CHANGES TO THE MEDICARE BENEFITS SCHEDULE FOR 1 NOVEMBER 2019 - Stakeholder Forum

 
CHANGES TO THE MEDICARE BENEFITS SCHEDULE FOR 1 NOVEMBER 2019 - Stakeholder Forum
CHANGES TO THE MEDICARE BENEFITS
    SCHEDULE FOR 1 NOVEMBER 2019

Stakeholder Forum

Tuesday, 17 September 2019

17 September, 2019                   1
CHANGES TO THE MEDICARE BENEFITS SCHEDULE FOR 1 NOVEMBER 2019 - Stakeholder Forum
Agenda
Time                   Item                   Presenter
10.30am – 10.50am Welcome and overview        Mr Andrew Simpson, Assistant
                  of the MBS Review           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      Mr Andrew Simpson, Assistant
                       • Eating Disorders     Secretary, MBS Reviews
                       • GP telehealth
                       • Diagnostic Imaging   Ms Mary Warner, Director, Medical
                       • Amended Medicare     Specialist Services Section
                         items
2.00pm     – 2.30pm
  17 September, 2019
                       Q&A                                                   2
CHANGES TO THE MEDICARE BENEFITS SCHEDULE FOR 1 NOVEMBER 2019 - Stakeholder Forum
Welcome and overview of the MBS Review

     Presenter:
     Mr Andrew Simpson,
     Assistant Secretary
     Department of Health
     MBS Reviews

17 September, 2019                   3
CHANGES TO THE MEDICARE BENEFITS SCHEDULE FOR 1 NOVEMBER 2019 - Stakeholder Forum
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.

17 September, 2019                                                          4
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

17 September, 2019                                                                     5
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

17 September, 2019                                                       6
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

17 September, 2019                                                               7
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

17 September, 2019                                                       8
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

17 September, 2019                                            9
1 November 2019 Changes

   ALL changes referred to in this presentation are
   subject to finalisation of regulatory amendments
               and parliamentary scrutiny

17 September, 2019                                    10
ANAESTHESIA MBS ITEM CHANGES

            Presenter:
            Dr Andrew Singer, Medical Advisor
            MBS Reviews

17 September, 2019                              11
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

17 September, 2019                                                12
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

17 September, 2019                                           13
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

17 September, 2019                                      14
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.)

   17 September, 2019                                                                    15
Regional nerve blocks – epidural injection cont.
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.

17 September, 2019                                                                        16
Regional nerve blocks – epidural injection

  • 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.

17 September, 2019                                                              17
Anaesthesia for Eye Surgeries
  • 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
Item Descriptor                                                 Proposed Fee
20142 Initiation of the management of anaesthesia for lens       $120.60 6 Units
      surgery (no change)                                        $100.50 5 Units
20144 Initiation of the management of anaesthesia for corneal    $160.80 8 Units
      transplant (no change)                                     $140.70 7 Units
20145 Initiation of the management of anaesthesia for            $160.80 8 Units
      vitrectomy (no change)                                     $140.70 7 Units

New    Descriptor                                                    Proposed
Item                                                                 Fee
22042* Introduction of a nerve block performed via a retrobulbar,    $20.10 1 unit
       peribulbar, or sub Tenon’s approach, or other complex eye
       block, when administered by an anaesthetist perioperatively

  17 September, 2019                                                          18
Anaesthesia for Eye Surgeries cont.

• 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.

 17 September, 2019                                                           19
Anaesthesia for Nose Surgery
• 20160 has been amended to clarify that it is for ‘intranasal’ procedures on
  Amended item 20160 Nose
  nose or accessory sinuses
• 20162 has been amended to ensure that item is being claimed for complex
  nose and sinus surgeries
• No change to fees

 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

 17 September, 2019                                                             20
Electrical conversion of arrhythmias

     • Fee reduction to better reflect the anaesthetic complexity

  Item               Descriptor                              Proposed Fee
  20410              Initiation of management of             $100.50 5 units
                     anaesthesia for electrical conversion   $80.40 4 units
                     of arrhythmias (no change).

