Australian Government

Department of Health and Ageing

Medicare Benefits Schedule Book

Operating from 01 October 2013

ISBN: 978-1-74241-825-4

Online ISBN: 978-1-74241-826-1

Publications approval number: D0960

Copyright Statements:

Paper-based publications

© Commonwealth of Australia 2012

This work is copyright. You may reproduce the whole or part of this work in unaltered form for your own personal use or, if you are part of an organisation, for internal use within your organisation, but only if you or your organisation do not use the reproduction for any commercial purpose and retain this copyright notice and all disclaimer notices as part of that reproduction. Apart from rights to use as permitted by the Copyright Act 1968 or allowed by this copyright notice, all other rights are reserved and you are not allowed to reproduce the whole or any part of this work in any way (electronic or otherwise) without first being given the specific written permission from the Commonwealth to do so. Requests and inquiries concerning reproduction and rights are to be sent to the Online, Services and External Relations Branch, Department of Health and Ageing, GPO Box 9848, Canberra ACT 2601, or via e-mail to copyright@health.gov.au.

Internet sites

© Commonwealth of Australia 2012

This work is copyright. You may download, display, print and reproduce the whole or part of this work in unaltered form for your own personal use or, if you are part of an organisation, for internal use within your organisation, but only if you or your organisation do not use the reproduction for any commercial purpose and retain this copyright notice and all disclaimer notices as part of that reproduction. Apart from rights to use as permitted by the Copyright Act 1968 or allowed by this copyright notice, all other rights are reserved and you are not allowed to reproduce the whole or any part of this work in any way (electronic or otherwise) without first being given the specific written permission from the Commonwealth to do so. Requests and inquiries concerning reproduction and rights are to be sent to the Online, Services and External Relations Branch, Department of Health and Ageing, GPO Box 9848, Canberra ACT 2601, or via e-mail to copyright@health.gov.au.

At the time of printing, the relevant legislation giving authority for the changes included in this edition of the book may still be subject to the approval of Executive Council and the usual Parliamentary scrutiny. This book is not a legal document, and, in cases of discrepancy, the legislation will be the source document for payment of Medicare benefits.

TABLE OF CONTENTS

19G.1.1. The Medicare Benefits Schedule - Introduction

G.1.2. Medicare - an outline19

G.1.3. Medicare benefits and billing practices19

G.2.1. Provider eligibility for Medicare20

G.2.2. Provider Numbers21

G.2.3. Locum tenens21

G.2.4. Overseas trained doctor21

G.2.5. Addresses of Medicare Australia, Schedule Interpretation and Changes to Provider Details22

G.3.1. Patient eligibility for Medicare22

G.3.2. Medicare cards22

G.3.3. Visitors to Australia and temporary residents22

G.3.4. Reciprocal Health Care Agreements22

G.4.1. General Practice23

G.5.1. Recognition as a Specialist or Consultant Physician24

G.5.2. Emergency Medicine25

G.6.1. Referral Of Patients To Specialists Or Consultant Physicians25

G.7.1. Billing procedures28

G.8.1. Provision for review of individual health professionals31

G.8.2. Medicare Participation Review Committee32

G.8.3. Referral of professional issues to regulatory and other bodies33

G.8.4. Comprehensive Management Framework for the MBS33

G.8.5. Medical Services Advisory Committee33

G.8.6. Pathology Services Table Committee33

G.8.7. Medicare Claims Review Panel33

G.9.1. Penalties and Liabilities33

G.10.1. Schedule fees and Medicare benefits34

G.10.2. Medicare safety nets34

G.11.1. Services not listed in the MBS35

G.11.2. Ministerial Determinations35

G.12.1. Professional services36

G.12.2. Services rendered on behalf of medical practitioners36

G.12.3. Mass immunisation37

G.13.1. Services which do not attract Medicare benefits37

G.14.1. Principles of interpretation of the MBS39

G.14.2. Services attracting benefits on an attendance basis39

G.14.3. Consultation and procedures rendered at the one attendance39

G.14.4. Aggregate items39

G.14.5. Residential aged care facility40

G.15.1. Practitioners should maintain adequate and contemporaneous records40

A.1.. Personal Attendance by Practitioner43

A.2.. Professional Attendances43

A.3.. Services not Attracting Medicare Benefits43

A.4.. Multiple Attendances on the Same Day43

A.5.. Attendances by General Practitioners (Items 3 to 51, 193, 195, 197, 199, 597, 599, 2497-2559 and 5000-5067)43

A.6.. Professional Attendances at an Institution (Items 4, 24, 37, 47, 58, 59, 60, 65, 5003, 5023, 5043, 5063, 5220, 5223, 5227 and 5228)45

A.7.. Attendances at a Hospital (Items 4, 24, 37, 47, 58, 59, 60, 65)45

A.8.. Residential Aged Care Facility Attendances (Items 20, 35, 43, 51, 92, 93, 95, 96, 5010, 5028, 5049, 5067, 5260, 5263, 5265, 5267)45

A.9.. Attendances at Hospitals, Residential Aged Care Facility and Institutions and Home Visits45

A.10.. After-Hours Attendances (Items 597, 598, 599, 600, 5000, 5003, 5010, 5020, 5023, 5028, 5040, 5043, 5049, 5060, 5063, 5067, 5220, 5223, 5228, 5260, 5263 and 5265)45

A.11.. Minor Attendance by a Consultant Physician (Items 119, 131)47

A.12.. Referred Patient Consultant Physician Treatment and Management Plan (Items 132 and 133)47

A.13.. Referred patient assessment, diagnosis and treatment and management plan for autism or any other pervasive developmental disorder (items 135 and 289)48

A.14.. Patient Assessment, Diagnosis and Treatment and Management Plan for a Child with Disability (Items 137 and 139)50

A.15.. Geriatrician Referred Patient Assessment and Management Plan (Items 141-147)52

A.16.. Prolonged Attendance in Treatment of a Critical Condition (Items 160 164)53

A.17.. Family Group Therapy (Items 170, 171, 172)53

A.18.. Acupuncture (Item 173, 193, 195, 197 and 199)53

A.19.. Consultant Psychiatrist - Initial consultations for NEW PATIENTS (Items 296 to 299 and 361) Referred Patient Assessment and Management Plan (Items 291, 293 and 359) and referral to Allied Mental Health Professionals54

A.20.. Psychiatric Attendances (Item 319)56

A.21.. Interview of Person other than a Patient by Consultant Psychiatrist (Items 348, 350, 352)57

A.22.. Consultant Occupational Physician Attendances (Items 385 to 388)57

A.23.. Contact Lenses (Items 10801-10809)58

A.24.. Refitting of Contact Lenses (Item 10816)58

A.25.. Health Assessments (Items 701, 703, 705, 707)58

A.26.. Health Assessment provided as a Healthy Kids Check60

A.27.. Health Assessment provided as a type 2 diabetes risk evaluation for people aged 40-49 years with a high risk of developing type 2 diabetes as determined by the Australian Type 2 Diabetes Risk Assessment Tool60

A.28.. Health Assessment provided for people aged 45-49 years who are at risk of developing chronic disease61

A.29.. Health Assessment provided for people aged 75 years and older62

A.30.. Health Assessment provided as a comprehensive medical assessment for residents of residential aged care facilities62

A.31.. Health Assessment provided for people with an intellectual disability62

A.32.. Health Assessment provided for refugees and other humanitarian entrants63

A.33.. Health Assessment for Aboriginal and Torres Strait Islander People (MBS Item 715)64

A.34.. A Health Assessment for an Aboriginal and Torres Strait Islander child (less than 15 years of age)65

A.35.. A health assessment for an Aboriginal and Torres Strait Islander adult (aged between 15 years and 54 years)66

A.36.. A health assessment for an Aboriginal and Torres Strait Islander older person (aged 55 years and over)66

A.37.. Chronic Disease Management Items (Items 721 to 732)67

A.38.. Medicare Dental Items For Patients With Chronic Conditions And Complex Care Needs - Services Provided By A Dental Practitioner On Referral From A GP [Items 85011-87777]70

A.39.. Multidisciplinary Case Conferences by Medical Practitioners (Other Than Specialist or Consultant Physician) - (Items 735 to 758)70

A.40.. Public Health Medicine - (Items 410 to 417)71

A.41.. Case Conferences by Consultant Physician - (Items 820 to 838)71

A.42.. Medication Management Reviews - (Items 900 and 903)73

A.43.. Taking a Cervical Smear from a Person who is Unscreened or Significantly Under-screened - (Items 2497 - 2509 and 2598 - 2616)76

A.44.. Completion of the Annual Diabetes Cycle of Care for Patients with Established Diabetes Mellitus - (Items 2517 - 2526 and 2620 - 2635)77

A.45.. Completion of the Asthma Cycle of Care - (Items 2546 - 2559 and 2664 - 2677)78

A.46.. GP Mental Health Treatment Items - (Items 2700 to 2717)79

A.47.. Provision of Focussed Psychological Strategies - (Items 2721 to 2727)84

A.48.. Pain and Palliative Medicine (Items 2801 to 3093)85

A.49.. Telepsychiatry - (Items 353 to 370)86

A.50.. Attendances by Medical Practitioners who are Emergency Physicians - (Items 501 to 536)87

A.51.. Prolonged Attendance by an Emergency Physician in Treatment of a Critical Condition - (Items 519 to 536)87

A.52.. Case Conferences by Consultant Psychiatrists - (Items 855 to 866)88

A.53.. Case Conference by Consultant Physicians in Geriatric/Rehabilitation Medicine - (Item 880)89

