CHANGES TO THE MEDICARE BENEFITS SCHEDULE FOR 1 … · 11/1/2019 · • Changes are coming to the...

CHANGES TO THE MEDICARE BENEFITS

SCHEDULE FOR 1 NOVEMBER 2019

Stakeholder Forum

Tuesday, 17 September 2019

17 September, 2019 1

Agenda


Time Item Presenter

10.30am – 10.50am Welcome and overview

of the MBS Review

Mr Andrew Simpson, Assistant

Secretary, MBS Reviews

10.50am – 12.00pm Anaesthesia changes Dr Andrew Singer,

Medical Advisor

12.00pm – 12.45pm Lunch

12.45pm – 1.45pm Colonoscopy changes Professor Fin Macrae

Member, Gastroenterology Clinical

Committee

Mr Ransome Mclean

A/g Director, MBS Reviews

1.45pm – 2.00pm Other MBS changes

• Eating Disorders

• GP telehealth

• Diagnostic Imaging

• Amended Medicare

items

Mr Andrew Simpson, Assistant

Secretary, MBS Reviews

Ms Mary Warner, Director, Medical

Specialist Services Section

2.00pm – 2.30pm Q&A

Welcome and overview of the MBS Review


Presenter:

Mr Andrew Simpson,

Assistant Secretary

Department of Health

MBS Reviews

Stakeholder Forum

• Changes are coming to the MBS on November 1 2019.

• Combination of new items, amendments and deletions.

• Complex, covering specialist services and primary care.

• Purpose of today is to give an overview of changes coming on

November 1

• Discuss the rationale for changes

• Provide detail on the changes

• Answer questions and prepare for a smooth transition on November 1.

417 September, 2019

The MBS Review

• The MBS has not been reviewed in 30 years

• The MBS Review Taskforce was established in 2015

• The MBS Review aims to improve quality care and ensure services funded through the MBS are high-value.

• The Taskforce is reviewing the 5,700 items under the MBS to ensure they:• align with contemporary clinical evidence and practice

• improve health outcomes for patients

• do not put patients at unnecessary risk

• The Taskforce provides advice to the Minister, including:• Evidence for services

• Appropriateness

• Best practice options

• Levels and frequency of support through the MBS

517 September, 2019

The MBS Review cont.

• Over 70 clinical committees and many more working groups

established

• It is anticipated that more than 60 reports will be delivered by the

Taskforce to Government by the completion of the MBS Review

• The Review is clinician led

• Over 700 clinicians, consumer and health system experts involved in

the Review

617 September, 2019

The MBS Review Process

• The process of reviewing and implementing changes to items taking approximately 2 years

• More than 30 reports have been delivered to government

• 5 phases of activity• Initial Review

• Consultation

• Consideration by Government

• Implementation

• Evaluation

Approximately 30 reports remain to be delivered to government or have just been finalised


Implementation

• Agreement by Government

• Establishment of an Implementation Liaison Group (ILG)

• Drafting of item descriptors, ensuring intent of changes is achieved

with minimal administrative disruption

• Approval of regulatory changes by the Governor-General

• Communications activities including forum


Future MBS Changes and Stakeholder Forums

• Stakeholders, including the AMA, RACGP and a variety of

colleges and societies have been engaged in the MBS

Review and are supportive of enhanced communications

activity

• Feedback from the AMA has highlighted the need for

earlier, proactive communication of MBS changes

• It is the intention of the Department to hold stakeholder

forums on a regular basis at approximately 8-12 weeks

prior to the implementation of MBS changes

• 2-3 forums a year


1 November 2019 Changes

ALL changes referred to in this presentation are

subject to finalisation of regulatory amendments

and parliamentary scrutiny


ANAESTHESIA MBS ITEM CHANGES


Presenter:

Dr Andrew Singer, Medical Advisor

MBS Reviews

The MBS Review of Anaesthesia


• The Anaesthesia Clinical Committee (ACC) of the MBS Review

Taskforce was established in 2016

• The ACC was assigned 528 MBS items to review and made

67 recommendations

• Consultation was undertaken on the ACC recommendations

between 2016 and 2018

• The report was amended as a result of consultation

• The Taskforce endorsed the final report in late 2018

The Anaesthesia changes – 1 November 2019


• From 1 November 2019, MBS items for anaesthesia

services are changing to reflect contemporary

anaesthesia practice

• These changes are a result of the Taskforce

recommendations and extensive consultation with

stakeholders

• Billing practices from 1 November 2019 will need to

be adjusted to reflect these changes

Summary of Changes


• The revised structure contains twenty eight amended items,

proposes ten new items and deletes thirty one items

• The revised structure:

• Better describes the procedures being performed by

anaesthetists

• Simplifies the MBS

• Reflects contemporary practice of anaesthesia services


Regional nerve blocks – epidural injection

• 18216, 18219, 18226 and 18227 have been amended to allow for

Combined Spinal-Epidural (CSE) infusion

• No change to fees

Item Descriptor

18216 Intrathecal, combined spinal-epidural or epidural infusion of a therapeutic substance,

initial injection or commencement of, including up to 1 hour of continuous attendance by

the medical practitioner (Anaes.)

