 41801 for ear, nose and throat (ENT) surgery involve:

Amendment to item 41674 to remove MBS coverage for cauterisation of the pharynx as this is no longer considered appropriate clinical practice.

Amendment to the items for tonsillectomy (41789 and 41793) and adenoidectomy (item 41801) to clarify that the item covers the service of injection of local anaesthetic and examination of the post nasal space to prevent inappropriate billing.


The changes support the Government’s priority of ensuring that Medicare funded services are safe, clinically effective and cost effective. They are based on recommendations of the Medicare Benefits Schedule Review Taskforce.


The changes to the ENT items will support safe clinical practice and prevent inappropriate billing.

Change to item description: (words to be added in red, words to be deleted with strikethrough)

41674

Cauterisation (other than by chemical means) or cauterisation by chemical means when performed under general anaesthesia or diathermy of septum or turbinates or pharynx—one or more of these procedures (including any consultation on the same occasion) other than a service associated with another operation on the nose (Anaes.) Fee: $100.50 Benefit: 75% = $75.40 85% = $85.45

41789

Tonsils or tonsils and adenoids, removal of, in a person aged less than 12 years, including any examination of the postnasal space and nasopharynx and infiltration of local anaesthetic; not being a service associated with item 41764 (S) (H) (Anaes.) Fee: $295.70 Benefit: 75% = $221.80

41793

Tonsils or tonsils and adenoids, removal of, in a person 12 years of age or over, including any examination of the postnasal space and nasopharynx and infiltration of local anaesthetic; not being a service associated with item 41764 (S) (H) (Anaes.) Fee: $371.50 Benefit: 75% = $278.65


Medicare Benefits Schedule Fact Sheet: Changes to Ear, Nose and Throat Items 41674, 41789, 41793 and 41801 Page 2 of 2

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41801

Adenoids, removal of, including any examination of the postnasal space and nasopharynx and infiltration of local anaesthetic; not being a service associated with item 41764 (S) (H) (Anaes.) Fee: $162.95 Benefit: 75% = $122.25


Medicare Benefits Schedule Fact Sheet: Changes to Medicare Benefits Schedule (MBS) Items for Bone Densitometry Page 1 of 3

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Changes to Medicare Benefits Schedule (MBS) Items for Bone Densitometry Last updated: 22/06/2017



Two new time-restricted MBS items will be introduced for bone mineral density testing (bone densitometry) for people aged 70 years and over. Patients 70 years and over will continue to be eligible for an initial screening study. Patients assessed as having mild to moderate osteopenia will be eligible for repeat testing every five years; and patients assessed with moderate to marked osteopenia will be eligible for repeat testing every two years. The current MBS item for people aged 70 years and over will be deleted from the MBS.

The Dual Energy X-Ray Absorptiometry (DEXA) bone densitometry MBS items will be amended to require that the scans must be performed by a:

(a) specialist or consultant physician; or

(b) person who holds a radiation license, as required by State or Territory law, and the scan is performed under the supervision of an appropriate specialist or consultant physician.

Changes will be made to the supervision requirements for Quantitative Computed Tomography (QCT) scans so that an appropriate specialist or consultant physician is available to monitor and influence the conduct of the scan and personally attend the patient if required. In relation to QCT scans, it is important to note that on 8 June 2017 the MBS Review Taskforce recommended the removal of two current QCT items, namely items 12309 and 12318, from the MBS. This change is subject to a decision by Government. Should this recommendation be confirmed, it would also take effect on 1 November 2017. The QCT qualification changes detailed in the following table would then apply only to the two new items for bone densitometry (12320 and 12322).

The changes also introduce a requirement that for all DEXA and QCT items the interpretation and report must be provided by a specialist or consultant physician.


The changes align MBS items with clinical best practice, enhance item specificity and improve the accuracy and quality of testing provided to patients by ensuring that the services are performed by suitably qualified practitioners. They follow the recommendations of the Medical Benefits Schedule Review Taskforce following the Diagnostic Imaging Clinical Committee Review of Bone Densitometry.


There are no changes to MBS recommended fees and benefits.

For those individuals with specific medical conditions or for patients undergoing particular treatments that may cause more rapid bone loss, a Medicare rebate is available for repeat testing at 12 monthly intervals.