A.54.. Neurosurgery Specialist Referred Consultation - (Items 6007 to 6015)90

A.55.. Cancer Care Case Conference - (Items 871 and 872)91

A.56.. Non-directive Pregnancy Support Counselling Service - (Item 4001)91

A.57.. Telehealth Patient-end Support Services by Health Professionals92

A.58.. Telehealth Specialist Services94

O.1.. Benefits For Services By Participating Optometrists95

O.2.. Participation By Optometrists95

O.3.. Provider Numbers96

O.4.. Patient Eligibility97

Medicare Cards97

Visitors to Australia and temporary residents97

Reciprocal Health Care Agreements97

O.5.. Benefits For Services By Participating Optometrists97

O.6.. Schedule Fees and Medicare Benefits99

Extended Medicare Safety Net99

O.7.. Billing Procedures102

O.8.. Limitations on Benefits105

O.9.. Referrals (Read in connection with the relevant paragraphs at O6)106

O.10.. Provision for Review of the Schedule107

O.11.. Provision for Review of Practitioner Behaviour108

GROUP A1 - GENERAL PRACTITIONER ATTENDANCES TO WHICH NO OTHER ITEM APPLIES119

LEVEL A119

LEVEL B119

LEVEL C121

LEVEL D121

GROUP A2 - OTHER NON-REFERRED ATTENDANCES TO WHICH NO OTHER ITEM APPLIES123

SUBGROUP 1 - OTHER MEDICAL PRACTITIONER ATTENDANCES123

CONSULTATION AT CONSULTING ROOMS123

CONSULTATION AT A PLACE OTHER THAN CONSULTING ROOMS OR A RESIDENTIAL AGED CARE FACILITY123

CONSULTATION AT A RESIDENTIAL AGED CARE FACILITY123

GROUP A3 - SPECIALIST ATTENDANCES TO WHICH NO OTHER ITEM APPLIES125

GROUP A4 - CONSULTANT PHYSICIAN ATTENDANCES TO WHICH NO OTHER ITEM APPLIES126

GROUP A3 - SPECIALIST ATTENDANCES TO WHICH NO OTHER ITEM APPLIES127

GROUP A4 - CONSULTANT PHYSICIAN ATTENDANCES TO WHICH NO OTHER ITEM APPLIES128

GROUP A29 - EARLY INTERVENTION SERVICES FOR CHILDREN WITH AUTISM, PERVASIVE DEVELOPMENTAL DISORDER OR DISABILITY130

GROUP A28 - GERIATRIC MEDICINE132

GROUP A5 - PROLONGED ATTENDANCES TO WHICH NO OTHER ITEM APPLIES136

PROLONGED PROFESSIONAL ATTENDANCE136

GROUP A6 - GROUP THERAPY137

GROUP A7 - ACUPUNCTURE138

LEVEL A138

LEVEL B138

LEVEL C138

LEVEL D139

GROUP A8 - CONSULTANT PSYCHIATRIST ATTENDANCES TO WHICH NO OTHER ITEM APPLIES140

GROUP A12 - CONSULTANT OCCUPATIONAL PHYSICIAN ATTENDANCES TO WHICH NO OTHER ITEM APPLIES147

GROUP A13 - PUBLIC HEALTH PHYSICIAN ATTENDANCES TO WHICH NO OTHER ITEM APPLIES149

PUBLIC HEALTH PHYSICIAN ATTENDANCES - AT CONSULTING ROOMS149

PUBLIC HEALTH PHYSICIAN ATTENDANCES - OTHER THAN AT CONSULTING ROOMS149

GROUP A21 - MEDICAL PRACTITIONER (EMERGENCY PHYSICIAN) ATTENDANCES TO WHICH NO OTHER ITEM APPLIES151

SUBGROUP 1 - CONSULTATIONS151

SUBGROUP 2 - PROLONGED PROFESSIONAL ATTENDANCES TO WHICH NO OTHER GROUP APPLIES152

GROUP A11 - URGENT ATTENDANCE AFTER HOURS153

SUBGROUP 1 - URGENT ATTENDANCE - AFTER HOURS153

SUBGROUP 2 - URGENT ATTENDANCE UNSOCIABLE AFTER HOURS153

GROUP A14 - HEALTH ASSESSMENTS154

HEALTH ASSESSMENTS154

ABORIGINAL AND TORRES STRAIT ISLANDER PEOPLES HEALTH ASSESSMENT155

GROUP A15 - GP MANAGEMENT PLANS, TEAM CARE ARRANGEMENTS, MULTIDISCIPLINARY CARE PLANS156

SUBGROUP 1 - GP MANAGEMENT PLANS, TEAM CARE ARRANGEMENTS AND MULTIDISCIPLINARY CARE PLANS156

SUBGROUP 2 - CASE CONFERENCES158

GROUP A17 - DOMICILIARY AND RESIDENTIAL MANAGEMENT REVIEWS162

GROUP A30 - MEDICAL PRACTITIONER (INCLUDING A GENERAL PRACTITIONER, SPECIALIST OR CONSULTANT PHYSICIAN) TELEHEALTH ATTENDANCES163

SUBGROUP 1 - TELEHEALTH ATTENDANCE AT CONSULTING ROOMS, HOME VISITS OR OTHER INSTITUTIONS163

SUBGROUP 2 - TELEHEALTH ATTENDANCE AT A RESIDENTIAL AGED CARE FACILITY163

SUBGROUP 1 - TELEHEALTH ATTENDANCE AT CONSULTING ROOMS, HOME VISITS OR OTHER INSTITUTIONS164

SUBGROUP 2 - TELEHEALTH ATTENDANCE AT A RESIDENTIAL AGED CARE FACILITY164

SUBGROUP 1 - TELEHEALTH ATTENDANCE AT CONSULTING ROOMS, HOME VISITS OR OTHER INSTITUTIONS165

SUBGROUP 2 - TELEHEALTH ATTENDANCE AT A RESIDENTIAL AGED CARE FACILITY165

SUBGROUP 1 - TELEHEALTH ATTENDANCE AT CONSULTING ROOMS, HOME VISITS OR OTHER INSTITUTIONS166

SUBGROUP 2 - TELEHEALTH ATTENDANCE AT A RESIDENTIAL AGED CARE FACILITY166

GROUP A18 - GENERAL PRACTITIONER ATTENDANCE ASSOCIATED WITH PIP INCENTIVE PAYMENTS167

SUBGROUP 1 - TAKING OF A CERVICAL SMEAR FROM AN UNSCREENED OR SIGNIFICANTLY UNDERSCREENED PERSON167

LEVEL A167

LEVEL B167

LEVEL C167

LEVEL D168

SUBGROUP 2 - COMPLETION OF A CYCLE OF CARE FOR PATIENTS WITH ESTABLISHED DIABETES MELLITUS169

LEVEL B169

LEVEL C169

LEVEL D170

SUBGROUP 3 - COMPLETION OF THE ASTHMA CYCLE OF CARE170

LEVEL B170

LEVEL C171

LEVEL D171

GROUP A19 - OTHER NON-REFERRED ATTENDANCES ASSOCIATED WITH PIP INCENTIVE PAYMENTS TO WHICH NO OTHER ITEM APPLIES172

SUBGROUP 1 - TAKING OF A CERVICAL SMEAR FROM AN UNSCREENED OR SIGNIFICANTLY UNDERSCREENED PERSON172

SUBGROUP 2 - COMPLETION OF AN ANNUAL CYCLE OF CARE FOR PATIENTS WITH ESTABLISHED DIABETES MELLITUS173

SUBGROUP 3 - COMPLETION OF THE ASTHMA CYCLE OF CARE174

GROUP A20 - GP MENTAL HEALTH TREATMENT176

SUBGROUP 1 - GP MENTAL HEALTH TREATMENT PLANS176

SUBGROUP 2 - FOCUSSED PSYCHOLOGICAL STRATEGIES177

GROUP A24 - PAIN AND PALLIATIVE MEDICINE179

SUBGROUP 1 - PAIN MEDICINE ATTENDANCES179

SUBGROUP 2 - PAIN MEDICINE CASE CONFERENCES180

SUBGROUP 3 - PALLIATIVE MEDICINE ATTENDANCES182

SUBGROUP 4 - PALLIATIVE MEDICINE CASE CONFERENCES183

GROUP A27 - PREGNANCY SUPPORT COUNSELLING185

GROUP A22 - GENERAL PRACTITIONER AFTER-HOURS ATTENDANCES TO WHICH NO OTHER ITEM APPLIES186

LEVEL A186

LEVEL B186

LEVEL C187

LEVEL D188

GROUP A23 - OTHER NON-REFERRED AFTER-HOURS ATTENDANCES TO WHICH NO OTHER ITEM APPLIES189

CONSULTATION AT CONSULTING ROOMS189

CONSULTATION AT A PLACE OTHER THAN CONSULTING ROOMS, HOSPITAL OR A RESIDENTIAL AGED CARE FACILITY189

CONSULTATION AT A RESIDENTIAL AGED CARE FACILITY190

GROUP A26 - NEUROSURGERY ATTENDANCES TO WHICH NO OTHER ITEM APPLIES191

GROUP A9 - CONTACT LENSES - ATTENDANCES193

INDEX195

D.1.1. Electroencephalography (EEG), Prolonged Recording - (item 11003)199

D.1.2. Electroencephalography (EEG), Ambulatory or Video - (Items 11004 and 11005)199

D.1.3. Neuromuscular Diagnosis - (Item 11012)199

D.1.4. Investigation of Central Nervous System Evoked Responses - (Items 11024 and 11027)199

D.1.5. Electroretinography - (Items 11204, 11205, 11210 and 11211)199

D.1.6. Computerised Perimetry Printed Results - (Items 11221 to 11225)199

D.1.7. Computerised Perimetry - (Items 11222 and 11225)199

D.1.8. Orbital Contents - (Items 11240, 11241, 11242 and 11243)199

D.1.9. Brain Stem Evoked Response Audiometry - (Item 11300)200

D.1.10. Electrocochleography - (Item 11304)200

D.1.11. Non-determinate Audiometry - (Item 11306)200

D.1.12. Audiology Services - (Items 11309 to 11321)200

D.1.13. Oto-Acoustic Emission Audiometry - (Item 11332)200

D.1.14. Respiratory Function Tests - (Item 11503)200

D.1.15. Capsule Endoscopy - (Item 11820 and 11823)201

D.1.16. Epicutaneous Patch Testing - (Items 12012, 12015 and 12018)201

D.1.17. Administration of Thyrotropin Alfa-rch for the Detection of Recurrent Well-differentiated Thyroid Cancer - (Item 12201)201

D.1.18. Investigations for Sleep Apnoea - (Items 12203, 12207, 12210, 12213, 12215, 12217 and 12250)201

D.1.19. Bone Densitometry - (Items 12306 to 12323)202

GROUP D1 - MISCELLANEOUS DIAGNOSTIC PROCEDURES AND INVESTIGATIONS205

SUBGROUP 1 - NEUROLOGY205

SUBGROUP 2 - OPHTHALMOLOGY206

SUBGROUP 3 - OTOLARYNGOLOGY207

SUBGROUP 4 - RESPIRATORY208

SUBGROUP 5 - VASCULAR209

SUBGROUP 6 - CARDIOVASCULAR210

SUBGROUP 7 - GASTROENTEROLOGY & COLORECTAL211

SUBGROUP 8 - GENITO/URINARY PHYSIOLOGICAL INVESTIGATIONS212

SUBGROUP 9 - ALLERGY TESTING213

SUBGROUP 10 - OTHER DIAGNOSTIC PROCEDURES AND INVESTIGATIONS213

GROUP D2 - NUCLEAR MEDICINE (NON-IMAGING)219

INDEX220

T.1.1. Hyperbaric Oxygen Therapy - (Items 13015, 13020, 13025 and 13030)224

T.1.2. Haemodialysis - (Items 13100 and 13103)224

T.1.3. Consultant Physician Supervision of Home Dialysis - (Item 13104)224

T.1.4. Assisted Reproductive Technology ART Services - (Items 13200 to 13221)224

T.1.5. Intracytoplasmic Sperm Injection - (Item 13251)225

T.1.6. Peripherally Inserted Central Catheters225

T.1.7. Administration of Blood or Bone Marrow already Collected (Item 13706)226

T.1.8. Collection of Blood - (Item 13709)226

T.1.9. Intensive Care Units - (Items 13870 to 13888)226

T.1.10. Procedures Associated with Intensive Care - (Items 13818, 13842, 13847, 13848 and 13857)227

T.1.11. Management and Procedures in Intensive Care Unit - (Items 13870, 13873, 13876)227

T.1.12. Cytotoxic Chemotherapy Administration - (Item 13915)228

T.1.13. Implanted Pump or Reservoir/Drug Delivery Device - (Items 13939 and 13942)228

T.1.14. PUVA or UVB Therapy - (Items 14050 and 14053)228

T.1.15. Laser Photocoagulation - (Items 14106 to 14124)228

T.1.16. Laser Photocoagulation (Item 14124)228

T.1.17. Facial Injections of Poly-L-Lactic Acid - (Items 14201 and 14202)228

T.1.18. Hormone and Living Tissue Implantation - (Items 14203 and 14206)228

T.1.19. Implantable Drug Delivery System for the Treatment of Severe Chronic Spasticity - (Items 14227 to 14242)229

T.1.20. Immunomodulating Agent - (Item 14245)229

T.1.21. Therapeutic procedures may be provided by a specialist trainee (Items 13015 to 51318)229

T.1.22. Telehealth Specialist Services229

T.2.1. Radiation Oncology - General231

T.2.2. Brachytherapy of the Prostate - (Item 15338)231

T.2.3. Planning Services - (Items 15500 to 15562 and 15850)231

T.2.4. Treatment Verification - (Items 15700 to 15705, 15710 and 15800)232

T.3.1. Therapeutic Dose of Yttrium 90 - (Item 16003)232

T.4.1. Antenatal Service Provided by a Nurse, Midwife or an Aboriginal and Torres Strait Islander health practitioner - (Item 16400)232