17 September, 2019                                                             21
Abdominal procedures
 • These items have been amended to reflect contemporary surgical and
   anaesthesia practice and anaesthetic complexity
Item         Descriptor                                        Proposed
                                                               fee
20706 Initiation of the management of anaesthesia for          $140.70
      laparoscopic procedures in the upper abdomen,            (no change)
      including laparoscopic cholecystectomy, not being a
      service to which another item in this Subgroup applies
20745 Initiation of the management of anaesthesia for either   $140.70 7
      or both of the following:                                units
      (a) upper gastrointestinal endoscopic procedures in      $120.60 6
      association with acute gastrointestinal haemorrhage;     units.
      (b) endoscopic retrograde
      cholangiopancreatography
20750 Initiation of the management of anaesthesia for hernia   $100.50 5
      repairs to the upper abdominal wall, other than a        units
      service to which another item in this Subgroup applies   $80.40 4
                                                               units
17 September, 2019                                                         22
Abdominal procedures cont.
 • 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
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)
17 September, 2019                                                                          23
Anaesthesia for Diagnostic & Biopsy procedures
  • Fee reductions to better reflect the anaesthetic complexity
  • Minor amendment to 21952 to clarify the procedure
Item         Descriptor                                      Proposed fee
21922 Initiation of the management of anaesthesia for        $120.60 6 units
      computerised axial tomography scanning,                (no change)
      magnetic resonance scanning or digital
      subtraction angiography scanning
21926 Initiation of the management of anaesthesia for        $80.40 4 units
      fluoroscopy (no change).                               $100.50 5 units
21936 Initiation of the management of anaesthesia for        $100.50 5 units
      heart - 2 dimensional real time transoesophageal       $120.60 6 units
      examination (no change).
21952 Initiation of the management of anaesthesia for  $80.40 4 units
      diagnostic muscle biopsy to assess for malignant $201.00 10 units.
      hyperpyrexia.

17 September, 2019                                                             24
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
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

   17 September, 2019                                                         25
Anaesthesia for Therapeutic and Diagnostic Services

 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

   17 September, 2019                                                           26
Anaesthesia for Therapeutic and Diagnostic Services

• 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.

 17 September, 2019                                                                27
Intrathecal or epidural injections

• Items 22031 and 22036 have had a minor administrative amendment to clarify the
  spelling of post-operative
• No change to fees
• 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

  17 September, 2019                                                              28
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”.

17 September, 2019                                                               29
Anaesthesia/Perfusion Modifying Units
                                 & Assistant for epidural blood patch
• Amended age requirements to better reflect the anaesthetic complexity.
• No fee change

 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
• 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
 Item       Descriptor                                            Proposed fee
 18297           Assistance at the administration of an epidural       $60.30
                 blood patch (a service to which item 18233 applies)   3 Units
                 by another medical practitioner

17 September, 2019                                                               30
Anaesthesia / perfusion time units

     • 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

Deleted Items         New Item   New MBS Online Descriptor          Proposed fee
                                                                        $40.20
23021, 23022, 23023 23025*       16 MINUTES TO 30 MINUTES
                                                                         $60.30
23031, 23032, 23033 23035*       31 MINUTES to 45 MINUTES
                                                                         $80.40
23041, 23042, 23043 23045*       46 MINUTES TO 1:00 HOUR
                                                                        $100.50
23051, 23052, 23053 23055*       1:01 HOURS TO 1:15 HOURS
                                                                        $120.60
23061, 23062, 23063 23065*       1:16 HOURS TO 1:30 HOURS
                                                                        $140.70
23071, 23072, 23073 23075*       1:31 HOURS TO 1:45 HOURS
                                                                        $160.80
23081, 23082, 23083 23085*       1:46 HOURS TO 2:00 HOURS

17 September, 2019                                                            31
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       $40.20
                     block proximal to the lower leg or forearm for post   2 Units
                     operative pain management.