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The two new items for individuals aged 70 years and over, take into account the clinical evidence that bone density loss is a relatively slow process, and that changes in bone loss cannot be reliably measured by yearly testing. The introduction of these new items will reduce the number of individuals in this age group who receive unnecessary repeat testing.

Changes to items:


MBS Items Description of change

Bone densitometry for patients aged 70 years and over (new items)

12320 12322

Item 12323 will be replaced by two new items with different testing intervals based on a risk profile, as follows: patients aged 70 years and over with no or mild osteopenia (down to T score of -1.5), one scan every 5 years. patients aged 70 years and over with moderate to marked osteopenia (T score of -1.5 to -2.5), one scan every 2 years. Patients diagnosed with osteoporosis will continue to be tested using other clinically appropriate MBS bone densitometry items. The fee for the two new items will be the same as for the current item 12323. Fee: $102.40

Qualification requirements for Dual Energy X-ray Absorptiometry (DEXA) scans

12306, 12312, 12315, 12321, 12320, 12322 (applies to the new items when performed using DEXA)

These items will be amended to require that the scans must be performed by a: (a) specialist or consultant physician; or (b) person who holds a radiation license, as required by State or Territory law, and the scan is performed under the supervision of an appropriate specialist or consultant physician. Additionally, these items will be amended to specify that the interpretation and report for these scans must be provided by a specialist or consultant physician. Fee: $102.40



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MBS Items Description of change

Quantitative Computed Tomography (QCT) scans

12309*, 12318*, 12320 & 12322 (applies to the new items when performed using QCT)

These items will be amended to require that an appropriate specialist or consultant physician must be available to monitor and influence the conduct of the scan and to personally attend the patient, if required. Additionally, these items will be amended to specify that the interpretation and report for these scans must be provided by a specialist or consultant physician. Fee: $102.40

NOTE: *it is recommended that these items are removed from the MBS.


Medicare Benefits Schedule Fact Sheet: Changes to Medicare Benefits Schedule (MBS) Items for Spinal X-Ray Services Page 1 of 2

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Changes to Medicare Benefits Schedule (MBS) Items for Spinal X-Ray Services Last updated: 22/06/2017



Requesting of MBS three and four region spinal x-ray items will be restricted to medical practitioners, physiotherapists and osteopaths only. In conjunction with the above amendment, the MBS one and two region spinal x-ray items will be amended so that allied health practitioners cannot request more than one, of any of the one and two region spinal x-ray services for the same patient on the same day.


The changes follow the Government’s consideration of recommendations of the MBS Review Taskforce as part of the Diagnostic Imaging Committee’s (Committee) MBS Review of Imaging for Low Back Pain. The changes are being made to support the government’s priority of ensuring that medical services receiving subsidies through the MBS are safe, clinically relevant and cost-effective. The changes will align MBS items with clinical best practice, enhance item specificity and reduce inappropriate requesting of spinal x-ray MBS items.

In light of its findings that there has been a high volume of unnecessary testing, and considering the associated radiation risks, the Committee proposed that requesting three and four region radiography of the spine be restricted. It was noted that this type of imaging has a limited clinical role largely confined to medical specialist assessment and management of scoliosis.

The Committee considered two region spinal radiographs to have clinical value in circumstances where the suspected pathology is at or close to the junction of two areas of the spine.


The change will mean that chiropractors will no longer be able to request Medicare-rebateable three and four region spinal x-ray items. All allied health practitioners will be restricted from requesting more than one, of any of the one and two region spinal x-ray service for the same patient on the same day. Medical practitioners are not affected by any of the changes.


Medicare Benefits Schedule Fact Sheet: Changes to Medicare Benefits Schedule (MBS) Items for Spinal X-Ray Services Page 2 of 2

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Changes to items:


Service Item/s Description of change

Spinal x-ray Three region

58121 58127

The requesting rights for these items will be restricted to medical practitioners, physiotherapists and osteopaths. Chiropractors will no longer be able to request these items. Under the recommendations only requesting rights are to be amended. In all other regards the items, including fees, remain unchanged.

Spinal x-ray Four region

58120 58126

The requesting rights for these items will be restricted to medical practitioners, physiotherapists and osteopaths. Chiropractors will no longer be able to request these items. Under the recommendations only requesting rights are to be amended. In all other regards the items, including fees, remain unchanged.