T.4.2. Items for Initial and Subsequent Obstetric Attendances (Items 16401 and 16404)233

T.4.3. Antenatal Care - (Item 16500)233

T.4.4. External Cephalic Version for Breech Presentation - (Item 16501)234

T.4.5. Labour and Delivery - (Items 16515, 16518, 16519 and 16525)234

T.4.6. Caesarean Section - (Item 16520)234

T.4.7. Complicated Confinement - (Item 16522)234

T.4.8. Labour and Delivery Where Care is Transferred by a Participating Midwife - (Items 16527 to 16528)235

T.4.9. Items for Planning and Management of a Pregnancy (Item 16590)235

T.4.10. Post-Partum Care - (Items 16564 to 16573)235

T.4.11. Interventional Techniques - (Items 16600 to 16636)235

T.4.12. Telehealth Specialist Services236

T.6.1. Pre-anaesthesia Consultations by an Anaesthetist - (Items 17610 to 17625)238

T.6.2. Referred Anaesthesia Consultations - (Items 17640 to 17655)239

T.6.3. Anaesthetist Consultations - Other - (Items 17680, 17690)240

T.6.4. Telehealth Specialist Services240

T.7.1. Regional or Field Nerve Blocks - General242

T.7.2. Maintenance of Regional or Field Nerve Block - (Items 18222 and 18225)242

T.7.3. Intrathecal or Epidural Injection - (Item 18232)242

T.7.4. Intrathecal or Epidural Infusion - (Items 18226 and 18227)242

T.7.5. Regional or Field Nerve Blocks - (Items 18234 to 18298)242

T.8.1. Surgical Operations242

T.8.2. Multiple Operation Rule243

T.8.3. Procedure Performed with Local Infiltration or Digital Block244

T.8.4. Aftercare (Post-operative Treatment)244

T.8.5. Abandoned surgery - (Item 30001)246

T.8.6. Repair of Wound - (Items 30023 to 30049)246

T.8.7. Biopsy for Diagnostic Purposes - (Items 30071 to 30096)246

T.8.8. Lipectomy - (Items 30165 to 30177)246

T.8.9. Treatment of Keratoses, Warts etc (Items 30185, 30186, 30187, 30189, 30192 and 36815)247

T.8.10. Cryotherapy and Serial Curettage Excision - (Items 30196 to 30203)247

T.8.11. Telangiectases or Starburst Vessels - (Items 30213 and 30214)247

T.8.12. Sentinel Node Biopsy for Breast Cancer - (Items 30299 to 30303)248

T.8.13. Dissection of Axillary Lymph Nodes - (Items 30335 and 30336)248

T.8.14. Laparotomy and Other Procedures on the Abdominal Viscera - (Item 30375)248

T.8.15. Diagnostic Laparoscopy - (Item 30390)248

T.8.16. Major Abdominal Incision - (Item 30396)248

T.8.17. Gastrointestinal Endoscopic Procedures - (Items 30473 to 30481, 30484 to 30487, 30490 to 30494, 30680 to 32023, 32084 to 32095, 32103, 32104 and 32106)248

T.8.18. Gastrectomy, Sub-total Radical - (Item 30523)249

T.8.19. Anti reflux Operations - (Items 30527 to 30533, 31464 and 31466)249

T.8.20. Radiofrequency ablation of mucosal metaplasia for the treatment of Barrett's Oesophagus (Item 30687)249

T.8.21. Endoscopic or Endobronchial Ultrasound +/- Fine Needle Aspiration - (Items 30688 - 30710)249

T.8.22. Removal of Skin Lesions - (Items 31200 to 31355)249

T.8.23. Removal of Skin Lesion From Face - (Items 31235 to 31245, 31265 to 31278, 31310 to 31320)250

T.8.24. Dissection of Lymph Nodes of Neck - (Items 31423 to 31438)250

T.8.25. Excision of Breast Lesions, Abnormalities or Tumours - Malignant or Benign - (Items 31500 to 31515)251

T.8.26. Subcutaneous Mastectomy - (Items 31521, 31524 and 31527)251

T.8.27. Fine Needle Aspiration of Breast Lesion - (Item 31533)251

T.8.28. Diagnostic Biopsy of Breast using Advanced Breast Biopsy Instrumentation - (Items 31539 and 31545)251

T.8.29. Preoperative Localisation of Breast Lesion Prior to the Use of Advanced Breast Biopsy Instrumentation - (Item 31542)251

T.8.30. Bariatric Procedures - (Items 31569 to 31581)251

T.8.31. Reversal of a Bariatric Procedure - (Item 31584)251

T.8.32. Per Anal Excision of Rectal Tumour using Rectoscopy - (Items 32103, 32104 and 32106)252

T.8.33. Varicose veins - (Items 32500 to 32517)252

T.8.34. Endovenous Laser Therapy (Items 32520 and 32522) and Radiofrequency Ablation (Items 32523 and 32526)252

T.8.35. Uterine Artery Embolisation - (Item 35410)252

T.8.36. Endovascular Coiling of Intracranial Aneurysms - (Item 35412)253

T.8.37. Arterial and Venous Patches - (Items 33545 to 33551and 34815)253

T.8.38. Carotid Percutaneous Transluminal Angioplasty with Stenting - (Item 35307)253

T.8.39. Peripheral Arterial or Venous Catheterisation - (Item 35317)253

T.8.40. Peripheral Arterial or Venous Embolisation - (Item 35321)253

T.8.41. Selective Internal Radiation Therapy (SIRT) using SIR-Spheres - (Items 35404, 35406 and 35408)253

T.8.42. Percutaneous Transluminal Coronary Angioplasty - (Items 38309, 38312, 38315 and 38318)253

T.8.43. Colposcopic Examination - (Item 35614)253

T.8.44. Hysteroscopy - (Item 35626)254

T.8.45. Curettage of Uterus under GA or Major Nerve Block - (Items 35639 and 35640)254

T.8.46. Neoplastic Changes of the Cervix - (Items 35644-35648)254

T.8.47. Sterilisation of Minors - Legal Requirements - (Items 35657, 35687, 35688, 35691, 37622 and 37623)254

T.8.48. Debulking of Uterus - (Item 35658)254

T.8.49. Nephrectomy - (Items 36526 and 36527)254

T.8.50. Sacral Nerve Stimulation - (Items 36658, 36660, and 36662)254

T.8.51. Sacral Nerve Stimulation (items 36663-36668)254

T.8.52. Ureteroscopy - (Item 36803)255

T.8.53. Selective Coronary Angiography - (Items 38215 to 38246)255

T.8.54. Transurethral Needle Ablation (TUNA) of the Prostate - (Items 37201 and 37202)255

T.8.55. Gold Fiducial Markers into the Prostate - (item 37217)255

T.8.56. Brachytherapy of the Prostate - (Item 37220)255

T.8.57. High Dose Rate Brachytherapy - (Item 37227)256

T.8.58. Radical or Debulking Operation for Ovarian Tumour - (Item 35720)256

T.8.59. Transcutaneous Sperm Retrieval - (Item 37605)256

T.8.60. Surgical Sperm Retrieval, by Open Approach - (Item 37606)256

T.8.61. Cardiac Pacemaker Insertion - (Items 38209, 38212, 38350, 38353 and 38356)256

T.8.62. Implantable ECG Loop Recorder - (Item 38285)256

T.8.63. Transluminal Insertion of Stent or Stents - (Item 38306)256

T.8.64. Permanent Cardiac Synchronisation Device (Items 38365, 38368 and 38654)257

T.8.65. Intravascular Extraction of Permanent Pacing Leads - (Item 38358)257

T.8.66. Cardiac Resynchronisation Therapy - (Item 38371)257

T.8.67. Implantable Cardioverter Defibrillator - (Items 38384 and 38387)257

T.8.68. Cardiac and Thoracic Surgical Items - (Items 38470 to 38766)257

T.8.69. Coronary Artery Bypass - (Items 38497 to 38504)257

T.8.70. Re-operation via Median Sternotomy - (Item 38640)257

T.8.71. Skull Base Surgery - (Items 39640 to 39662)257

T.8.72. Intradiscal Injection of Chymopapain - (Item 40336)258

T.8.73. Removal of Ventilating Tube from Ear - (Item 41500)258

T.8.74. Meatoplasty - (Item 41515)258

T.8.75. Reconstruction of Auditory Canal - (Item 41524)258

T.8.76. Removal of Nasal Polyp or Polypi - (Items 41662, 41665 and 41668)258

T.8.77. Larynx, Direct Examination - (Item 41846)258

T.8.78. Microlaryngoscopy - (Item 41858)258

T.8.79. Imbedded Foreign Body - (Item 42644)258

T.8.80. Corneal Incisions - (Item 42672)258

T.8.81. Cataract surgery (Items 42698 and 42701)258

T.8.82. Posterior Juxtascleral Depot injection - (Item 42741)258

T.8.83. Cyclodestructive Procedures - (Items 42770)258

T.8.84. Insertion of drainage device for glaucoma (Item 42752)259

T.8.85. Laser Trabeculoplasty - (Items 42782 and 42783)259

T.8.86. Laser Iridotomy - (Items 42785 and 42786)259

T.8.87. Laser Capsulotomy - (Items 42788 and 42789)259

T.8.88. Laser Vitreolysis or Corticolysis of Lens Material or Fibrinolysis - (Items 42791 and 42792)259

T.8.89. Division of Suture by Laser - (Item 42794)260

T.8.90. Laser Coagulation of Corneal or Scleral Blood Vessels - (Item 42797)260

T.8.91. Ophthalmic Sutures - (Item 42845)260

T.8.92. Full face Chemical Peel - (Items 45019 and 45020)260

T.8.93. Abrasive Therapy/Resurfacing - (Items 45021 to 45026)260

T.8.94. Foreign Implant - (Item 45051)260

T.8.95. Escharotomy - (Item 45054)261

T.8.96. Local Skin Flap - Definition261

T.8.97. Free Grafting to Burns - (Items 45406 to 45418)261

T.8.98. Revision of Scar - (Items 45506 to 45518)261

T.8.99. Augmentation Mammaplasty - (Items 45524, 45527 and 45528)261

T.8.100. Breast Reconstruction, Myocutaneous Flap - (Item 45530)262

T.8.101. Breast Prosthesis, Removal and Replacement of - (Items 45552 to 45555)262

T.8.102. Breast Ptosis - (Items 45556 to 45559)262

T.8.103. Nipple and/or Areola Reconstruction - (Items 45545 and 45546)262

T.8.104. Liposuction - (Items 45584, 45585 and 45586)263

T.8.105. Meloplasty for Correction of Facial Asymmetry - (Items 45587 and 45588)263

T.8.106. Reduction of Eyelids - (Items 45617 and 45620)263

T.8.107. Rhinoplasty - (Items 45638, 45639)263

T.8.108. Contour Restoration - (Item 45647)264

T.8.109. Vermilionectomy - (Item 45669)264

T.8.110. Osteotomy of Jaw - (Items 45720 to 45752)264

T.8.111. Genioplasty - (Item 45761)264

T.8.112. Tumour, Cyst, Ulcer or Scar - (Items 45801 to 45813)264

T.8.113. Fracture of Mandible or Maxilla - (Items 45975 to 45996)264

T.8.114. Reduction of Dislocation or Fracture264

T.8.115. Removal of Multiple Exostoses (Items 47933 and 47936)264

T.8.116. Lumbar Discectomy - (Item 48636)265

T.8.117. Discectomy in Relation to Anterior Interbody Spinal Fusion - (Items 48660 to 48675)265

T.8.118. Internal Fixation - (Items 48678 to 48690)265

T.8.119. Wrist Surgery - (Items 49200 to 49227)265

T.8.120. Diagnostic Arthroscopy and Arthroscopic Surgery of the Knee (Items 49557 and 49563)265