Applicable once per presentation per medical practitioner

18219 Intrathecal, combined spinal-epidural or epidural infusion of a therapeutic substance,

initial injection or commencement of, if continuous attendance by the medical

practitioner extends beyond the first hour (Anaes.)


Item Descriptor

18226 Intrathecal, combined spinal-epidural or epidural infusion of a therapeutic

substance, initial injection or commencement of, including up to 1 hour of

continuous attendance by the medical practitioner—for a patient in labour, if the

service is provided between 8 pm to 8 am on any weekday, or on a Saturday,

Sunday or public holiday

Applicable once per presentation per medical practitioner

18227 Intrathecal, combined spinal-epidural or epidural infusion of a therapeutic

substance, initial injection or commencement of, where continuous attendance by

a medical practitioner extends beyond the first hour, for a patient in labour, where

the service is provided in the after hours period, being the period from 8pm to 8am

on any weekday, or any time on a Saturday, a Sunday or a public holiday.

Regional nerve blocks – epidural injection cont.


• An Explanatory Note has been added to items 18216 and 18226 to clarify

the intention of the items

TN.10.7

The administration of epidural anaesthesia during labour is covered by Item

18216 or 18219 in Group T7 of the Schedule whether administered by the

medical practitioner undertaking the confinement or by another medical

practitioner. Subsequent "top-ups" are covered by Item 18222 or 18225.

For the purposes of items 18216 and 18226 items, one attendance

means that the medical practitioner cannot claim either of these items if

the additional attendance is to optimise the initial treatment. Optimise

means extension or improvement in analgesic quality of an existing

block, without the insertion of a new block as a separate procedure.

Regional nerve blocks – epidural injection


Anaesthesia for Eye Surgeries

Item Descriptor Proposed Fee

20142 Initiation of the management of anaesthesia for lens

surgery (no change)

$120.60 6 Units

$100.50 5 Units

20144 Initiation of the management of anaesthesia for corneal

transplant (no change)

$160.80 8 Units

$140.70 7 Units

20145 Initiation of the management of anaesthesia for

vitrectomy (no change)

$160.80 8 Units

$140.70 7 Units

• Three anaesthesia for eye surgeries MBS items have amended fees to

reflect the anaesthesia complexity

• A new item for complex eye blocks is also being introduced

New

Item

Descriptor Proposed

Fee

22042* Introduction of a nerve block performed via a retrobulbar,

peribulbar, or sub Tenon’s approach, or other complex eye

block, when administered by an anaesthetist perioperatively

$20.10 1 unit


• The Explanatory Note for new item 22042 clarifies co-claiming of the item

TN.10.8 - Additional Services Performed in Connection with Anaesthesia -

Subgroup 19

These items (with the exception of peri-operative nerve blocks (22030-22042)

and perfusion services (22055-22075) have also been retained in the MBS in the

non-RVG format, for use by practitioners who provide these services other than

in association with anaesthesia.

Item 22042: This item can be co-claimed with item 20142 (anaesthesia for

lens surgery), when anaesthesia or sedation was also provided by the

same anaesthetist.

Item 22042 cannot be co-claimed with item 20142, 20144, 20145 and 20147

when a general anaesthetic is the primary anaesthetic approach.

Anaesthesia for Eye Surgeries cont.


Anaesthesia for Nose Surgery

Amended item 20160 Nose

Item Descriptor

20160 Initiation of the management of anaesthesia for intranasal

or accessory sinuses, not being a service to which another

item in this Subgroup applies

20162 Initiation of the management of anaesthesia for intranasal

surgery for malignancy or for intranasal ablation

• 20160 has been amended to clarify that it is for ‘intranasal’ procedures on

nose or accessory sinuses

• 20162 has been amended to ensure that item is being claimed for complex

nose and sinus surgeries



Electrical conversion of arrhythmias

Item Descriptor Proposed Fee

20410 Initiation of management of

anaesthesia for electrical conversion

of arrhythmias (no change).

$100.50 5 units

$80.40 4 units

• Fee reduction to better reflect the anaesthetic complexity


Abdominal procedures

Item Descriptor Proposed

fee


laparoscopic procedures in the upper abdomen,

including laparoscopic cholecystectomy, not being a

service to which another item in this Subgroup applies

$140.70

(no change)

20745 Initiation of the management of anaesthesia for either

or both of the following:

(a) upper gastrointestinal endoscopic procedures in

association with acute gastrointestinal haemorrhage;

(b) endoscopic retrograde

cholangiopancreatography

$140.70 7

units

$120.60 6

units.

20750 Initiation of the management of anaesthesia for hernia

repairs to the upper abdominal wall, other than a

service to which another item in this Subgroup applies

$100.50 5

units

$80.40 4

units

• These items have been amended to reflect contemporary surgical and

anaesthesia practice and anaesthetic complexity


Abdominal procedures cont.