Spinal x-ray One region

58100 58102 58103 58105 58106 58109 58111 58117

These items will be amended to restrict allied health practitioners from requesting more than one of these items for the same patient on the same day. Only requesting rights are to be amended. In all other regards the items, including medical practitioner access and MBS recommended fees, remain unchanged.

Spinal x-ray Two region

58112 58123

These items will be amended to restrict allied health practitioners from requesting more than one of these items for the same patient on the same day. Only requesting rights are to be amended. In all other regards the items, including medical practitioner access and MBS recommended fees, remain unchanged.


Medicare Benefits Schedule Fact Sheet: Changes to colonoscopy items Page 1 of 10

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Changes to Colonoscopy Services Last updated: 22/08/2017

Effective 1 March 2018 (subject to the passage of legislation)


MBS items for colonoscopy 32090 and 32093 will be replaced by 20 new MBS items that better describe the indications for initial colonoscopy and ensure appropriate surveillance intervals of patients at increased risk of developing colorectal cancer. The new items also define the examination of the colon ‘to the caecum’ to ensure that a comprehensive examination is performed.

Claiming restrictions will apply with other colonoscopy services (same day, same patient, same practitioner).


These changes are intended to address significant national variation in per capita use of colonoscopy that cannot be explained by clinical or patient demographic factors. These changes are based on recommendations of the Medicare Benefits Schedule Review Taskforce.



32090, 32093

Draft new items on the MBS (final wording of items subject to finalisation and passage of legislation):

32222 Endoscopic examination of the colon to the caecum by COLONOSCOPY with or without biopsy.

For patient following a positive faecal occult blood test, not being a service

association with a service to which items 32088, 32089 applies (National

Bowel Cancer Screening Program participants) and items 32223 to 32240

applies

Payable not more than once every 2 years (Anaes.)

Fee: $334.35 Benefit: 75% = $250.80 85% = $284.20 32223 Endoscopic examination of the colon to the caecum by COLONOSCOPY with or

without biopsy

For symptomatic patient or

patient with iron deficiency

Not being a service associated with a service to which items 32222, 32224 to 32240

applies (Anaes.)

Fee: $334.35 Benefit: 75% = $250.80 85% = $284.20



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32224 Endoscopic examination of the colon to the caecum by COLONOSCOPY with or without biopsy

For patient following surgery for colorectal cancer

Not being a service associated with a service to which items 32222, 32223, 32225 to


Fee: $334.35 Benefit: 75% = $250.80 85% = $284.20


For patient with MODERATE risk of colorectal cancer due to family history of

colorectal cancer (1 first degree relative < 55yrs at diagnosis OR 2 first degree

relatives OR 1 first degree relative and 1 second degree relative on the same

side of the family, any age at diagnosis)

Not being a service associated with a service to which items 32222 to 32224 and

32226 to 32240 applies (Anaes.) Payable not more than once every 5 years

Fee: $334.35 Benefit: 75% = $250.80 85% = $284.20


For patient with HIGH risk of colorectal cancer due to known or suspected

familial condition including FAP or Lynch Syndrome


32227 to 32240 applies (Anaes.)

Payable not more than once every 12 months

Fee: $334.35 Benefit: 75% = $250.80 85% = $284.20


For patient with previous history of 1-2 adenomas AND all <10mm, no villous

features, no high grade dysplasia; OR

For patient with inflammatory bowel disease, Group 3 (ulcerative colitis

without high risk features when two previous colonoscopies are

macroscopically inactive and histologically negative for dysplasia)


32228 to 32240 applies (Anaes.) Payable not more than once every 5 years Fee: $334.35 Benefit: 75% = $250.80 85% = $284.20


For patient with previous history of 3-4 adenomas, sessile serrated OR any

adenoma >10mm, villous features, high grade dysplasia; OR



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For patient with inflammatory bowel disease, Group 2 (quiescent ulcerative

colitis without high risk features)


32229 to 32240 applies (Anaes.) Payable not more than once every 3 years


without biopsy (i) For patient with previous history of 5-9 adenomas; OR (ii) For patient with inflammatory bowel disease, Group 1 (any high risk feature including:

Chronically active ulcerative colitis

Primary sclerosing cholangitis

Colorectal cancer in first degree relative at <50y age

Stricture, multiple inflammatory polyps or shortened colon

Previous dysplasia)