17 September, 2019                                                                   32
Deleted items
Item         Descriptor                                    Comment
20705      Initiation of the management of anaesthesia for Services under this item are expected
           diagnostic laparoscopy procedures                to be claimed under item 20706.
20805      Initiation of the management of anaesthesia for Services under this item are expected
           diagnostic laparoscopic procedures               to be claimed under item 20806.
20953      Initiation of the management of anaesthesia for Services under this item are expected
           endometrial ablation or resection in association to be claimed under item 20952.
           with hysteroscopy
21927      Initiation of the management of anaesthesia for This item is considered obsolete.
           barium enema or other opaque study of the
           small bowel
22001      Collection of blood for autologous transfusion This item has been deleted the
           or when homologous blood is required for         service is considered part of normal
           immediate transfusion in an emergency            clinical practice.
           situation, when performed in association with
           the administration of anaesthesia                Reference to this item has been
                                                            removed from the Health Insurance
                                                            (General Medical Services Table)
                                                            Regulations 2019.

  17 September, 2019                                                                       33
Deleted items
Item       Descriptor                                             Comment
22018     Measurement of the mechanical or gas exchange           This item has been deleted
          function of the respiratory system, using               the service is considered part
          measurements of parameters that incorporate serial      of normal clinical practice.
          arterial blood gas analysis and include at least 2 of
          the following parameters:                               As a result of this deletion
          (a) pressure;                                           reference to 22018 has been
          (b) volume;                                             removed from items 11507
          (c) flow;                                               and 11512.
          (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
22070     Cardioplegia, blood or crystalloid, administration by   This item has been deleted
          any route, that is:                                     the service is considered part
          (a) a service to which item 22060 applies; and          of normal clinical practice.
          (b) not a service associated with a service to which
          an item in Subgroup 21 applies
 17 September, 2019                                                                           34
Any questions

17 September, 2019   35
COLONOSCOPY MBS ITEM CHANGES

         Presenter:
         Professor Fin Macrae
         Member, Gastroenterology Clinical Committee
         &
         Mr Ransome Mclean, a/g Director MBS Reviews

17 September, 2019                                     36
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

17 September, 2019                                                           37
Medicare Benefits for items 32090 and 32093
  $120,000,000

  $100,000,000

   $80,000,000

   $60,000,000

   $40,000,000

   $20,000,000

            $0
                     2008   2009   2010   2011       2012     2013      2014   2015   2016   2017   2018
                                                 Item 32290    Item 32093

17 September, 2019                                                                                     38
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

17 September, 2019                                                             39
MBS Colonoscopies performed

17 September, 2019                                 40
MBS Colonoscopies
                        performed

17 September, 2019            41
MBS Colonoscopies performed 2013-2014

17 September, 2019                                    42
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.

17 September, 2019                                                                 43
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.

17 September, 2019                                                                                       44
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

17 September, 2019                                                   45
NEW ITEM
                                                                        MBS item 32222
                                                                  Proposed
Item                        Item Descriptor                                    Explanatory Notes
                                                                     Fee
        Endoscopic examination of the colon to the caecum
        by colonoscopy, for a patient:                                       Explanatory Note
                                                                             detailing appropriate
        (a) following a positive faecal occult blood test; or                colonoscopy intervals
        (b) who has symptoms consistent with pathology of the                for patients with a
        colonic mucosa; or                                                   positive FOBT and
        (c) who has anaemia or iron deficiency; or                           subsequent
        (d) for whom diagnostic imaging has shown an                         colonoscopy with no
        abnormality of the colon; or                                         abnormalities detected.
                                                                  $339.70
  1     (e) who is undergoing the first examination following
        surgery for colorectal cancer; or
        (f) who is undergoing pre-operative evaluation; or                   Explanatory Note
        (g) for whom a repeat colonoscopy is required due to                 stating that 32084
        inadequate bowel preparation for the patient’s previous              should be billed if
        colonoscopy; or                                                      preparation is
        (h) for the management of inflammatory bowel disease                 inadequate to allow
                                                                             visualisation to the
        Applicable only once on a day under a single episode of              caecum.
        anaesthesia or other sedation (Anaes.)