Item Descriptor

20790* Initiation of the management of anaesthesia for procedures within

the peritoneal cavity in upper abdomen, including any of the

following:

(a) open cholecystectomy;

(b) gastrectomy;

(c) laparoscopically assisted nephrectomy;

(d) bowel shunts

20840* Initiation of the management of anaesthesia for all open

procedures within the lower abdominal peritoneal cavity,

including appendicectomy, not being a service to which another

item in this Subgroup applies

20902 Initiation of the management of anaesthesia for anorectal

procedures (including surgical haemorrhoidectomy, but not

banding of haemorrhoids)

• Banding of haemorrhoids can be claimed under MBS item 20810

• No change to fees• * denotes that the GMST wording differs but the intent of the descriptor is the same


Item Descriptor Proposed fee


computerised axial tomography scanning,

magnetic resonance scanning or digital

subtraction angiography scanning

$120.60 6 units

(no change)


fluoroscopy (no change).

$80.40 4 units

$100.50 5 units


heart - 2 dimensional real time transoesophageal

examination (no change).

$100.50 5 units

$120.60 6 units


diagnostic muscle biopsy to assess for malignant

hyperpyrexia.

$80.40 4 units

$201.00 10 units.

Anaesthesia for Diagnostic & Biopsy procedures

• Fee reductions to better reflect the anaesthetic complexity

• Minor amendment to 21952 to clarify the procedure


Item Descriptor

22002 Administration of homologous blood or bone marrow already collected, when

performed in association with the management of anaesthesia

22012* Central venous, pulmonary arterial, systemic arterial or cardiac intracavity

blood pressure monitoring by indwelling catheter—once per day for each type

of pressure for a patient:

(a) when performed in association with the management of anaesthesia for

the patient; and

(b) other than a service to which item 13876 applies

(c) is categorised as having a high risk of complications or during the

procedure develops either complications or a high risk of complications

Anaesthesia for Therapeutic and Diagnostic Services

• The changes to item 22002 better reflects current clinical practice

• Items 22012, 22014 and 22025 descriptors have been amended to better

describe the intention of the item and patient population

• No change to the fees



Item Descriptor

22014* Central venous, pulmonary arterial, systemic arterial or cardiac intracavity

blood pressure monitoring by indwelling catheter—once per day for each type

of pressure for a patient:

(a) when performed in association with the management of anaesthesia for

the patient; and

(b) relating to another discrete operation on the same day for the patient; and

(c) other than a service to which item 13876 applies

(d) who is categorised as having a high risk of complications or

develops during the current procedure either complications or a high

risk of complications

22025* Intra-arterial cannulation when performed in association with the management

of anaesthesia in a patient who:

(a) is categorised as having a high risk of complications; or

(b) develops a high risk of complications during the procedure


• Amendment to the Explanatory Note for items 22012, 22014 and 22025 to

clarify ‘high risk’

TN10.8

Items 22012 and 22014

Benefits are payable under items 22012 and 22014 only once for each type of

pressure, up to a maximum of 4 pressures per patient per calendar day, and

irrespective of the number of practitioners involved in monitoring the pressures

For items 22012, 22014 and 22025 :

A patient who is categorised as having a high risk of complications is one

where clinical indications allow for the following items to be claimed (in

conjunction with items 22012, 22014 and 22025) with item 25000, item 25005

or item 25010 modifiers, and/or item 25015, and/or items 25020, 25025

and/or when the basic surgical item value is 10 or more units, and/or is

conjunction with items in group T10 Subgroup 13 (Shoulder and Axilla), or

with items 23170 – 24136 (for procedures of greater than four hours

duration) noting this is not an exhaustive list.



Intrathecal or epidural injections

• Items 22031 and 22036 have had a minor administrative amendment to clarify the

spelling of post-operative


• An amendment to the Explanatory Note to:

• clarify the intention of the post operative pain management

• reflect the deletion of item 22050 and the creation of item 22042

TN.10.17

Benefits are only payable for intra-operative nerve blocks performed for the

management of post-operative pain that are specifically catered for under items

22031 to 22050 22042

For items 22031 and 22036, postoperative pain management means that the

injected therapeutic substance is expected to prolong the analgesic effect of

the epidural or intrathecal technique


Intra-Operative Transoesophageal Echocardiography

• A new Explanatory Note has been created to ensure patient safety by

identifying the appropriate qualifications clinicians should have to provide

the service described under item 22051

Item 22051 is payable where the provider is appropriately credentialed to

provide the particular service, by a recognised body for the credentialing

of peri-operative cardiac ultrasound services. Credentialing must be

based on criteria consistent with those recommended by The Australian

and New Zealand College of Anaesthetists (ANZCA) in the current

version of their Professional Document PS46 "Guidelines on Training

and Practice of Perioperative Cardiac Ultrasound in Adults”.


• Amended age requirements to better reflect the anaesthetic complexity.