32230 to 32240 applies (Anaes.) Payable not more than once every 12 months


without biopsy

For patient with previous history of >10 adenomas or incomplete excision of

large, sessile adenoma



Payable not more than 4 times per year


without biopsy

For failed preparation of the colon



Fee: $334.35 Benefit: 75% = $250.80 85% = $284.20 32232 Endoscopic examination of the colon to the caecum by COLONOSCOPY for the

REMOVAL OF 1 OR MORE POLYPS,

For patient following a positive faecal occult blood test, not in association with

items 32088, 32089 for National Bowel Cancer Screening Program



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participants


32233 to 32240 applies (Anaes.) Payable no more than once every 2 years



For symptomatic patient or

patient with iron deficiency





For patient following surgery for colorectal cancer





For patient with MODERATE risk of colorectal cancer due to family history of

colorectal cancer (1 first degree relative <55yrs at diagnosis OR 2 first degree

relatives OR 1 first degree relative and 1 second degree relative on the same

side of the family, any age at diagnosis)





For patient with a HIGH risk of colorectal cancer due to known or suspected

familial condition including FAP or Lynch Syndrome




REMOVAL OF 1 OR MORE POLYPS or LESIONS,

For patient with previous history of 1-2 adenomas AND all <10mm, no villous

features, no high grade dysplasia; OR

For patient with inflammatory bowel disease, Group 3 (ulcerative colitis

without high risk features when two previous colonoscopies are



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macroscopically inactive and histologically negative for dysplasia)




REMOVAL OF 1 OR MORE POLYPS or LESIONS

For patient with previous history of 3-4 adenomas or any adenoma >10mm,

villous features, high grade dysplasia; sessile serrated OR

For patient with inflammatory bowel disease, Group 2 (quiescent ulcerative

colitis without high risk features)




REMOVAL OF 1 OR MORE POLYPS or LESIONS (i) For patient with previous history of 5-9 adenomas, OR (ii) For patient with inflammatory bowel disease, Group 1 (any high risk feature including:

Chronically active ulcerative colitis

Primary sclerosing cholangitis

Colorectal cancer in first degree relative at <50y age

Stricture, multiple inflammatory polyps or shortened colon

Previous dysplasia)





For patient with previous history of >10 adenomas, or incomplete excision of

large or sessile adenoma

Not being a service associated with a service to which items 32222 to 322239 applies

(Anaes.)

Fee: $469.20 Benefit: 75% = $351.90 85% = $398.85 32241 Endoscopic examination of the colon by COLONOSCOPY for the treatment of

radiation proctitis, angiodysplasia or post-polypectomy bleeding, 1 or more of, not a

service association with a service to which item 32212 applies (Anaes.)

Fee: $469.20 Benefit: 75% = $351.90 85% = $398.85



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Explanatory Note

Gastrointestinal Endoscopic Procedures - (Items 30473 to 30481, 30484 to 30487, 30490 to 30494, 30680 to 32023, 32084 to 32095, 32103, 32104 and 32106, 32222 to 32241)

The following are guidelines for appropriate minimum standards for the performance of GI endoscopy in relation to (a) cleaning, disinfection and sterilisation procedures, and (b) anaesthetic and resuscitation equipment.

These guidelines are based on the advice of the Gastroenterological Society of Australia, the Sections of HPB and Upper GI and of Colon and Rectal Surgery of the Royal Australasian College of Surgeons, and the Colorectal Surgical Society of Australia.

Cleaning, disinfection and sterilisation procedures Endoscopic procedures should be performed in facilities where endoscope and accessory reprocessing protocols follow procedures outlined in:

1. Infection and Endoscopy (3rd edition), Gastroenterological Society of Australia; 2. Australian Guidelines for the Prevention and Control of Infection in Healthcare

(NHMRC, 2010); 3. Australian Standard AS 4187-1994 (and Amendments), Standards Association of

Australia.

Anaesthetic and resuscitation equipment Where the patient is anaesthetised, anaesthetic equipment, administration and monitoring, and post-operative and resuscitation facilities should conform to the standards outlined in 'Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures' (PS09), Australian & New Zealand College of Anaesthetists, Gastroenterological Society of Australia and Royal Australasian College of Surgeons.