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

17 September, 2019                                                                                  46
NEW ITEM
                                                                               MBS item 32223
                                                                  Propose
 Item                      Item Descriptor                                      Explanatory Notes
                                                                   d Fee
         Endoscopic examination of the colon to the                         Explanatory Note stating
         caecum by colonoscopy, for a patient:                              patients with a low-risk
                                                                            family history should
         (a) who has had a colonoscopy that revealed 1 to 4                 undergo FOBT.
         adenomas, each of which was less than 10 mm in
         diameter, had no villous features and had no high                   A patient may be considered
         grade dysplasia; or                                                at MODERATE risk of
                                                                            colorectal cancer if family
         (b) who has a moderate risk of colorectal cancer due               history of colorectal cancer
         to family history; or                                    $339.70
                                                                            (1 FDR less than 55yrs of
   2
                                                                            age at diagnosis OR 2 FDRs
         (c) who has a history of colorectal cancer and has                 OR 1 FDR and 2 SDRs any
         had an initial post-operative colonoscopy that did not             age at diagnosis).
         reveal any adenomas or colorectal cancer
                                                                             For patients with 1-2
         Applicable only once in any 5-year period (Anaes.)                 adenoma (
NEW ITEM
                                                                           MBS item 32224
                                                                     Propose
   Item                          Item Descriptor                               Explanatory Notes
                                                                      d Fee
           Endoscopic examination of the colon to the caecum         $339.70
           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
     3         (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.)

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

17 September, 2019                                                                             48
NEW ITEM
                                                                   MBS item 32225
                                                            Proposed
Item                       Item Descriptor                             Explanatory Notes
                                                               Fee
        Endoscopic examination of the colon to the          $339.70
        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
  4     (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.)

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

17 September, 2019                                                                         49
NEW ITEM
                                                                   MBS item 32226
                                                             Proposed
 Item                       Item Descriptor                             Explanatory Notes
                                                                Fee
         Endoscopic examination of the colon to the   $339.70
         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
   5
         (b) a genetic mutation associated with hereditary
         colorectal cancer

         Applicable only once in any 12-month period
         (Anaes.)

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

17 September, 2019                                                                          50
NEW ITEM
                                                                         MBS item 32227
                                                              Proposed
Item                            Item Descriptor                           Explanatory Notes
                                                                 Fee
        Endoscopic examination of the colon to the            $476.70
        caecum by colonoscopy:

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

              (i) radiation proctitis;

  6           (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.)

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

17 September, 2019                                                                            51
NEW ITEM
                                                                    MBS item 32228

                                                         Proposed
Item                      Item Descriptor                             Explanatory Notes
                                                            Fee
        Endoscopic examination of the colon to the       $339.70
        caecum by colonoscopy, other than a service to
        which item 32222, 32223, 32224, 32225 or 32226
  7     applies

        Applicable only once (Anaes.)

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

17 September, 2019                                                                        52
NEW ITEM
                                                                   MBS item 32229

                                                              Proposed
Item                       Item Descriptor                               Explanatory Notes
                                                                 Fee
        Removal of one or more polyps during                  $274.00
        colonoscopy, in association with a service to which
  8     item 32222, 32223, 32224, 32225, 32226 or
        32228 applies (Anaes.)

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

17 September, 2019                                                                           53
Deleted MBS item

32088

FIBREOPTIC COLONOSCOPY                   Item will be obsolete due to
examination of the colon beyond the       new item 32222 capturing
hepatic flexure WITH or WITHOUT           colonoscopy following FOBT.
BIOPSY, following a positive faecal       This will be used for FOBT
occult blood test for a participant
registered on the National Bowel          picked up via the National
Cancer Screening Program (Anaes.)         Bowel Screening Program.