T.8.121. Paediatric Patients - (Items 50450 to 50658)265

T.8.122. Treatment of Fractures in Paediatric Patients - (Items 50500 to 50588)265

T.8.123. Non-resectable Hepatocellular Carcinoma Destruction of by Open or Laparoscopic Radiofrequency Ablation - (Item 50952)265

T.8.124. Paracentesis of anterior chamber or vitreous cavity and/or intravitreal injection - (Items 42738 to 42740)265

T.9.1. Assistance at Operations - (Items 51300 to 51318)266

T.9.2. Benefits Payable under Item 51300266

T.9.3. Benefits Payable Under Item 51303266

T.9.4. Benefits Payable Under Item 51309266

T.9.5. Assistance at Cataract and Intraocular Lens Surgery - (Item 51318)267

T.10.1. Relative Value Guide For Anaesthetics - (Group T10)267

T.10.2. Eligible Services268

T.10.3. RVG Unit Values268

T.10.4. Deriving the Schedule Fee under the RVG270

T.10.5. Minimum Requirements for Claiming Benefits under Items in the RVG (including sedation)271

T.10.6. Account Requirements271

T.10.7. General Information271

T.10.8. Additional Services Performed in Connection with Anaesthesia - Subgroup 19272

T.10.9. Assistance in the Administration of Anaesthesia272

T.10.10. Perfusion Services - (Items 22055 to 22075)273

T.10.11. Anaesthesia as a Therapeutic Procedure - (Item 21965)273

T.10.12. Discontinued Procedure - (Item 21990)273

T.10.13. Anaesthesia in Connection with a Procedure not Identified as Attracting a Medicare Benefit for Anaesthesia - (Item 21997)273

T.10.14. Anaesthesia in Connection with a Dental Service - (Items 22900 and 22905)274

T.10.15. Anaesthesia in Connection with Cleft Lip and Cleft Palate Repair - (Items 20102 and 20172)274

T.10.16. Anaesthesia in Connection with an Oral and MaxillofaciaI Service - (Category 4 of the Medicare Benefits Schedule)274

T.10.17. Intra-operative Blocks for Post Operative Pain - (Items 22031 to 22050)274

T.10.18. Anaesthesia in Connection with Extensive Surgery on Facial Bones - (Item 20192)274

T.10.19. Intrathecal or Epidural Injection for Control of Post-operative Pain - Initial - (Item 22031)274

T.10.20. Intrathecal or Epidural Injection for Control of Post-operative Pain - Subsequent - (Item 22036)274

T.10.21. Regional or Field Nerve Blocks for Post-operative Pain - (Items 22040 - 22050)274

T.10.22. Anaesthesia for Radical Procedures on the Chest Wall - (Item 20474)274

T.10.23. Anaesthesia for Extensive Spine or Spinal Cord Procedures - (Item 20670)275

T.10.24. Anaesthesia for Femoral Artery Embolectomy - (Item 21274)275

T.10.25. Anaesthesia for Cardiac Catheterisation - (Item 21941)275

T.10.26. Anaesthesia for 2 Dimensional Real Time Transoesophageal Echocardiography - (Item 21936)275

T.10.27. Anaesthesia for Services on the Upper and Lower Abdomen - (Subgroups 6 and7)275

T.10.28. Anaesthesia for Microvascular Free Tissue Flap Surgery - (Items 20230, 20355, 20475, 20704, 20804, 20905, 21155, 21275, 21455, 21535, 21685, 21785 and 21865)275

T.10.29. Anaesthesia for Endoscopic Ureteric Surgery - Including Laser Procedure - (Item 20911)275

T.11.1. Botulinum Toxin - (Items 18350 to 18373)275

GROUP T1 - MISCELLANEOUS THERAPEUTIC PROCEDURES278

SUBGROUP 1 - HYPERBARIC OXYGEN THERAPY278

SUBGROUP 2 - DIALYSIS278

SUBGROUP 3 - ASSISTED REPRODUCTIVE SERVICES279

SUBGROUP 4 - PAEDIATRIC & NEONATAL280

SUBGROUP 5 - CARDIOVASCULAR281

SUBGROUP 6 - GASTROENTEROLOGY281

SUBGROUP 8 - HAEMATOLOGY281

SUBGROUP 9 - PROCEDURES ASSOCIATED WITH INTENSIVE CARE AND CARDIOPULMONARY SUPPORT282

SUBGROUP 10 - MANAGEMENT AND PROCEDURES UNDERTAKEN IN AN INTENSIVE CARE UNIT282

SUBGROUP 11 - CHEMOTHERAPEUTIC PROCEDURES283

SUBGROUP 12 - DERMATOLOGY284

SUBGROUP 13 - OTHER THERAPEUTIC PROCEDURES285

GROUP T2 - RADIATION ONCOLOGY287

SUBGROUP 1 - SUPERFICIAL287

SUBGROUP 2 - ORTHOVOLTAGE287

SUBGROUP 3 - MEGAVOLTAGE287

SUBGROUP 4 - BRACHYTHERAPY289

SUBGROUP 5 - COMPUTERISED PLANNING291

SUBGROUP 6 - STEREOTACTIC RADIOSURGERY293

SUBGROUP 7 - RADIATION ONCOLOGY TREATMENT VERIFICATION293

SUBGROUP 8 - BRACHYTHERAPY PLANNING AND VERIFICATION293

GROUP T3 - THERAPEUTIC NUCLEAR MEDICINE294

GROUP T4 - OBSTETRICS295

GROUP T6 - ANAESTHETICS300

SUBGROUP 1 - ANAESTHESIA CONSULTATIONS300

GROUP T7 - REGIONAL OR FIELD NERVE BLOCKS302

GROUP T11 - BOTULINUM TOXIN INJECTIONS305

GROUP T10 - RELATIVE VALUE GUIDE FOR ANAESTHESIA - Medicare Benefits are only payable for anaesthesia performed in association with an eligible service307

SUBGROUP 1 - HEAD307

SUBGROUP 2 - NECK308

SUBGROUP 3 - THORAX309

SUBGROUP 4 - INTRATHORACIC310

SUBGROUP 5 - SPINE AND SPINAL CORD310

SUBGROUP 6 - UPPER ABDOMEN311

SUBGROUP 7 - LOWER ABDOMEN312

SUBGROUP 8 - PERINEUM314

SUBGROUP 9 - PELVIS (EXCEPT HIP)315

SUBGROUP 10 - UPPER LEG (EXCEPT KNEE)316

SUBGROUP 11 - KNEE AND POPLITEAL AREA317

SUBGROUP 12 - LOWER LEG (BELOW KNEE)318

SUBGROUP 13 - SHOULDER AND AXILLA319

SUBGROUP 14 - UPPER ARM AND ELBOW320

SUBGROUP 15 - FOREARM WRIST AND HAND321

SUBGROUP 16 - ANAESTHESIA FOR BURNS322

SUBGROUP 17 - ANAESTHESIA FOR RADIOLOGICAL OR OTHER DIAGNOSTIC OR THERAPEUTIC PROCEDURES322

SUBGROUP 18 - MISCELLANEOUS324

SUBGROUP 19 - THERAPEUTIC AND DIAGNOSTIC SERVICES324

SUBGROUP 20 - ADMINISTRATION OF ANAESTHESIA IN CONNECTION WITH A DENTAL SERVICE326

SUBGROUP 21 - ANAESTHESIA/PERFUSION TIME UNITS326

SUBGROUP 22 - ANAESTHESIA/PERFUSION MODIFYING UNITS - PHYSICAL STATUS333

SUBGROUP 23 - ANAESTHESIA/PERFUSION MODIFYING UNITS - OTHER334

SUBGROUP 24 - ANAESTHESIA AFTER HOURS EMERGENCY MODIFIER334

SUBGROUP 25 - PERFUSION AFTER HOURS EMERGENCY MODIFIER334

SUBGROUP 26 - ASSISTANCE AT ANAESTHESIA334

GROUP T8 - SURGICAL OPERATIONS336

SUBGROUP 1 - GENERAL336

BARIATRIC364

SUBGROUP 2 - COLORECTAL365

SUBGROUP 3 - VASCULAR371

VARICOSE VEINS371

BYPASS OR ANASTOMOSIS FOR OCCLUSIVE ARTERIAL DISEASE372

BYPASS, REPLACEMENT, LIGATION OF ANEURYSMS373

ENDARTERECTOMY AND ARTERIAL PATCH375

EMBOLECTOMY, THROMBECTOMY AND VASCULAR TRAUMA376

LIGATION, EXCISION, ELECTIVE REPAIR, DECOMPRESSION OF VESSELS377

OPERATIONS FOR VASCULAR ACCESS379

COMPLEX VENOUS OPERATIONS379

SYMPATHECTOMY380

DEBRIDEMENT AND AMPUTATIONS FOR VASCULAR DISEASE380

MISCELLANEOUS VASCULAR PROCEDURES381

ENDOVASCULAR INTERVENTIONAL PROCEDURES381

INTERVENTIONAL RADIOLOGY PROCEDURES382

SUBGROUP 4 - GYNAECOLOGICAL383

SUBGROUP 5 - UROLOGICAL390

GENERAL390

OPERATIONS ON BLADDER393

OPERATIONS ON PROSTATE396

OPERATIONS ON URETHRA, PENIS OR SCROTUM398

OPERATIONS ON TESTES, VASA OR SEMINAL VESICLES400

PAEDIATRIC GENITURINARY SURGERY401

SUBGROUP 6 - CARDIO-THORACIC402

CARDIOLOGY PROCEDURES402

CATHETER BASED ARRHYTHMIA ABLATION404

ENDOVASCULAR INTERVENTIONAL PROCEDURES404

MISCELLANEOUS CARDIAC PROCEDURES405

THORACIC SURGERY407

CARDIAC SURGERY PROCEDURES408

VALVULAR PROCEDURES408

SURGERY FOR ISCHAEMIC HEART DISEASE409

ARRHYTHMIA SURGERY410

PROCEDURES ON THORACIC AORTA410

TECHNIQUES FOR PRESERVATION OF ARRESTED HEART411

CIRCULATORY SUPPORT PROCEDURES411

RE-OPERATION412

MISCELLANEOUS CARDIOTHORACIC SURGICAL PROCEDURES412

CARDIAC TUMOURS412

CONGENITAL CARDIAC SURGERY413

MISCELLANEOUS PROCEDURES ON THE CHEST414

SUBGROUP 7 - NEUROSURGICAL415

GENERAL415

PAIN RELIEF415

PERIPHERAL NERVES416

CRANIAL NERVES417

CRANIO-CEREBRAL INJURIES417

SKULL BASE SURGERY418

INTRA-CRANIAL NEOPLASMS418

CEREBROVASCULAR DISEASE419

INFECTION419

CEREBROSPINAL FLUID CIRCULATION DISORDERS419

CONGENITAL DISORDERS420

SPINAL DISORDERS420

SKULL RECONSTRUCTION421

EPILEPSY421

STEREOTACTIC PROCEDURES422

MISCELLANEOUS423

SUBGROUP 8 - EAR, NOSE AND THROAT423

SUBGROUP 9 - OPHTHALMOLOGY431

SUBGROUP 10 - OPERATIONS FOR OSTEOMYELITIS439

ACUTE439

CHRONIC439

SUBGROUP 11 - PAEDIATRIC439

SURGERY IN NEONATE OR YOUNG CHILD439

THORACIC SURGERY441

ABDOMINAL SURGERY441

MISCELLANEOUS SURGERY443

SUBGROUP 12 - AMPUTATIONS443

SUBGROUP 13 - PLASTIC AND RECONSTRUCTIVE SURGERY444

GENERAL444

SKIN FLAP SURGERY445

FREE GRAFTS446

OTHER GRAFTS AND MISCELLANEOUS PROCEDURES449

ORAL AND MAXILLOFACIAL SURGERY457

SUBGROUP 14 - HAND SURGERY461

SUBGROUP 15 - ORTHOPAEDIC466

TREATMENT OF DISLOCATIONS466

TREATMENT OF FRACTURES467

GENERAL475

BONE GRAFTS477

OSTEOTOMY AND OSTEECTOMY477

EPIPHYSEODESIS478

SPINE478

SHOULDER480

ELBOW482

WRIST482

HIP483

KNEE484

ANKLE486

FOOT487

OTHER JOINTS488

MALIGNANT DISEASE489

LIMB LENGTHENING AND DEFORMITY CORRECTION490

SINGLE EVEN MULTILEVEL SURGERY FOR CHILDREN WITH CEREBRAL PALSY492

TREATMENT OF FRACTURES IN PAEDIATRIC PATIENTS494

SPINE SURGERY FOR SCOLIOSIS AND KYPHOSIS IN PAEDIATRIC PATIENTS497

TREATMENT OF HIP DYSPLASIA OR DISLOCATION IN PAEDIATRIC PATIENTS498

SUBGROUP 16 - RADIOFREQUENCY ABLATION498

GROUP T9 - ASSISTANCE AT OPERATIONS499

INDEX500

OM.1.1. Benefits for Medical Services Performed by Approved Dental Practitioners535