Conjoint Committee For the purposes of Item 32023, the procedure is to be performed by a colorectal surgeon or gastroenterologist with endoscopic training who is recognised by the Conjoint Committee for the Recognition of Training in Gastrointestinal Endoscopy.

New Colonoscopy Items MBS items for colonoscopy have been revised to align MBS reimbursement with National Health and Medical Research Council (NHMRC) clinical guidelines:

NHMRC Clinical Practice Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer

NHMRC Clinical Practice Guidelines for Surveillance Colonoscopy – in adenoma follow-up; following curative resection of colorectal cancer; and for cancer surveillance in inflammatory bowel disease

NHMRC Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer: A Guide for General Practitioners

These national guidelines do not support the use of colonoscopy for patients at average or slightly above average risk of colorectal cancer who do not have symptoms or a positive FOBT.

The Cancer Council of Australia, the Gastroenterological Society of Australia and the Colorectal Surgical Society of Australia and New Zealand have endorsed the following algorithms designed to be used in conjunction with the NHMRC approved guidelines:

Colonoscopic Surveillance Intervals – Adenomas. 2013,

Colonoscopic Surveillance Intervals – Following Surgery for Colorectal Cancer. 2013



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Colorectal Cancer Screening – Family History. 2013, and

Colonoscopic Surveillance Intervals – Inflammatory Bowel Disease. 2013

For more information see the colorectal cancer pages on the Cancer Council Australia website

Timing of colonoscopy following polypectomy should conform to the recommended surveillance intervals set out in the endorsed algorithms, taking into account individualised risk assessment. In the absence of reliable clinical history, clinicians should use their best clinical judgement to determine the interval between testing and the item that best suits the condition of the patient.

All patients who require a colonoscopy will receive a service. However, MBS rebates will not be payable for services which do not meet the clinical indications and the item requirements for a colonoscopy or a repeat colonoscopy where the interval is specified in the item. Practitioners should ensure that their practice conforms to the approved clinical guidelines

Definition of previous history For items 32227 to 32230 and 32237 to 32240 the most appropriate item to be billed is determined by the previous history of the patient. The previous history for the purpose of these items is defined by number, size and type of adenomas removed during the most recent prior colonoscopy.

Diagnostic colonoscopy Items 32222 to 32231 Diagnostic colonoscopy items 32222, 32225 to 32230 have mandated intervals for repeat surveillance testing as clinically recommended in the approved guidelines and algorithms. These services are payable under Medicare only when provided in accordance with the approved intervals.

For item 32227 to 32230 the patient’s previous history is used to determine the appropriate item to bill. In the absence of reliable patient history or evidence the practitioner should be guided by their best clinical judgement (see examples below).

Therapeutic colonoscopy Items 32232 to 32241 Therapeutic colonoscopy items 32233 and 32235 to 32240 do not have mandated intervals for repeat surveillance testing. However, services should conform to the recommended surveillance intervals set out in the endorsed algorithms, taking into account individualised risk assessment. Service patterns by individual practitioners may be subject to audit and peer review assessment.

For item 32237 to 32240 the patient’s previous history is used to determine the appropriate item to bill. In the absence of reliable patient history or evidence the practitioner should be guided by their best clinical judgement (see examples below)

Colonoscopy following surgery for colorectal cancer Items 32224 and 32234 should only be used following surgery for colorectal cancer. Subsequent follow-ups should be billed under the most appropriate item. The guidelines and algorithms recommend that surveillance intervals following surgery for colorectal cancer will differ depending on if the colon was cleared of adenomas and synchronous cancers pre-operatively. If the colon was cleared then colonoscopy should be performed at 1 year post-op. If not, colonoscopy should be performed at 3-6 months post-op. The subsequent colonoscopic interval and items to bill will be dependent on the findings at these follow-ups. If results are normal a 5 yearly repeat is recommended. Where adenomas are found the number of adenomas will determine the interval surveillance in accordance with the guidelines and algorithms. For items 32224 and 32234, service patterns by individual practitioners may be subject to audit and peer review assessment. Follow-up of rectal cancers with examination of the rectum by digital examination, sigmoidoscopy or endorectal ultrasound should be considered independent of colonoscopic surveillance.


http://www.cancer.org.au/health-professionals/clinical-guidelines/colorectal-cancer.html



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Colonoscopy for symptomatic patients In clinical situations where the practitioner forms and fully documents the opinion that the patient’s symptoms dictate that colonoscopy is the most appropriate diagnostic procedure (this excludes screening) then item 32223 or 32233 can be billed. Claims under these items will be subject to increased oversight and review, particularly if larger claims than expected are observed.