• No fee change

Anaesthesia/Perfusion Modifying Units

& Assistant for epidural blood patch

Item Descriptor

25015* Anaesthesia, perfusion or assistance in the management of

anaesthesia, where the patient is less than 12 months of age or 70

years or greater for a patient less than 4 years or 75 years or older


18297 Assistance at the administration of an epidural

blood patch (a service to which item 18233 applies)

by another medical practitioner

$60.30

3 Units

• A new item is being introduced to provide assistance in the administration of an

epidural blood patch

• The item is located in T7 of the MBS. The proposed fee is based on average

the time it takes to perform the procedure (30 minutes – 2 units) plus and an

additional unit


Anaesthesia / perfusion time units

Deleted Items New Item New MBS Online Descriptor Proposed fee

23021, 23022, 23023 23025* 16 MINUTES TO 30 MINUTES$40.20

23031, 23032, 23033 23035* 31 MINUTES to 45 MINUTES $60.30

23041, 23042, 23043 23045* 46 MINUTES TO 1:00 HOUR $80.40

23051, 23052, 23053 23055* 1:01 HOURS TO 1:15 HOURS $100.50

23061, 23062, 23063 23065* 1:16 HOURS TO 1:30 HOURS $120.60

23071, 23072, 23073 23075* 1:31 HOURS TO 1:45 HOURS$140.70

23081, 23082, 23083 23085* 1:46 HOURS TO 2:00 HOURS$160.80

• Perfusion or assistance anaesthesia items for under two hours is a

result of consolidating items to reflect 15 minutes time increments

• This change has resulted in the deletion of 21 items and the

creation of seven substitute items


Consolidated items

• Items 22040, 22045 and 22050 are being deleted.

• A new item has been introduced which combines the services previously

claimed under these items

• The fee for the new item was recommended by the Taskforce to reflect

the anaesthetic complexity

Item Descriptor Schedule fee

22041* Perioperative introduction of a plexus or nerve

block proximal to the lower leg or forearm for post

operative pain management.

$40.20

2 Units


Deleted items

Item Descriptor Comment


diagnostic laparoscopy procedures

Services under this item are expected

to be claimed under item 20706.


diagnostic laparoscopic procedures




endometrial ablation or resection in association

with hysteroscopy




barium enema or other opaque study of the

small bowel

This item is considered obsolete.

22001 Collection of blood for autologous transfusion

or when homologous blood is required for

immediate transfusion in an emergency

situation, when performed in association with

the administration of anaesthesia

This item has been deleted the

service is considered part of normal

clinical practice.

Reference to this item has been

removed from the Health Insurance

(General Medical Services Table)

Regulations 2019.


Deleted items

Item Descriptor Comment

22018 Measurement of the mechanical or gas exchange

function of the respiratory system, using

measurements of parameters that incorporate serial

arterial blood gas analysis and include at least 2 of

the following parameters:

(a) pressure;

(b) volume;

(c) flow;

(d) gas concentration in inspired or expired air;

(e) alveolar gas or blood;

performed in association with the management of

anaesthesia, and for which a written record of the

results is prepared, other than a service associated

with a service to which item 11503 applies

This item has been deleted

the service is considered part

of normal clinical practice.

As a result of this deletion

reference to 22018 has been

removed from items 11507

and 11512.

22070 Cardioplegia, blood or crystalloid, administration by

any route, that is:

(a) a service to which item 22060 applies; and

(b) not a service associated with a service to which

an item in Subgroup 21 applies

This item has been deleted

the service is considered part

of normal clinical practice.

Any questions

3517 September, 2019

COLONOSCOPY MBS ITEM CHANGES


Presenter:

Professor Fin Macrae

Member, Gastroenterology Clinical Committee

&

Mr Ransome Mclean, a/g Director MBS Reviews

Why do we need to review colonoscopy items?

The number of colonoscopies, with or without polypectomy, is also increasing.

• In 2018-19:

• 311,364 colonoscopies without polypectomy (MBS item 32090)

• 310,015 colonoscopies with polypectomy (MBS item 32093)

• From 2008 to 2018:

• 26.4% increase in colonoscopies without polypectomy (MBS item 32090)

• 140.5 % increase in colonoscopies with polypectomy (MBS item 32093)

• Continue to increase with ageing population and impact of National Bowel Cancer Screening Program


38

$0

$20,000,000

$40,000,000

$60,000,000

$80,000,000

$100,000,000

$120,000,000

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Medicare Benefits for items 32090 and 32093

Item 32290 Item 32093

17 September, 2019

Why do we need to review colonoscopy items?

• Australian Atlas of Healthcare Variation 2015:

• The Atlas mapped colonoscopies by where people lived, age

standardized the data and provided the results in deciles.

• In addition to a general increase in MBS-funded colonoscopies, the

Atlas also showed:

• Large variations in colonoscopy rates

• Highest rate 30 times that of the lowest

• Rates higher in metropolitan areas, and higher in high SES populations

• Inadequate access to services in certain parts of the country

• Significant waiting lists


MBS Colonoscopies performed


41

MBS Colonoscopies

performed

17 September, 2019

MBS Colonoscopies performed 2013-2014


Review of MBS items - Colonoscopy

• Gastroenterology Clinical Committee reconvened at the request of the

Minister to further review the MBS items for colonoscopy.

• The Committee agreed on the key aims of developing

recommendations for colonoscopy MBS items that:

• facilitate the provision of effective, evidence-based colonoscopy services

• reduce low-value care

• improve access to MBS-funded colonoscopy services for those who need it

• are implementable and practical.