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

Stakeholder Forum - 17 September 2019                                    54
Deleted MBS item

32089                                       Item will be obsolete due to
                                             new item 32222 capturing
Endoscopic examination of the colon          colonoscopy following FOBT.
beyond the hepatic flexure by                This will be used for FOBT
FIBREOPTIC COLONOSCOPY for the               picked up via the National
REMOVAL OF 1 OR MORE POLYPS,                 Bowel Screening Program.
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.
Stakeholder Forum - 17 September 2019                                       55
Deleted MBS items
32090

Fibreoptic colonoscopy —examination of      Replace items 32090 & 32093
colon beyond the hepatic flexure with or     with new items to align
without biopsy (Anaes.)                      colonoscopy services with
32093
                                             Australian clinical practice
                                             guidelines
Endoscopic examination of the colon
beyond the hepatic flexure by fibreoptic    New items better describe
colonoscopy for the removal of one or
more polyps, or the treatment of             the indications for initial
radiation proctitis, angiodysplasia or       colonoscopy and ensure
post-polypectomy bleeding by argon           appropriate surveillance
plasma coagulation, one or more of
(Anaes.)                                     intervals for patients who are
                                             at increased risk of
Services under these items are               developing colorectal cancer
expected to be claimed under items
32222-32229.

Stakeholder Forum - 17 September 2019                                         56
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.

Stakeholder Forum - 17 September 2019                                     57
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

Stakeholder Forum - 17 September 2019                                    58
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 (
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.

Stakeholder Forum - 17 September 2019                                           60
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.

Stakeholder Forum - 17 September 2019                                             61
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.

Stakeholder Forum - 17 September 2019                                    62
Any questions

17 September, 2019   63
NEW MEDICARE ITEMS FOR 1 NOVEMBER 2019

                     Mr Andrew Simpson,
                     Assistant Secretary
                     MBS Reviews

17 September, 2019                         64
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.

17 September, 2019                                                     65
Overview of the Eating Disorders
                                                      Treatment Pathway
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.

17 September, 2019                                                                         66
General Practitioner (GP) Telehealth

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

 17 September, 2019                                                  67
Subgroup 5—General practitioner video conferencing
                                consultation attendance for patients in rural and remote areas

Item        Descriptor                                                                Proposed fee
            Professional attendance by video conference by a general
            practitioner for an obvious problem characterised by the
2461        straightforward nature of the task that requires a short                         17.50
            patient history and, if required, limited examination and
            management—each attendance
            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;
2463                                                                                         38.20
            (d) implementing a management plan;
            (e) providing appropriate preventive health care;
            for one or more health-related issues, with appropriate
            documentation—each attendance

  17 September, 2019                                                                             68
Subgroup 5—General practitioner video conferencing consultation
                                attendance for patients in rural and remote areas cont.

Item      Descriptor                                                              Proposed fee
         Professional attendance by video conference by a general practitioner,
2464     of at least 20 minutes in duration but less than 40 minutes, including any 73.95
         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
         Professional attendance by video conference by a general practitioner, 108.85
2465     of at least 40 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
   17 September, 2019                                                                       69
Subgroup 6—Other non referred video conferencing
                        consultation attendance for patients in rural and remote areas

Item Descriptor                                                    Proposed
                                                                   fee
2471 Professional attendance by video conference of not more             11.00
     than 5 minutes in duration by a medical practitioner who is
     not a general practitioner—each attendance
2472 Professional attendance by video conference of more than            21.00
     5 minutes in duration but not more than 25 minutes by a
     medical practitioner who is not a general practitioner—each
     attendance
2475 Professional attendance by video conference of more than            38.00
     25 minutes in duration but not more than 45 minutes by a
     medical practitioner who is not a general practitioner—each
     attendance
2478 Professional attendance by video conference of more than            61.00
     45 minutes in duration by a medical practitioner who is not
     a general practitioner—each attendance