How to use the items with new patients who have undergone previous colonoscopy

Patients whose care continues within one practice should have a certain history available to guide decision making regarding surveillance intervals. For new patients, practitioners should make reasonable efforts to establish a patient’s previous colonoscopy history. Once these items are established, the patients’ MBS claims history for those patients who do not require polypectomy will assist with this. The following case examples are provided to guide practitioners in the appropriate use of these new items.

Example 1 – New patient A new patient is referred with advice that they had 2 polyps removed at their last colonoscopy but the pathology results and size is unknown. The practitioner may decide that 32227 is the most appropriate item to bill. This means that 1) no polyps were removed at this colonoscopy and 2) the patient can be recalled for a repeat colonoscopy in 5 years. Alternatively the lack of certain history, particularly around the type of polyp removed, may lead the clinician to believe that a shorter interval is appropriate and hence an item that corresponds with a higher risk category could be chosen, for instance item 32228. This establishes the patient’s Medicare claims history and is available for other practitioners if the patient moves. If in the future the patient has polyps removed which are adenomas then this will establish a new and possibly different previous history which may place the patient in a different risk category and item range.

Example 2 – New patient For the same scenario as above, but where polyps are removed during the current colonoscopy, the practitioner would choose the B item that mirrors 32227 (ie 32237), as the assessment of patient history is the same. However advice to the patient about the appropriate interval for further colonoscopy will depend on the number, size and type of adenomas removed at this colonoscopy. This judgement will usually rely on the outcome of pathology testing and hence will not be available at the time of colonoscopy.

For audit purposes it is important to record the most appropriate item. In accordance with good practice, clinicians are required to maintain records that include pathology results which can be made available to the patient or other practitioners as required.

Hierarchy of items Patients may fit several categories and the most appropriate fit is a matter for clinician judgement with the highest risk indicating what subsequent colonoscopy intervals are appropriate. The examples provided below show that the result of the histopathology will not lengthen the surveillance intervals (in the case of patient with FAP or Lynch) and may actually shorten the surveillance intervals (in the case of patient with FDR or SDR with CRC).

Example 1 A patient at high risk of CRC with FAP or Lynch Syndrome has a number of polyps removed at a surveillance colonoscopy. Item 32236 is the appropriate item to bill. If the histology result returns 1-2 adenomas for patients at low to moderate risk then the next surveillance colonoscopy is recommended in 5 years. However, the patient’s familial condition means that a shorter interval (12 months) is recommended and payable.



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Example 2 A patient at moderate risk with a first or second degree family history of CRC has a number of polyps removed at a surveillance colonoscopy. Item 32235 is the appropriate item to bill based on the patient’s family history. If the histology result returns 3-4 adenomas then the next surveillance colonoscopy is recommended in 3 years instead of 5 years.

General guidance “To the caecum” requirements for colonoscopy examinations do not apply to patients who have no caecum following right hemi colectomy or have an obstructed right sided tumour. For these patients the examination should be to the anastomosis or tumour.

Surveillance colonoscopy should be planned based on high-quality endoscopy in a well-prepared colon using most recent and previous procedure information when histology is known. Many patients > 80 years have little to gain from surveillance of adenomas given a 10-20 year lead-time for the progression of adenoma to cancer. The finding of serrated lesions may alter management. Small, pale, distal hyperplastic polyps only do not require follow-up.

General practitioners should ensure colonoscopy referral practices align with applicable NHMRC guidelines and the Royal Australian College of General Practitioners’ guidelines for preventive activities in general practice (the red book). When referring patients for a colonoscopy, general practitioners should ensure a complete patient history of any previous colonoscopy with histopathology result is provided to the clinician performing the investigation. In addition, general practitioners are urged to recommend biennial faecal occult blood test (FOBT) screening to age-appropriate patients. The National Bowel Cancer Screening Program (the Program) will be fully rolled out in Australia by 2020 by which time all 50-74 year old Australian residents will be invited to participate in biennial FOBT screening through the Program.