Summary of agreed changes to colonoscopy items


1 Reimbursement should be aligned with best clinical practice for colonoscopy agreed across relevant

medical specialties.

2 Items should be restructured to reflect clinical indications and surveillance intervals for colonoscopy.

A new suite of items is recommended.

3 Current colonoscopy items require examination ‘beyond the hepatic flexure’. This should be

amended ‘to the caecum’ to emphasise the importance of a complete colonoscopy. For patients post

right hemicolectomy this examination should be to the anastomosis.

4 Reference to ‘fibre optic’ should be removed as all contemporary colonoscopes are digital.

5 Reference to ‘flexible’ should be removed as all colonoscopes are flexible.

6 Restrictions should be introduced on the co-claiming of services 32090 and 32093 on the same day,

same patient, during a single episode of sedation/anaesthesia.

7 Remove the treatment of radiation proctitis, angiodysplasia or post-polypectomy bleeding from the

polyp removal colonoscopy item and create a separate item for this service. It is also recommended

that specific reference to Argon Plasma Coagulation be removed to enable any therapy to be used.

8 New colonoscopy items for symptomatic patients/patients with iron deficiency; and for patients

following a positive FOBT test.

Changes to the MBS

• Changes will be implemented on 1 November 2019.

• Eight new colonoscopy items will be added to MBS to replace four

current MBS items:

• NEW

• 32222, 32223, 32224, 32225, 32226, 32227, 32228, 32229

• DELETED

• 32088, 32089, 32090, 32093



NEW ITEM

MBS item 32222

Item Item DescriptorProposed

FeeExplanatory Notes

1

Endoscopic examination of the colon to the caecum

by colonoscopy, for a patient:

(a) following a positive faecal occult blood test; or

(b) who has symptoms consistent with pathology of the

colonic mucosa; or

(c) who has anaemia or iron deficiency; or

(d) for whom diagnostic imaging has shown an

abnormality of the colon; or

(e) who is undergoing the first examination following

surgery for colorectal cancer; or

(f) who is undergoing pre-operative evaluation; or

(g) for whom a repeat colonoscopy is required due to

inadequate bowel preparation for the patient’s previous

colonoscopy; or

(h) for the management of inflammatory bowel disease

Applicable only once on a day under a single episode of

anaesthesia or other sedation (Anaes.)

$339.70

Explanatory Note

detailing appropriate

colonoscopy intervals

for patients with a

positive FOBT and

subsequent

colonoscopy with no

abnormalities detected.

Explanatory Note

stating that 32084

should be billed if

preparation is

inadequate to allow

visualisation to the

caecum.

MBS fee: $339.70 Benefit: 75% = $254.80 85% = $288.75


NEW ITEM

MBS item 32223

Item Item DescriptorPropose

d FeeExplanatory Notes

2

Endoscopic examination of the colon to the

caecum by colonoscopy, for a patient:

(a) who has had a colonoscopy that revealed 1 to 4

adenomas, each of which was less than 10 mm in

diameter, had no villous features and had no high

grade dysplasia; or

(b) who has a moderate risk of colorectal cancer due

to family history; or

(c) who has a history of colorectal cancer and has

had an initial post-operative colonoscopy that did not

reveal any adenomas or colorectal cancer

Applicable only once in any 5-year period (Anaes.)

$339.70

Explanatory Note stating

patients with a low-risk

family history should

undergo FOBT.

A patient may be considered

at MODERATE risk of

colorectal cancer if family

history of colorectal cancer

(1 FDR less than 55yrs of

age at diagnosis OR 2 FDRs

OR 1 FDR and 2 SDRs any

age at diagnosis).

For patients with 1-2

adenoma (<10mm with no

high-risk histological

features) colonoscopy every

10 years is sufficient.

MBS fee: $339.70 Benefit: 75% = $254.80 85% = $288.75


NEW ITEM

MBS item 32224

Item Item DescriptorPropose

d FeeExplanatory Notes

3

Endoscopic examination of the colon to the caecum

by colonoscopy, for a patient who has a moderate

risk of colorectal cancer due to:

(a) a history of adenomas, including an adenoma that:

(i) was greater than 10 mm in diameter; or

(ii) had villous features; or

(iii) had high grade dysplasia; or

(iv) was an advanced serrated adenoma; or

(b) having had a previous colonoscopy that revealed 5

to 9 adenomas, each of which was less than 10 mm in

diameter, had no villous features and had no high grade

dysplasia

Applicable only once in any 3-year period (Anaes.)

$339.70

MBS fee: $339.70 Benefit: 75% = $254.80 85% = $288.75


NEW ITEM

MBS item 32225



4


caecum by colonoscopy, for a patient who has

a high risk of colorectal cancer due to having

had a previous colonoscopy that:

(a) revealed 10 or more adenomas; or

(b) included a piecemeal, or possibly incomplete,

excision of a large, sessile polyp

Applicable not more than 4 times in any 12-month

period (Anaes.)