  17 September, 2019                                                           70
Subgroup 7 – Non Specialist Practitioner video conferencing
                          consultation for patients in rural and remote areas

Item      Descriptor                                                  Proposed fee

2480      Professional attendance by video conference of not more 14.00
          than 5 minutes in duration by a medical practitioner – each
          attendance

2481      Professional attendance by video conference of more than 30.55
          5 minutes in duration but not more than 25 minutes by a
          medical practitioner – each attendance

2482      Professional attendance by video conference of more than 59.15
          25 minutes in duration but not more than 45 minutes by a
          medical practitioner – each attendance

2483      Professional attendance by video conference of more than 87.10
          45 minutes in duration who is not a medical practitioner –
          each attendance

 17 September, 2019                                                                71
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.

17 September, 2019                                                          72
Diagnostic Imaging Cont.

MRI Cont.
Item                 Description of the new service                       Proposed fee
63531                MRI of both breasts where the patient has a breast   $690.00 (K)
(K) &                lesion, the results of conventional imaging          $345.00 (NK)
63532                examinations are inconclusive for the presence of
(NK)                 breast cancer, and biopsy has not been possible
63533                MRI of both breasts where the patient has been       $690.00 (K)
(K) and              diagnosed with breast cancer, discrepancy exists     $345.00 (NK)
63534                between clinical assessment and conventional
(NK)                 imaging assessment, and the results of breast MRI
                     may alter treatment planning

17 September, 2019                                                                  73
Diagnostic Imaging 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

Item             Description of the new service                       Proposed fee
61524            Whole body 18F-FDG PET study where the patient $953.00
                 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
61525            Whole body 18F-FDG PET study, where the              $953.00
                 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

 17 September, 2019                                                                  74
Diagnostic Imaging Cont.
X-RAY
• One new item is being introduced for the mobile provision of skeletal x-ray to
  patients within residential aged care facilities
Item      Description of the new service                                            Proposed fee
57541 The service must be requested by a medical practitioner who has               $73.65
      attended the patient in person and the request must identify one or
      more of the following indications:                                            If the service
                                                                                    is bulked
          (a) the patient has experienced a fall and one or more of the following   billed, 95% of
          items apply to the service: 57509, 57515, 57521, 57527, 57530,            the fee is
          57533, 57536, 57539 (x-rays of the extremities) 57703, 57705, 57709,      payable.
          57711, 57712, 57714, 57715, 57717 (x-rays of the shoulder or pelvis),     The diagnostic
          58521, 58523, 58524, 58526, 58527, 58529 (x-rays of the ribs and          imaging
          sternum); or                                                              multiple
          (b) pneumonia or heart failure is suspected and item 58503 or 58505       services rules
          (chest x-rays) applies to the service; or                                 do not apply
          (c) acute abdomen or bowel obstruction is suspected and item 58903        to this item.
          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.
   17 September, 2019                                                                        75
Any questions

17 September, 2019   76
AMENDED MEDICARE ITEMS FOR 1 NOVEMBER 2019

        Presenter:
        Ms Mary Warner, Director,
        Medical Specialist Services Section

17 September, 2019                            77
AMENDED MEDICARE ITEMS FOR 1 NOVEMBER 2019
      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                                                       78
Amended Medicare Items For 1 November 2019 cont.

      Minor Amendments for 1 November 2019
      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.

15 October, 2019                                                                      79
Amended Medicare Items For 1 November 2019 cont.

   Minor Amendments for 1 November 2019
   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                                                                80
Amended Medicare Items For 1 November 2019 cont.

   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.

15 October, 2019                                                              81
Communication documents on 1 November 2019 changes will be provided
at: http://www.mbsonline.gov.au under Factsheets

17 September, 2019                                             82
Any questions

17 September, 2019               83
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