OM.1.2. Changes to the Scheme Effective from 1 November 2004535

OM.2.1. Definition of Oral and Maxillofacial Surgery535

OM.2.2. Services That Can Be Provided535

OM.3.1. Principles of Interpretation535

OM.3.2. Multiple Operation Rule535

OM.3.3. After Care (Post-operative Treatment)536

OM.3.4. Administration of Anaesthetics by Medical Practitioners536

OM.4.1. Consultations - (Items 51700 and 51703)536

OM.4.2. Assistance at Operations - (Items 51800 and 51803)536

OM.4.3. Repair of Wound - (Item 51900)537

OM.4.4. Lipectomy, Wedge Excision - Two or More Excisions - (Item 51906)537

OM.4.5. Upper Aerodigestive Tract Endoscopic Procedure - (Item 52035)537

OM.4.6. Tumour, cyst, Ulcer or Scar - (Items 52036 to 52054)538

OM.4.7. Aspiration of Haematoma - (Item 52056)538

OM.4.8. Osteotomy of Jaw - (Items 52342 to 52375)538

OM.4.9. Genioplasty - (Item 52378)538

OM.4.10. Fracture of Mandible or Maxilla - (Items 53400 to 53439)538

OM.4.11. Skin Sensitivity Testing - (Item 53600)538

OM.4.12. Destruction of Nerve Branch by Neurolytic Agent - (Item 53706)538

GROUP O1 - CONSULTATIONS540

GROUP O2 - ASSISTANCE AT OPERATION541

GROUP O3 - GENERAL SURGERY542

GROUP O4 - PLASTIC & RECONSTRUCTIVE547

GROUP O5 - PREPROSTHETIC550

GROUP O6 - NEUROSURGICAL551

GROUP O7 - EAR, NOSE & THROAT552

GROUP O8 - TEMPOROMANDIBULAR JOINT554

GROUP O9 - TREATMENT OF FRACTURES556

GROUP O10 - DIAGNOSTIC PROCEDURES AND INVESTIGATIONS558

GROUP O11 - REGIONAL OR FIELD NERVE BLOCKS559

INDEX560

DIA... Diagnostic Imaging Services - Overview567

DIB... What Is A Diagnostic Imaging Service567

DIC... Who May Provide A Diagnostic Imaging Service567

DID... Requests For Diagnostic Imaging Services568

DIE... Registration of Site Undertaking Diagnostic Imaging Procedures573

DIF... Details Required on Accounts, Receipts and Medicare Assignment of Benefit Forms575

DIG... Maintaining Records of Diagnostic Imaging Services576

DIH... Contravention of State and Territory Laws and Disqualified Practitioners576

DII... Prohibited Practices576

DIJ... Multiple Services Rules577

DIK... Group I1 - Ultrasound579

DIL... Group I2 - Computed Tomography (CT)582

DIM... Group I3 - Diagnostic Radiology585

DIN... Group I4 - Nuclear Medicine Imaging587

General587

DIO... Group I5 - Magnetic Resonance Imaging588

DIP... Management of bulk-billed services591

DIQ... Bulk Billing Incentive591

DIR... Extension of the Capital Sensitivity Rule to all Diagnostic Imaging Equipment591

DIS... Restriction on item 55054591

GROUP I1 - ULTRASOUND593

SUBGROUP 1 - GENERAL593

SUBGROUP 2 - CARDIAC597

SUBGROUP 3 - VASCULAR600

SUBGROUP 4 - UROLOGICAL603

SUBGROUP 5 - OBSTETRIC AND GYNAECOLOGICAL604

SUBGROUP 6 - MUSCULOSKELETAL624

GROUP I2 - COMPUTED TOMOGRAPHY632

GROUP I3 - DIAGNOSTIC RADIOLOGY641

SUBGROUP 1 - RADIOGRAPHIC EXAMINATION OF EXTREMITIES641

SUBGROUP 2 - RADIOGRAPHIC EXAMINATION OF SHOULDER OR PELVIS642

SUBGROUP 3 - RADIOGRAPHIC EXAMINATION OF HEAD642

SUBGROUP 4 - RADIOGRAPHIC EXAMINATION OF SPINE645

SUBGROUP 5 - BONE AGE STUDY AND SKELETAL SURVEYS646

SUBGROUP 6 - RADIOGRAPHIC EXAMINATION OF THORACIC REGION647

SUBGROUP 7 - RADIOGRAPHIC EXAMINATION OF URINARY TRACT648

SUBGROUP 8 - RADIOGRAPHIC EXAMINATION OF ALIMENTARY TRACT AND BILIARY SYSTEM648

SUBGROUP 9 - RADIOGRAPHIC EXAMINATION FOR LOCALISATION OF FOREIGN BODIES650

SUBGROUP 10 - RADIOGRAPHIC EXAMINATION OF BREASTS650

SUBGROUP 11 - RADIOGRAPHIC EXAMINATION IN CONNECTION WITH PREGNANCY651

SUBGROUP 12 - RADIOGRAPHIC EXAMINATION WITH OPAQUE OR CONTRAST MEDIA652

SUBGROUP 13 - ANGIOGRAPHY653

SUBGROUP 14 - TOMOGRAPHY656

SUBGROUP 15 - FLUOROSCOPIC EXAMINATION656

SUBGROUP 16 - PREPARATION FOR RADIOLOGICAL PROCEDURE657

SUBGROUP 17 - INTERVENTIONAL TECHNIQUES657

GROUP I4 - NUCLEAR MEDICINE IMAGING658

GROUP I5 - MAGNETIC RESONANCE IMAGING669

SUBGROUP 1 - SCAN OF HEAD - FOR SPECIFIED CONDITIONS669

SUBGROUP 2 - SCAN OF HEAD - FOR SPECIFIED CONDITIONS669

SUBGROUP 3 - SCAN OF HEAD AND NECK VESSELS - FOR SPECIFIED CONDITIONS671

SUBGROUP 4 - SCAN OF HEAD AND CERVICAL SPINE - FOR SPECIFIED CONDITIONS671

SUBGROUP 3 - SCAN OF HEAD AND NECK VESSELS - FOR SPECIFIED CONDITIONS672

SUBGROUP 5 - SCAN OF HEAD AND CERVICAL SPINE - FOR SPECIFIED CONDITIONS672

SUBGROUP 6 - SCAN OF SPINE - ONE REGION OR TWO CONTIGUOUS REGIONS - FOR SPECIFIED CONDITIONS672

SUBGROUP 7 - SCAN OF SPINE - ONE REGION OR TWO CONTIGUOUS REGIONS - FOR SPECIFIED CONDITIONS673

SUBGROUP 8 - SCAN OF SPINE - THREE CONTIGUOUS REGIONS OR TWO NON-CONTIGUOUS REGIONS - FOR SPECIFIED CONDITIONS674

SUBGROUP 9 - SCAN OF SPINE - THREE CONTIGUOUS REGIONS OR TWO NON-CONTIGUOUS REGIONS - FOR SPECIFIED CONDITIONS675

SUBGROUP 10 - SCAN OF CERVICAL SPINE AND BRACHIAL PLEXUS - FOR SPECIFIED CONDITIONS676

SUBGROUP 11 - SCAN OF MUSCULOSKELETAL SYSTEM - FOR SPECIFIED CONDITIONS677

SUBGROUP 12 - SCAN OF MUSCULOSKELETAL SYSTEM - FOR SPECIFIED CONDITIONS677

SUBGROUP 13 - SCAN OF MUSCULOSKELETAL SYSTEM - FOR SPECIFIED CONDITIONS678

SUBGROUP 14 - SCAN OF CARDIOVASCULAR SYSTEM - FOR SPECIFIED CONDITIONS679

SUBGROUP 15 - MAGNETIC RESONANCE ANGIOGRAPHY - SCAN OF CARDIOVASCULAR SYSTEM - FOR SPECIFIED CONDITIONS679

SUBGROUP 16 - MAGNETIC RESONANCE ANGIOGRAPHY - FOR SPECIFIED CONDITIONS - PERSON UNDER THE AGE OF 16 YEARS680

SUBGROUP 17 - MAGNETIC RESONANCE IMAGING - FOR SPECIFIED CONDITIONS - PERSON UNDER THE AGE OF 16 YEARS680

SUBGROUP 18 - MAGNETIC RESONANCE IMAGING - FOR SPECIFIED CONDITIONS - PERSON UNDER THE AGE OF 16 YEARS680

SUBGROUP 19 - SCAN OF BODY - FOR SPECIFIED CONDITIONS681

SUBGROUP 20 - SCAN OF PELVIS AND UPPER ABDOMEN - FOR SPECIFIED CONDITIONS683

SUBGROUP 21 - SCAN OF BODY - FOR SPECIFIED CONDITIONS684

SUBGROUP 20 - SCAN OF PELVIS AND UPPER ABDOMEN - FOR SPECIFIED CONDITIONS684

SUBGROUP 21 - SCAN OF BODY - FOR SPECIFIED CONDITIONS684

SUBGROUP 22 - MODIFYING ITEMS684

SUBGROUP 32 - MAGNETIC RESONANCE IMAGING - PIP BREAST IMPLANT685

SUBGROUP 33 - MAGNETIC RESONANCE IMAGING - FOR SPECIFIED CONDITIONS - PERSON UNDER THE AGE OF 16YRS685

GROUP I6 - MANAGEMENT OF BULK-BILLED SERVICES688

INDEX689

P.1.1. Pathology Services in Relation to Medicare Benefits - Outline of Arrangements697

P.1.2. Exemptions to Basic Requirements697

P.1.3. Circumstances Where Medicare Benefits Not Attracted698

P.2.1. Responsibilities of Treating/Requesting Practitioners698

P.2.2. Responsibilities of Approved Pathology Practioners699

P.2.3. Pathology Tests not Covered by Request703

P.3.1. Details Required on Accounts, Receipts or Assignment Forms703

P.3.2. Approved Pathology Practitioners703

P.3.3. Prescribed Pathology Services704

P.4.1. Inbuilt Multiple Services Rule704

P.4.2. Exemptions704

P.5.1. Episode Cone704

P.5.2. Exemptions704

P.6.1. Bulk Billing Incentives for Episodes Consisting of a P10 Service704

P.6.2. Patient Episode Initiation Fees (PEIs)705

P.6.3. Patient Episode Initiation Fees for Certain Tissue Pathology and Cytology Items705