$339.70

MBS fee: $339.70 Benefit: 75% = $254.80 85% = $288.75


NEW ITEM

MBS item 32226



5


caecum by colonoscopy, for a patient who has

a high risk of colorectal cancer due to:

(a) a known or suspected familial condition, such

as familial adenomatous polyposis, Lynch

syndrome or serrated polyposis syndrome; or

(b) a genetic mutation associated with hereditary

colorectal cancer

Applicable only once in any 12-month period

(Anaes.)

$339.70

MBS fee: $339.70 Benefit: 75% = $254.80 85% = $288.75


NEW ITEM

MBS item 32227



6


caecum by colonoscopy:

(a) for the treatment of bleeding, including one or

more of the following:

(i) radiation proctitis;

(ii) angioectasia;

(iii) post-polypectomy bleeding; or

(b) for the treatment of colonic strictures with

balloon dilatation

Applicable only once on a day under a single

episode of anaesthesia or other sedation (Anaes.)

$476.70

MBS fee: $476.70 Benefit: 75% = $357.55 85% = $405.20


NEW ITEM

MBS item 32228



7


caecum by colonoscopy, other than a service to

which item 32222, 32223, 32224, 32225 or 32226

applies

Applicable only once (Anaes.)

$339.70

MBS fee: $339.70 Benefit: 75% = $254.80 85%=$288.75


NEW ITEM

MBS item 32229



8

Removal of one or more polyps during

colonoscopy, in association with a service to which

item 32222, 32223, 32224, 32225, 32226 or

32228 applies (Anaes.)

$274.00

MBS fee: $274.00 Benefit: 75% = $205.50 85% = $232.90

Deleted MBS item

32088

FIBREOPTIC COLONOSCOPY examination of the colon beyond the hepatic flexure WITH or WITHOUT BIOPSY, following a positive faecal occult blood test for a participant registered on the National Bowel Cancer Screening Program (Anaes.)

Services under this item are expected to be claimed under items 32222-32229

54Stakeholder Forum - 17 September 2019

Item will be obsolete due to

new item 32222 capturing

colonoscopy following FOBT.

This will be used for FOBT

picked up via the National

Bowel Screening Program.

Deleted MBS item

32089

Endoscopic examination of the colon

beyond the hepatic flexure by

FIBREOPTIC COLONOSCOPY for the

REMOVAL OF 1 OR MORE POLYPS,

following a positive faecal occult blood

test for a participant registered on the

National Bowel Cancer Screening

Program (Anaes.)

Services under this item are

expected to be claimed under

items 32222-32229.


Item will be obsolete due to

new item 32222 capturing

colonoscopy following FOBT.

This will be used for FOBT

picked up via the National

Bowel Screening Program.

Deleted MBS items

32090

Fibreoptic colonoscopy —examination of colon beyond the hepatic flexure with or without biopsy (Anaes.)

32093

Endoscopic examination of the colon beyond the hepatic flexure by fibreopticcolonoscopy 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 (Anaes.)

Services under these items are expected to be claimed under items 32222-32229.


Replace items 32090 & 32093

with new items to align

colonoscopy services with

Australian clinical practice

guidelines

New items better describe

the indications for initial

colonoscopy and ensure

appropriate surveillance

intervals for patients who are

at increased risk of

developing colorectal cancer

What does this mean for providers?

• The new items better describe the indications for initial colonoscopy

and ensure appropriate surveillance intervals of patients who are at

increased risk of developing colorectal cancer

• Providers will need to familiarise themselves with the changes,

associated rules and explanatory notes

• Ensure services billed to Medicare meet eligibility requirements

outlined in the legislation.


What does this mean for patients?

• Improved value for the patient and healthcare system

• Effective and evidence-based colonoscopy services

• Patients will receive Medicare rebates for colonoscopy services that

are clinically appropriate and reflect modern clinical and evidence

based practice

• Improved patient safety and quality of care

• Reduction in unnecessary colonoscopies

• Improved access to MBS funded services to those who need it


What is the definition of previous history (items 32222-32225)?

• For items 32223-32225, 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 ANY previous

colonoscopy.

• Although with a patient with a previous history of 1-2 low risk

adenomas (<10mm with no high-risk histological features) is eligible a

colonoscopy every five years under item 32223, the clinical guidelines

indicate that colonoscopy every 10 years is sufficient.


What is the Definition of moderate risk of colorectal cancer due to

family history (in item 32223)?

• For item 32223, a patient is considered at moderate risk of colorectal

cancer if there is moderate risk family history of colorectal cancer –

defined as:

• 1 first degree relative less than 55 years of age at diagnosis; OR

• 2 first degree relatives with a history of colorectal cancer; OR

• 1 first degree relative and 2 second degree relatives with a history of

colorectal cancer.

• The national clinical practice guidelines support the use of faecal

occult blood tests for patients as a first line test for patients with a low

risk family history of colorectal cancer.


Why is there an Exception item (item 32228)?

• Timing of colonoscopy following polypectomy should conform to the recommended surveillance intervals set out in the guidelines, 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.

• Where the clinician is unable to access sufficient patient information to enable a colonoscopy to be performed under items 32222-32226, but in their clinical opinion believe that there is a clinical need for a colonoscopy, then item 32228 is available in this situation.