Failed preparation of the colon (item 32231) Item 32231 is to be billed where a colonoscopy is unsatisfactory due to a failed preparation of the colon. Under these circumstances a second complete colonoscopy is payable. For example, a patient may be referred for a colonoscopy due to a positive FOBT test. The first colonoscopy examination has failed due to a poorly prepared colon but the caecum has been reached. Item 32231 is payable. The second colonoscopy examination is performed satisfactorily. Item 32222 is payable. If the caecum cannot be reached as this would cause risks to the patient, the most appropriate item to bill is sigmoidoscopy/colonoscopy item 32084.

It should be noted these services cannot be billed together for the same patient, same provider, on the same day during a single episode of sedation/anaesthesia.

Co-claiming restrictions Colonoscopy services in the item range 32222 to 32231 and 32232 to 32241 cannot be billed together for the same patient, same provider, on the same day during a single episode of sedation/anaesthesia. Colonoscopy services in this item range cannot be billed with Sigmoidoscopy services in the item range 32081 – 32084 for the same patient, same provider, on the same day during a single episode of sedation/anaesthesia. Colonoscopy item 32241 cannot be co-claimed with item 32212 (treatment of radiation proctitis with formalin) same patient, same practitioner, same day during a single episode of sedation/anaesthesia.

Patient eligibility for colonoscopy services The new structure of the colonoscopy items reflect the current evidence for the use of colonoscopy, including appropriate intervals between colonoscopies used in surveillance of patients who are at increased risk of developing colorectal cancer.



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Patients seeking Medicare rebates for colonoscopy services 32222, 32225 to 32231 and 32232 will need to ensure that they are eligible for the service prior to proceeding with the procedure. MBS payments for these services are aligned with approved guidelines and algorithms on the appropriate screening and interval surveillance for colonoscopy.

For further information visit the Cancer Council Australia website.

The Department of Human Services will be able to confirm whether a colonoscopy service has been claimed through Medicare by an individual patient and the date of the service. It will also be able to confirm any restriction on the frequency of the item claimed which would prevent a rebate from being paid if the service was provided again within the restricted period. Patients can seek clarification from the Department of Human Services by calling 132 011.

Patients can also access their own claiming history with a My Health Record or by establishing a Medicare online account through myGov or the Express Plus Medicare mobile app.

Further information about these services can be found on the Department of Human Services website.

In the second year of operation (from March 2019) practitioners providing colonoscopy services will be able to call Medicare on a dedicated call line to check the patient’s claiming history and ensure time restrictions do not apply to the proposed service. The patient’s Medicare card number will be required together with the range of item numbers to be checked. For example, the new item numbers for colonoscopy services are in the range 32222 to 32231 and 32232 to 32241. The operator will interrogate the patient’s claiming history and provide advice on any claim paid for a colonoscopy service within the range of items specified and the date of the service. For new patients who are unsure of past colonoscopy history this advice will assist the practitioner to determine the correct item to bill for the proposed service.

Alternatively, the Health Professionals Online System (HPOS) is a secure way for health professionals and administrators to check if a patient is eligible for a Medicare benefit for a specific item on the date of the proposed service. However, this system will only return advice that the service is payable or not payable on the proposed service date. It will not return full advice on when the last service was provided or when the patient will become eligible for the service again. For example, if the service has a 3 year restriction and the last service was provided in November 2017, the advice will be that the item is not payable if the proposed service date is before November 2020. It will not advise that the last service was provided in November 2017.

Further information about this service can be found on the Department of Human Services website.

All patients who require a colonoscopy will receive a service. However, MBS rebates will not be payable for services which do not meet the clinical indications and the item requirements for a colonoscopy or a repeat colonoscopy where the interval is specified in the item. Practitioners should ensure that their practice conforms to the approved clinical guidelines.



https://www.humanservices.gov.au/customer/services/express-plus-mobile-apps

https://www.humanservices.gov.au/customer/services/express-plus-mobile-apps

https://www.humanservices.gov.au/health-professionals/services/medicare/hpos

https://www.humanservices.gov.au/health-professionals/services/medicare/hpos

Documents

Increasing the MBS Rebate for Selected Procedures ... · Medicare Benefits Schedule Fact Sheet: Increasing the MBS Rebate for Selected Procedures Performed by General Practitioners