P.6.4. Hospital, Government etc Laboratories705

P.7.1. Assignment of Medicare Benefits - Patient Assignment705

P.7.2. Approved Pathology Practitioner Eligibility706

P.8.1. Accredited Pathology Laboratories - Need for Accreditation706

P.8.2. Applying for Accreditation706

P.8.3. Effective Period of Accreditation706

P.8.4. Assessment of Applications for Accreditation706

P.8.5. Refusal of Accreditation and Right of Review706

P.8.6. National Pathology Accreditation Advisory Council (NPAAC)706

P.8.7. Change of Address/Location706

P.8.8. Change of Ownership of a Laboratory707

P.8.9. Approved Collection Centres (ACC)707

P.9.1. Approved Pathology Practitioners707

P.9.2. Applying for Acceptance of the Approved Pathology Practitioner Undertaking707

P.9.3. Undertakings708

P.9.4. Obligations and Responsibilities of Approved Pathology Practitioners708

P.10.1. Approved Pathology Authorities708

P.10.2. Applying for Acceptance of an Approved Pathology Authority Undertaking708

P.10.3. Undertakings709

P.10.4. Obligations and Responsibilities of Approved Pathology Authorities710

P.11.1. Breaches of Undertakings710

P.11.2. Decisions by Minister710

P.11.3. Appeals710

P.12.1. Initiation of Excessive Pathology Services710

P.12.2. Classes of Persons710

P.12.3. Decisions by Minister for Health and Ageing710

P.12.4. Appeals710

P.13.1. Personal Supervision710

P.13.2. Extract from Undertaking711

P.13.3. Notes on the Above712

P.14.1. Changes to the Pathology Services Table712

P.15.1. Explanatory Notes - Definitions712

P.15.2. Group of Practitioners712

P.15.3. Initiate712

P.15.4. Patient Episode712

P.15.5. Episode Cone713

P.15.6. Personal Supervision713

P.15.7. Prescribed Pathology Service713

P.15.8. Proprietor of a Laboratory713

P.15.9. Specialist Pathologist713

P.15.10. Designated Pathology Service713

P.16.1. Interpretation of The Schedule - Items Referring to 'The Detection Of'714

P.16.2. Blood Grouping - (Item 65096)714

P.16.3. Glycosylated Haemoglobin - (Item 66551)714

P.16.4. Iron Studies - (Item 66596)714

P.16.5. Faecal Occult Blood - (Items 66764 to 66770)714

P.16.6. Antibiotics/Antimicrobial Chemotherapeutic Agents714

P.16.7. Human Immunodeficiency Virus (HIV) Diagnostic Tests - (Iincluded in Items 69384, 69387, 69390, 69393, 69396, 69405, 69408, 69411, 69413 and 69415)714

P.16.8. Hepatitis - (Item 69481)714

P.16.9. Eosinophil Cationic Protein - (Item 71095)714

P.16.10. Tissue Pathology and Cytology - (Items 72813 to 73061)714

P.16.11. Cervical and Vaginal Cytology - (Items 73053 to 73057)714

P.16.12. Fragile X (A) Tests - (Items 73300 and 73305)715

P.16.13. Additional Bulk Billing Payment for Pathology Services - (Item 74990 and 74991)715

P.16.14. Transfer of Existing Items from Group P1 (Haematology) to Group P7 Genetics Effective 1 May 2006.715

P.17.1. Abbreviations, Groups of Tests716

P.17.2. Tests not Listed716

P.17.3. Audit of Claims716

P.17.4. Groups of Tests716

P.18.1. Complexity Levels for Histopathology Items717

P.19.1. Pathology Services Table717

Precedence of items718

Thyroid function testing721

Antineutrophil Cytoplasmic Antibody726

GROUP P1 - HAEMATOLOGY729

GROUP P2 - CHEMICAL733

GROUP P3 - MICROBIOLOGY743

GROUP P4 - IMMUNOLOGY749

GROUP P5 - TISSUE PATHOLOGY754

GROUP P6 - CYTOLOGY757

GROUP P7 - GENETICS759

GROUP P8 - INFERTILITY AND PREGNANCY TESTS762

GROUP P9 - SIMPLE BASIC PATHOLOGY TESTS763

GROUP P10 - PATIENT EPISODE INITIATION765

GROUP P11 - SPECIMEN REFERRED767

GROUP P12 - MANAGEMENT OF BULK-BILLED SERVICES768

GROUP P13 - BULK BILLED PATHOLOGY EPISODE INCENTIVE ITEMS769

INDEX770

COMPLEXITY LEVELS FOR HISTOPATHOLOGY ITEMS778

C.1.1. Introduction - Medicare Benefits786

C.2.1. Dental Practitioner Eligibility786

C.3.1. Patient Eligibility786

C.3.2. Application for approval for repairs to previous reconstructive work787

C.3.3. Visitors to Australia789

C.3.4. Health Care Expenses Incurred Overseas789

C.4.1. Schedule Fees and Medicare Benefits789

C.4.2. Where Medicare Benefits are not Payable789

C.4.3. Limiting Rule789

C.5.1. Penalties790

C.6.1. Billing of the Patient790

C.6.2. Claiming of Benefits790

C.7.1. Interpretation of the Cleft Lip and Cleft Palate Scheme792

C.7.2. Multiple Operation Rule792

C.7.3. Administration of Anaesthetics793

C.7.4. Definitions793

C.7.5. Referral of Oral and Maxillofacial Surgical Services - (Items 75150 to 75621)793

C.7.6. General and Prosthodontic Services - (Item 75800)793

C.7.7. Over-servicing793

C.8.1. Cleft Lip and Cleft Palate Clinics793

C.8.2. Commonwealth Department of Health and Ageing Addresses795

C.8.3. Medicare Australia Addresses796

GROUP C1 - ORTHODONTIC SERVICES798

GROUP C2 - ORAL AND MAXILLOFACIAL SERVICES801

GROUP C3 - GENERAL AND PROSTHODONTIC SERVICES803

M.1.1. Additional Bulk Billing Payment for General Medical Services - (Items 10990 and 10991)807

M.1.2. After-hours services provided in areas eligible for the higher bulk billing payment - (Item 10992)807

M.3.1. Individual Allied Health Services (Items 10950 to 10970) for Chronic Disease Management - Eligible Patients808

M.3.2. Individual Allied Health Services (Items 10950 to 10970) for Chronic Disease Management - Referral Requirements809

M.3.3. Individual Allied Health Services - (Items 10950 to 10970) for Chronic Disease Management - Eligible Providers and Services809

M.3.4. Individual Allied Health Services - (Items 10950 to 10970) for Chronic Disease Management - Professional Eligibility811

M.3.5. Individual Allied Health Services (10950 to 10970) for Chronic Disease Management - Further Information812

M.6.1. Provision of Psychological Therapy Services by Clinical Psychologists - (Items 80000 TO 80020)812

M.6.2. Psychological Therapy Services Attracting Medicare Rebates812

Service length and type813

M.6.3. Referral Requirements (GPs, Psychiatrists or Paediatricians to Clinical Psychologists for Psychological Therapy)814

M.6.4. Clinical Psychologist Professional Eligibility815

M.7.1. Provision of Focussed Psychological Strategies Services by Allied Health Providers - (Items 80100 to 80170)816

M.8.1. Pregnancy Support Counselling - Eligible Patients - (Items 81000 to 81010)820

M.8.2. Pregnancy Support Counselling - Eligible Services - (Items 81000 to 81010)820

M.8.3. Pregnancy Support Counselling - Referral Requirements - (Items 81000 to 81010)821

M.8.4. Pregnancy Support Counselling - Allied Health Professional Eligibility -(Items 81000 to 81010)822

M.9.1. Group Allied Health Services (Items 81100 to 81125) for People with Type 2 Diabetes - Eligible Patients -822

M.9.2. Group Allied Health Services (Items 81100 to 81125) for People with Type 2 Diabetes - GP Referral Requirements823

M.9.3. Group Allied Health Services (Items 81100 to 81125) for People with Type 2 Diabetes - Eligible Allied Health Professionals823

M.9.4. Assessment for Group Allied Health Services (Items 81100, 81110 and 81120) for People with Type 2 Diabetes823

M.9.5. Group Allied Health Services (Items 81105, 81115 and 81125) for People with Type 2 Diabetes - Service Requirements and Referral Forms824

M.9.6. Group Allied Health Services (Items 81100 to 81125) for People with Type 2 Diabetes - Additional Requirements824

Retention of Referral Form for Medicare Australia Audit Purposes824

M.9.7. Group Allied Health Services (Items 81100 to 81125) for People with Type 2 Diabetes - Further Information825

M.10.1. Provision of Autism, Pervasive Developmental Disorder or Disability Services by Allied Health Professionals - (Items 82000 to 82035)825

M.11.1. Follow-up Allied Health Services for people of Aboriginal or Torres Straight Islander descent (Items 81300 to 81360)828

M.12.1. Immunisation services provided by an Aboriginal and Torres Strait Islander health practitioner - (Item 10988)831

M.12.2. Wound management services provided by an Aboriginal and Torres Strait Islander health practitioner (item 10989)832

M.12.3. Healthy Kids check provided by a Practice Nurse or an Aboriginal and Torres Strait Islander health practitioner (Item 10986)833

M.12.4. Follow up service provided by a practice nurse or Aboriginal and Torres Strait Islander health practitioner, on behalf of a Medical Practitioner, for an Indigenous person who has received a health assessment (Item 10987)834

M.12.5. Provision of monitoring and support for a person with a chronic disease by a practice nurse or Aboriginal and Torres Strait Islander health practitioner (item 10997)835

M.12.6. Telehealth Support Services by Health Professionals837

M.13.1. Maternity Services by Participating Midwives - Overview838

M.13.2. Participating Midwives838

M.13.3. Eligible Midwives839

M.13.4. Midwife Professional Indemnity Insurance839

M.13.5. Collaborative Arrangements839

M.13.6. Provider Numbers841

M.13.7. Schedule Fees and Medicare Benefits841

M.13.8. Safety Nets841

M.13.9. Safety Net Capping for Midwifery Items841

M.13.10. Where Medicare Benefits are not payable841

M.13.11. Billing of Patient842

M.13.12. Assignment of Benefits (Direct-Billing) Arrangements842

M.13.13. Assignment of Benefit Forms843

M.13.14. Time Limits Applicable to Lodgement of Claims for Assigned Benefits843

M.13.15. Overview of the Maternity Items843

M.13.16. Maternity Services Attracting Medicare Rebates843

M.13.17. Conditions Governing the Provision and Claiming of Items844

Service length and type844

M.13.18. Referral Requirements844

M.13.19. Requesting Requirements845

M.14.1. Participating Nurse Practitioners Services - Overview846

M.14.2. Eligible Nurse Practitioners847

M.14.3. Provider Numbers847

M.14.4. Participating Nurse Practitioners847

M.14.5. Collaborative Arrangements847

M.14.6. Schedule Fees and Medicare Benefits848

M.14.7. Where Medicare Benefits are not payable848

M.14.8. Billing of the Patient848

M.14.9. Assignment of Benefits (Direct-Billing Arrangements849

M.14.10. Assignment of Benefit Forms849

M.14.11. Time Limits applicable to lodgement of claims for assigned benefits849

M.14.12. Overview of the Nurse Practitioner items849

M.14.13. Nurse Practitioner services attracting Medicare rebates850

M.14.14. Conditions governing the provision and claiming of items850

M.14.15. Referral requirements850

M.14.16. Requesting requirements850

M.15.1. Brain Stem Evoked Response Audiometry - (Item 82300)851

M.15.2. Non-Determinate Audiometry - (Item 82306)851

M.15.3. Conditions for Audiology Services - (Items 82309 to 82318)851

M.15.4. Oto-Acoustic Emission Audiometry - (Item 82332)852

M.15.5. Provision of Diagnostic Audiology Services by Audiologists - (Items 82300 to 82332)852