• Please note: This item is available once per patient per lifetime.


What is meant by Time intervals

(Items 32223, 32224, 32225 and 32226)?

• Items 32223, 32224, 32225 and 32226 have clinically appropriate

time intervals for repeat colonoscopy.

• These services are payable under Medicare only when provided in

accordance with the approved intervals.

• 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.


Any questions


NEW MEDICARE ITEMS FOR 1 NOVEMBER 2019


Mr Andrew Simpson,

Assistant Secretary

MBS Reviews


Eating Disorders

• A suite of new eating disorder items are being introduced, to support

a model of best practice evidence based care for patients with

anorexia nervosa and other eligible patients with eating disorders.

• The new item structure contains 64 new items for eating disorders.

• Eligible patients will be able to access up to 40 psychological services

and 20 dietetic services in a 12 month period.

• The items have been designed with the aim of supporting ongoing

multidisciplinary care in the community.


From 1 November 2019, there will be 64 new items for Eating Disorders. The

new item structure includes:

• 12 new items (90250-90257 and 90260-90263) for GP, medical practitioner,

consultant psychiatrist and paediatrician preparation of eating disorders

treatment and management plans.

• 6 new items (90264-90269) for GP, medical practitioner, consultant psychiatrist and

paediatrician review of eating disorders treatment and management plans.

• 12 new items (90271-90282) for GP, medical practitioner, consultant psychiatrist and

paediatrician provision of psychological treatment services.

• 2 new items (82350-82351) for Dietitian provision of eating disorders dietitian

health services.

• 32 new items (82352-82383) for Clinical Psychologist and Psychologist,

Occupational Therapists and Social Workers provision of eating disorder

psychological treatment services.

Overview of the Eating Disorders

Treatment Pathway


GP Telehealth• 12 new items are being introduced for people living in rural and remote

areas (Modified Monash Model areas 6-7)

• Eligible patients in MM6-7 regions, have an established clinical

relationship with telehealth provider

• $33.5 million for new GP telehealth MBS items

• The new items align with draft recommendations of General Practice and

Primary Care Clinical Committee

• Information to stakeholders on final MBS items will be provided soon

General Practitioner (GP) Telehealth



2461

Professional attendance by video conference by a general

practitioner for an obvious problem characterised by the

straightforward nature of the task that requires a short

patient history and, if required, limited examination and

management—each attendance

17.50

2463

Professional attendance by video conference by a general

practitioner, of less than 20 minutes in duration, including

any of the following that are clinically relevant:

(a) taking a patient history;

(b) performing a clinical examination;

(c) arranging any necessary investigation;

(d) implementing a management plan;

(e) providing appropriate preventive health care;

for one or more health-related issues, with appropriate

documentation—each attendance

38.20

Subgroup 5—General practitioner video conferencing

consultation attendance for patients in rural and remote areas



2464

Professional attendance by video conference by a general practitioner,

of at least 20 minutes in duration but less than 40 minutes, including any

of the following that are clinically relevant:






for one or more health-related issues, with appropriate documentation—

each attendance

73.95

2465

Professional attendance by video conference by a general practitioner,

of at least 40 minutes in duration, including any of the following that are

clinically relevant:






for one or more health-related issues, with appropriate documentation—

each attendance

108.85

Subgroup 5—General practitioner video conferencing consultation

attendance for patients in rural and remote areas cont.


Item Descriptor Proposed

fee

2471 Professional attendance by video conference of not more

than 5 minutes in duration by a medical practitioner who is

not a general practitioner—each attendance

11.00

2472 Professional attendance by video conference of more than

5 minutes in duration but not more than 25 minutes by a

medical practitioner who is not a general practitioner—each

attendance

21.00



medical practitioner who is not a general practitioner—each

attendance

38.00


45 minutes in duration by a medical practitioner who is not

a general practitioner—each attendance

61.00

Subgroup 6—Other non referred video conferencing

consultation attendance for patients in rural and remote areas


Subgroup 7 – Non Specialist Practitioner video conferencing consultation for patients in rural and remote areas


2480 Professional attendance by video conference of not more

than 5 minutes in duration by a medical practitioner – each

attendance

14.00



medical practitioner – each attendance

30.55



medical practitioner – each attendance

59.15


45 minutes in duration who is not a medical practitioner –

each attendance

87.10


Diagnostic Imaging New Items

Magnetic Resonance Imaging (MRI)

• Four new interim items for MRI scans of the breast to support future

consideration by Medical Services Advisory Committee (MSAC).

• Services are for:

• the diagnosis of breast cancer where other diagnostic imaging has

proven inconclusive; and

• for treatment planning where an earlier diagnostic imaging result is

inconsistent with the clinical assessment.

• A dedicated breast coil must be used for these new services.

• These services can be provided on both full and partial eligible MRI

machines.