GROUP M3 - ALLIED HEALTH SERVICES855

GROUP M12 - SERVICES PROVIDED BY A PRACTICE NURSE OR ABORIGINAL AND TORRES STRAIT ISLANDER HEALTH PRACTITIONER ON BEHALF OF A MEDICAL PRACTITIONER862

SUBGROUP 1 - TELEHEALTH SUPPORT SERVICE ON BEHALF OF A MEDICAL PRACTITIONER862

SUBGROUP 2 - TELEHEALTH SUPPORT SERVICE ON BEHALF OF A MEDICAL PRACTITIONER AT A RESIDENTIAL AGED CARE FACILITY862

SUBGROUP 3 - SERVICES PROVIDED BY A PRACTICE NURSE OR ABORIGINAL AND TORRES STRAIT ISLANDER HEALTH PRACTITIONER ON BEHALF OF A MEDICAL PRACTITIONER862

GROUP M1 - MANAGEMENT OF BULK-BILLED SERVICES864

GROUP M12 - SERVICES PROVIDED BY A PRACTICE NURSE OR ABORIGINAL AND TORRES STRAIT ISLANDER HEALTH PRACTITIONER ON BEHALF OF A MEDICAL PRACTITIONER866

SUBGROUP 3 - SERVICES PROVIDED BY A PRACTICE NURSE OR ABORIGINAL AND TORRES STRAIT ISLANDER HEALTH PRACTITIONER ON BEHALF OF A MEDICAL PRACTITIONER866

GROUP M6 - PSYCHOLOGICAL THERAPY SERVICES867

GROUP M7 - FOCUSSED PSYCHOLOGICAL STRATEGIES (ALLIED MENTAL HEALTH)868

GROUP M8 - PREGNANCY SUPPORT COUNSELLING871

GROUP M9 - ALLIED HEALTH GROUP SERVICES872

GROUP M11 - ALLIED HEALTH SERVICES FOR INDIGENOUS AUSTRALIANS WHO HAVE HAD A HEALTH CHECK875

GROUP M10 - AUTISM, PERVASIVE DEVELOPMENTAL DISORDER AND DISABILITY SERVICES880

GROUP M13 - MIDWIFERY SERVICES884

SUBGROUP 1 - MBS ITEMS FOR PARTICIPATING MIDWIVES884

SUBGROUP 2 - TELEHEALTH ATTENDANCES885

GROUP M14 - NURSE PRACTITIONERS887

SUBGROUP 1 - NURSE PRACTITIONERS887

SUBGROUP 2 - TELEHEALTH ATTENDANCE888

SUBGROUP 3 - TELEHEALTH ATTENDANCE AT A RESIDENTIAL AGED CARE FACILITY889

GROUP M15 - DIAGNOSTIC AUDIOLOGY SERVICES891

INDEX894

SUMMARY OF CHANGES FROM 1/10/2013

The 1/10/2013 changes to the MBS are summarised below and are identified in the Schedule pages by one or more of the following words appearing above the item number

(a) new itemNew

(b) amended descriptionAmend

(c) fee amendedFee

(d) item number changedRenum

(e) EMSN changedEMSN

New Items

18375

Amended Description

635076350863510635116351363514635166351763519635206352263523

G.1.1. The Medicare Benefits Schedule - Introduction

Schedules of Services

Each professional service contained in the Schedule has been allocated a unique item number. Located with the item number and description for each service is the Schedule fee and Medicare benefit, together with a reference to an explanatory note relating to the item (if applicable).

If the service attracts an anaesthetic, the word (Anaes.) appears following the description. Where an operation qualifies for the payment of benefits for an assistant, the relevant items are identified by the inclusion of the word (Assist.) in the item description. Medicare benefits are not payable for surgical assistance associated with procedures which have not been so identified.

In some cases two levels of fees are applied to the same service in General Medical Services, with each level of fee being allocated a separate item number. The item identified by the letter "S" applies in the case where the procedure has been rendered by a recognised specialist in the practice of his or her specialty and the patient has been referred. The item identified by the letter "G" applies in any other circumstance.

Higher rates of benefits are also provided for consultations by a recognised consultant physician where the patient has been referred by another medical practitioner or an approved dental practitioner (oral surgeons).

Differential fees and benefits also apply to services listed in Category 5 (Diagnostic Imaging Services). The conditions relating to these services are set out in Category 5.

Explanatory Notes

Explanatory notes relating to the Medicare benefit arrangements and notes that have general application to services are located at the beginning of the schedule, while notes relating to specific items are located at the beginning of each Category. While there may be a reference following the description of an item to specific notes relating to that item, there may also be general notes relating to each Group of items.

G.1.2. Medicare - an outline

The Medicare Program (‘Medicare’) provides access to medical and hospital services for all Australian residents and certain categories of visitors to Australia. Medicare Australia administers Medicare and the payment of Medicare benefits. The major elements of Medicare are contained in the Health Insurance Act 1973, as amended, and include the following:

(a). Free treatment for public patients in public hospitals.

(b). The payment of ‘benefits’, or rebates, for professional services listed in the Medicare Benefits Schedule (MBS). In general, the Medicare benefit is 85% of the Schedule fee, otherwise the benefits are

i. 100% of the Schedule fee for services provided by a general practitioner to non-referred, non-admitted patients;

ii. 100% of the Schedule fee for services provided on behalf of a general practitioner by a practice nurse or Aboriginal and Torres Strait Islander health practitioner;

iii. 75% of the Schedule fee for professional services rendered to a patient as part of an episode of hospital treatment (other than public patients);

iv. 75% of the Schedule fee for professional services rendered as part of a privately insured episode of hospital-substitute treatment.

Medicare benefits are claimable only for ‘clinically relevant’ services rendered by an appropriate health practitioner. A ‘clinically relevant’ service is one which is generally accepted by the relevant profession as necessary for the appropriate treatment of the patient.

When a service is not clinically relevant, the fee and payment arrangements are a private matter between the practitioner and the patient.

Services listed in the MBS must be rendered according to the provisions of the relevant Commonwealth, State and Territory laws. For example, medical practitioners must ensure that the medicines and medical devices they use have been supplied to them in strict accordance with the provisions of the Therapeutic Goods Act 1989.

Where a Medicare benefit has been inappropriately paid, Medicare Australia may request its return from the practitioner concerned.

G.1.3. Medicare benefits and billing practices

Key information on Medicare benefits and billing practices

The Health Insurance Act 1973 stipulates that Medicare benefits are payable for professional services. A professional service is a clinically relevant service which is listed in the MBS. A medical service is clinically relevant if it is generally accepted in the medical profession as necessary for the appropriate treatment of the patient.

Medical practitioners are free to set their fees for their professional service. However, the amount specified in the patient’s account must be the amount charged for the service specified. The fee may not include a cost of goods or services which are not part of the MBS service specified on the account.

Billing practices contrary to the Act

A non-clinically relevant service must not be included in the charge for a Medicare item. The non-clinically relevant service must be separately listed on the account and not billed to Medicare.

Goods supplied for the patient’s home use (such as wheelchairs, oxygen tanks, continence pads) must not be included in the consultation charge. Medicare benefits are limited to services which the medical practitioner provides at the time of the consultation – any other services must be separately listed on the account and must not be billed to Medicare.

Charging part of all of an episode of hospital treatment or a hospital substitute treatment to a non-admitted consultation is prohibited. This would constitute a false or misleading statement on behalf of the medical practitioner and no Medicare benefits would be payable.

An account may not be re-issued to include charges and out-of-pocket expenses excluded in the original account. The account can only be reissued to correct a genuine error.

Potential consequence of improperly issuing an account

The potential consequences for improperly issuing an account are

(a)No Medicare benefits will be paid for the service;

(b)The medical practitioner who issued the account, or authorised its issue, may face charges under sections 128A or 128B of the Health Insurance Act 1973.

(c)Medicare benefits paid as a result of a false or misleading statement will be recoverable from the doctor under section 129AC of the Health Insurance Act 1973.

Providers should be aware that Medicare Australia is legally obliged to investigate doctors suspected of making false or misleading statements, and may refer them for prosecution if the evidence indicates fraudulent charging to Medicare. If Medicare benefits have been paid inappropriately or incorrectly, Medicare Australia will take recovery action.

The Department of Human Services (DHS) has developed a Health Practitioner Guideline for responding to a request to substantiate that a patient attended a service. There is also a Health Practitioner Guideline for substantiating that a specific treatment was performed. These guidelines are located on the DHS website.

G.2.1. Provider eligibility for Medicare

To be eligible to provide medical service which will attract Medicare benefits, or to provide services for or on behalf of another practitioner, practitioners must meet one of the following criteria:

(a) be a recognised specialist, consultant physician or general practitioner; or

(b) be in an approved placement under section 3GA of the Health Insurance Act 1973; or

(c) be a temporary resident doctor with an exemption under section 19AB of the Health Insurance Act 1973, and working in accord with that exemption.

Any practitioner who does not satisfy the requirements outlined above may still practice medicine but their services will not be eligible for Medicare benefits.

NOTE: New Zealand citizens entering Australia do so under a special temporary entry visa and are regarded as temporary resident doctors.

NOTE: It is an offence under Section 19CC of the Health Insurance Act 1973 to provide a service without first informing a patient where a Medicare benefit is not payable for that service (i.e. the service is not listed in the MBS).

Non-medical practitioners

To be eligible to provide services which will attract Medicare benefits under MBS items 10950-10977 and MBS items 80000-88000 and 82100-82140 and 82200-82215, allied health professionals, dentists, and dental specialists, participating midwives and participating nurse practitioners must be

(a) registered according to State or Territory law or, absent such law, be members of a professional association with uniform national registration requirements; and

(b) registered with Medicare Australia to provide these services.

G.2.2. Provider Numbers

Practitioners eligible to have Medicare benefits payable for their services and/or who for Medicare purposes wish to raise referrals for specialist services and requests for pathology or diagnostic imaging services, may apply in writing to Medicare Australia for a Medicare provider number for the locations where these services/referrals/requests will be provided. The form may be downloaded from www.medicareaustralia.gov.au

For Medicare purposes, an account/receipt issued by a practitioner must include the practitioner’s name and either the provider number for the location where the service was provided or the address where the services were provided.

Medicare provider number information is released in accord with the secrecy provisions of the Health Insurance Act 1973 (section 130) to authorized external organizations including private health insurers, the Department of Veterans’ Affairs and the Department of Health and Ageing.

When a practitioner ceases to practice at a given location they must inform Medicare promptly. Failure to do so can lead to the misdirection of Medicare cheques and Medicare information.

Practitioners at practices participating in the Practice Incentives Program (PIP) should use a provider number linked to that practice. Under PIP, only services rendered by a practitioner whose provider number is linked to the PIP will be considered for PIP payments.

G.2.3. Locum tenens

Where a locum tenens will be in a practice for more than two weeks or in a practice for less than two weeks but on a regular basis, the locum should apply for a provider number for the relevant location. If the locum will be in a practice for less than two weeks and will not be returning there, they should contact Medicare Australia (provider liaison – 132 150) to discuss their options (for example, use one of the locum’s other provider numbers).

A locum must use the provider number allocated to the location if

(a) they are an approved general practice or specialist trainee with a provider number issued for an approved training placement; or

(b) they are associated with an approved rural placement under Section 3GA of the Health Insurance Act 1973; or

(c) they have access to Medicare benefits as a result of the issue of an exemption under section 19AB of the Health Insurance Act 1973 (i.e. they have access to Medicare benefits at specific practice locations); or

(d) they will be at a practice which is participating in the Practice Incentives Program; or

(e) they are associated with a placement on the MedicarePlus for Other Medical Practitioners (OMPs) program, the After Hours OMPs program, the Rural OMPs program or Outer Metropolitan OMPs program.

G.2.4. Overseas trained doctor

Ten year moratorium

Section 19AB of the Health Insurance Act 1973 states that services provided by overseas trained doctors (including New Zealand trained doctors) and former overseas medical students trained in Australia, will not attract Medicare benefits for 10 years from either

(a) their date of registration as a medical practitioner for the purposes of the Health Insurance Act 1973; or

(b) their date of permanent residency (the reference date will vary from case to case).

Exclusions - Practitioners who before 1 January 1997 had

(a) registered with a State or Territory medical board and retained a continuing right to remain in Australia; or

(b) lodged a valid application with the Australian Medical Council (AMC) to undertake examinations whose successful completion would normally entitle the candidate to become a medical practitioner.

The Minister of Health and Ageing may grant an overseas trained doctor (OTD) or occupational trainee (OT) an exemption to the requirements of the ten year moratorium, with or without conditions. When applying for a Medicare provider number, the OTD or OT must

(a) demonstrate that they need a provider number and that their employer supports their request; and

(b) provide the following documentation:

i. Australian medical registration papers; and

ii. a copy of their personal details in their passport and all Australian visas and entry stamps; and

iii. a letter from the employer stating why the person requires a Medicare provider number and/or prescriber number is required; and

iv. a copy of the employment contract.

G.2.5. Addresses of Medicare Australia, Schedule Interpretation and Changes to Provider Details

NEW SOUTH WALES

Medicare Australia Paramatta Office

130 George Street

PARRAMATTA NSW 2150

VICTORIA

Medicare Australia Melbourne Office

Level 10

595 Collins Street

MELBOURNE VIC 3000

QUEENSLAND

Medicare Australia Brisbane Office

143 Turbot Street

BRISBANE QLD 4000

SOUTH AUSTRALIA

Medicare Australia Adelaide Office

209 Greenhill Road

EASTWOOD SA 5063

WESTERN AUSTRALIA

Medicare Australia Perth Office

Level 4

130 Stirling Street

PERTH WA 6003

TASMANIA

Medicare Australia Hobart Office

199 Collins Street

HOBART TAS 7000

NORTHERN TERRITORY

As per South Australia

AUSTRALIAN CAPITAL TERRITORY

Medicare Australia National Office

134 Reed Street North

GREENWAY ACT 2901

Schedule Interpretations

The day-to-day administration and payment of benefits under the Medicare arrangements is the responsibility of Medicare Australia. Inquiries concerning matters of interpretation of Schedule items should be directed to Medicare Australia and not to the Department of Health and Ageing. The following telephone numbers have been reserved by Medicare Australia exclusively for inquiries relating to the Schedule:

Provider Enquiries: 132 150

Public Enquiries: 132 011

Changes to Provider Details

It is important that Medicare Australia be notified promptly of changes to practice addresses to ensure correct provider details for each practice location. Changes to practice address details can be made in writing to the Medicare Australia office, listed above, in the State of the practice location.

G.3.1. Patient eligibility for Medicare

An "eligible person" is a person who resides permanently in Australia. This includes New Zealand citizens and holders of permanent residence visas. Applicants for permanent residence may also be eligible persons, depending on circumstances. Eligible persons must enrol with Medicare before they can receive Medicare benefits.

Medicare covers services provided only in Australia. It does not refund treatment or evacuation expenses overseas.

G.3.2. Medicare cards

The green Medicare card is for people permanently in Australia. Cards may be issued for individuals or families.

The blue Medicare card bearing the words “INTERIM CARD” is for people who have applied for permanent residence.

Visitors from countries with which Australia has a Reciprocal Health Care Agreement receive a card bearing the words "RECIPROCAL HEALTH CARE"

G.3.3. Visitors to Australia and temporary residents

Visitors and temporary residents in Australia are not eligible for Medicare and should therefore have adequate private health insurance.

G.3.4. Reciprocal Health Care Agreements

Australia has Reciprocal Health Care Agreements with New Zealand, Ireland, the United Kingdom, the Netherlands, Sweden, Finland, Norway, Italy, Malta and Belgium.

Visitors from these countries are entitled to medically necessary treatment while they are in Australia, comprising public hospital care (as public patients), Medicare benefits and drugs under the Pharmaceutical Benefits Scheme (PBS). Visitors must enroll with Medicare Australia to receive benefits. A passport is sufficient for public hospital care and PBS drugs.

Exceptions:

· Visitors from Ireland and New Zealand are entitled to public hospital care and PBS drugs, and should present their passports before treatment as they are not issued with Medicare cards.

· Visitors from Italy and Malta are covered for a period of six months only.

The Agreements do not cover treatment as a private patient in a public or private hospital. People visiting Australia for the purpose of receiving treatment are not covered.

G.4.1. General Practice

Some MBS items may only be used by general practitioners. For MBS purposes a general practitioner is a medical practitioner who is

(a) vocationally registered under section 3F of the Health Insurance Act 1973 (see General Explanatory Note below); or

(b) a Fellow of the Royal Australian College of General Practitioners (FRACGP), who participates in, and meets the requirements for the RACGP Quality Assurance and Continuing Medical Education Program; or

(c) a Fellow of the Australian College of Rural and Remote Medicine (FACRRM) who participates in, and meets the requirements for the ACRRM Quality Assurance and Continuing Medical Education Program; or

(d) is undertaking an approved general practice placement in a training program for either the award of FRACGP or a training program recognised by the RACGP being of an equivalent standard; or

(e) is undertaking an approved general practice placement in a training program for either the award of FACRRM or a training program recognised by ACRRM as being of an equivalent standard.

A medical practitioner seeking recognition as an FRACGP should apply to Medicare Australia, having completed an application form available from Medicare Australia’s website. A general practice trainee should apply to General Practice Education and Training Limited (GPET) for a general practitioner trainee placement. GPET will advise Medicare Australia when a placement is approved. General practitioner trainees need to apply for a provider number using the appropriate provider number application form available on Medicare Australia’s website.

Vocational recognition of general practitioners

The only qualifications leading to vocational recognition are FRACGP and FACRRM. The criteria for recognition as a GP are:

(a) certification by the RACGP that the practitioner

· is a Fellow of the RACGP; and

· practice is, or will be within 28 days, predominantly in general practice; and

· has met the minimum requirements of the RACGP for taking part in continuing medical education and quality assurance programs.

(b) certification by the General Practice Recognition Eligibility Committee (GPREC) that the practitioner

· is a Fellow of the RACGP; and

· practice is, or will be within 28, predominantly in general practice; and

· has met minimum requirements of the RACGP for taking part in continuing medical education and quality assurance programs.

(c) certification by ACRRM that the practitioner

· is a Fellow of ACRRM; and

· has met the minimum requirements of the ACRRM for taking part in continuing medical education and quality assurance programs.

In assessing whether a practitioner’s medical practice is predominantly in general practice, the practitioner must have at least 50% of clinical time and services claimed against Medicare. Regard will also be given as to whether the practitioner provides a comprehensive primary medical service, including treating a wide range of patients and conditions using a variety of accepted medical skills and techniques, providing services away from the practitioner's surgery on request, for example, home visits and making appropriate provision for the practitioner's patients to have access to after hours medical care.

Further information on eligibility for recognition should be directed to:

Program Relations Officer, RACGP

Tel: (03) 8699 0494 Email at: qacpd@racgp.org.au

Secretary, General Practice Recognition Eligibility Committee:

Email at gprec@health.gov.au

Executive Assistant, ACRRM:

Tel: (07) 3105 8200 Email at acrrm@acrrm.org.au

How to apply for vocational recognition

Medical practitioners seeking vocational recognition should apply to Medicare Australia using the approved Application Form available on the Medicare Australia website: www.humanservices.gov.au. Applicants should forward their applications, as appropriate, to

The Secretariat

The General Practice Recognition Eligibility Committee

National Registration and Accreditation Scheme Policy Section

MDP 152

Department of Health and Ageing

GPO Box 9848

CANBERRA ACT 2601

email address: gprec@health.gov.au

The Secretariat

The General Practice Recognition Appeal Committee

National Registration and Accreditation Scheme Policy Section

MDP 152

Department of Health and Ageing

GPO Box 9848

CANBERRA ACT 2601

email address: gprac@health.gov.au

The relevant body will forward the application together with its certification of eligibility to the Medicare Australia CEO for processing.

Continued vocational recognition is dependent upon:

(a) the practitioner’s practice continuing to be predominantly in general practice (for medical practitioners in the Register only); and

(b) the practitioner continuing to meet minimum requirements for participation in continuing professional development programs approved by the RACGP or the ACRRM.

Further information on continuing medical education and quality assurance requirements should be directed to the RACGP or the ACRRM depending on the college through which the practitioner is pursuing, or is intending to pursue, continuing medical education.

Medical practitioners refused certification by the RACGP, the ACRRM or GPREC may appeal in writing to The Secretariat, General Practice Recognition Appeal Committee (GPRAC), National Registration and Accreditation Scheme Policy Section, MDP 152, Department of Health and Ageing, GPO Box 9848, Canberra, ACT, 2601.

Removal of vocational recognition status

A medical practitioner may at any time request Medicare Australia to remove their name from the Vocational Register of General Practitioners.

Vocational recognition status can also be revoked if the RACGP, the ACRRM or GPREC certifies to Medicare Australia that it is no longer satisfied that the practitioner should remain vocationally recognised. Appeals of the decision to revoke vocational recognition may be made in writing to GPRAC, at the above address.

A practitioner whose name has been removed from the register, or whose determination has been revoked for any reason must make a formal application to re-register, or for a new determination.

G.5.1. Recognition as a Specialist or Consultant Physician

A medical practitioner who:

· is registered as a specialist under State or Territory law; or

· holds a fellowship of a specified specialist College and has obtained, after successfully completing an appropriate course of study, a relevant qualification from a relevant College

and has formally applied and paid the prescribed fee, may be recognised by the Minister as a specialist or consultant physician for the purposes of the Health Insurance Act 1973.

A relevant specialist College may also give Medicare Australia’s Chief Executive Officer a written notice stating that a medical practitioner meets the criteria for recognition.

A medical practitioner who is training for a fellowship of a specified specialist College and is undertaking training placements in a private hospital or in general practice, may provide services which attract Medicare rebates. Specialist trainees should consult the information available at www.medicareaustralia.gov.au.

Once the practitioner is recognised as a specialist or consultant physician for the purposes of the Health Insurance Act 1973, Medicare benefits will be payable at the appropriate higher rate for services rendered in the relevant speciality, provided the patient has been appropriately referred to them.

Further information about applying for recognition is available at www.medicareaustralia.gov.au.

The Department of Human Services (DHS) has developed an Health Practitioner Guideline to substantiate that a valid referral existed (specialist or consultant physician) which is located on the DHS website.

G.5.2. Emergency Medicine

A practitioner will be acting as an emergency medicine specialist when treating a patient within 30 minutes of the patient’s presentation, and that patient is

(a)at risk of serious morbidity or mortality requiring urgent assessment and resuscitation; or

(b)suffering from suspected acute organ or system failure; or

(c)suffering from an illness or injury where the viability or function of a body part or organ is acutely threatened; or

(d)suffering from a drug overdose, toxic substance or toxin effect; or

(e)experiencing severe psychiatric disturbance whereby the health of the patient or other people is at immediate risk; or

(f)suffering acute severe pain where the viability or function of a body part or organ is suspected to be acutely threatened; or

(g)suffering acute significant haemorrhage requiring urgent assessment and treatment; and

(h)treated in, or via, a bona fide emergency department in a hospital.

Benefits are not payable where such services are rendered in the accident and emergency departments or outpatient departmen