Item Description of the new service Proposed fee

63531

(K) &

63532

(NK)

MRI of both breasts where the patient has a breast

lesion, the results of conventional imaging

examinations are inconclusive for the presence of

breast cancer, and biopsy has not been possible

$690.00 (K)

$345.00 (NK)

63533

(K) and

63534

(NK)

MRI of both breasts where the patient has been

diagnosed with breast cancer, discrepancy exists

between clinical assessment and conventional

imaging assessment, and the results of breast MRI

may alter treatment planning

$690.00 (K)

$345.00 (NK)

Diagnostic Imaging Cont.

MRI Cont.


Positron Emission Tomography (PET)

• Two new items for FDG are being introduced for the evaluation of breast cancer

• These items were recommended by the MSAC in November 2018



61524 Whole body 18F-FDG PET study where the patient

is referred by a specialist or consultant physician,

performed for the staging of locally advanced

(Stage III) breast cancer in a patient considered

potentially suitable for active therapy

$953.00

61525 Whole body 18F-FDG PET study, where the

patient is referred by a specialist or consultant

physician, performed for the evaluation of

suspected metastatic or suspected locally or

regionally recurrent breast carcinoma in a patient

considered suitable for active therapy

$953.00


X-RAY

• One new item is being introduced for the mobile provision of skeletal x-ray to

patients within residential aged care facilities



57541 The service must be requested by a medical practitioner who has

attended the patient in person and the request must identify one or

more of the following indications:

(a) the patient has experienced a fall and one or more of the following

items apply to the service: 57509, 57515, 57521, 57527, 57530,

57533, 57536, 57539 (x-rays of the extremities) 57703, 57705, 57709,

57711, 57712, 57714, 57715, 57717 (x-rays of the shoulder or pelvis),

58521, 58523, 58524, 58526, 58527, 58529 (x-rays of the ribs and

sternum); or

(b) pneumonia or heart failure is suspected and item 58503 or 58505

(chest x-rays) applies to the service; or

(c) acute abdomen or bowel obstruction is suspected and item 58903

or 58905 (plain abdominal x-rays) applies to the service.

This item can be claimed once only per visit at a residential aged

care facility irrespective of the number of patients x-rayed.

$73.65

If the service

is bulked

billed, 95% of

the fee is

payable.

The diagnostic

imaging

multiple

services rules

do not apply

to this item.

Any questions


AMENDED MEDICARE ITEMS FOR 1 NOVEMBER 2019


Presenter:

Ms Mary Warner, Director,

Medical Specialist Services Section

AMENDED MEDICARE ITEMS FOR 1 NOVEMBER 2019

15 October, 2019 78

Minor Amendments for 1 November 2019

• On 1 November 2019, there will be a number of minor

amendments to Medicare Benefits Schedule (MBS) items for the

following services:

• Sleep Studies

• Spinal Surgery

• Ear Nose and Throat (ENT)

• Gene Testing

• Plastic and Reconstructive Surgery.

• These amendments will:

• clarify the policy intent of these services;

• address anomalies;

• make enhancements (including for data collection and

compliance purposes).

15 October, 2019 79


Sleep Studies

• Item 12205 – Information from the existing MBS Explanatory Note will

be moved into the item descriptor to provide more clarity around the

clinical circumstances to which the item applies.

• Item 12207 – The term ‘cardio-respiratory failure’ will be replaced with

‘respiratory failure’ given patients with pure cardiac failure do not have

an exceptional need for this investigation.

Spinal Surgery

• Items 51051, 51052 and 51053 – The term ‘motion segment’ will be

replaced with the appropriate term ‘vertebra’ or ‘vertebrae’.

• Items 51061 to 51066 – The term 'spine fusion' will be replaced with the

appropriate term ‘spinal fusion’.

• Items 51113 and 51114 – Allow appropriate co-claiming of these items

with the paediatric scoliosis or kyphosis items (50600 to 50644).

• Item 51145 – Inclusion of the term (Assist.) in the item descriptor.

Amended Medicare Items For 1 November 2019 cont.

15 October, 2019 80


ENT

• Item 41846 – This item will be replaced with new item 41501 for

stroboscopy to better describe the procedure and help ensure compliance.

Urology

• Amendment to the definition of a non-Medicare service to include

Etracorporeal Magnetic Innervation (ExMI), a non-surgical therapy for the

treatment of urinary incontinence. This change will restrict Medicare

benefits for consultation services provided with, or in connection to, ExMI.

Gene Testing

• Items 73345-73350 – Amendment to six cystic fibrosis gene testing items

to clarify the clinical requirements for the services.

Plastic And Reconstructive Surgery

• Item 45626 – Split item 45626 for the treatment of ectropion/entropion into

two items for data collection purposes. This change will have no effect on

patient rebates and the fee for both services will be identical.


15 October, 2019 81

Post Implementation Reviews

• The Department will be reviewing the outcomes of MBS changes made

following the implementation of MBS Review Taskforce recommendations

(e.g. MBS changes for thoracic medicine).

• Timing of post implementation reviews may vary, but in some cases may

occur 6-12 months post the MBS changes.

• In the short term, post-implementation reviews will primarily seek to

identify if there may be any unintended consequences for patients as a

result of MBS changes made.



Communication documents on 1 November 2019 changes will be provided

at: http://www.mbsonline.gov.au under Factsheets

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

Any questions


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