CHANGES TO THE MEDICARE BENEFITS SCHEDULE FOR 1 NOVEMBER 2019 - Stakeholder Forum
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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 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
Welcome and overview of the MBS Review
Presenter:
Mr Andrew Simpson,
Assistant Secretary
Department of Health
MBS Reviews
17 September, 2019 3
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 4The 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 7Implementation • 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 10ANAESTHESIA MBS ITEM CHANGES
Presenter:
Dr Andrew Singer, Medical Advisor
MBS Reviews
17 September, 2019 11The 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 12The 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 13Summary 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 14Regional 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 15Regional 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 16Regional 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 17Anaesthesia 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 18Anaesthesia 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 20Electrical 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 21Abdominal 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 22Abdominal 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 23Anaesthesia 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 24Anaesthesia 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 25Anaesthesia 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 26Anaesthesia 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 28Intra-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 30Anaesthesia / 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 31Consolidated 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 32Deleted 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 33Deleted 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 34Any 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 36Why 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 37Medicare 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 38Why 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 39MBS Colonoscopies performed 17 September, 2019 40
MBS Colonoscopies
performed
17 September, 2019 41MBS 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 43Summary 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 44Changes 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 45NEW 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 46NEW 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 48NEW 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 49NEW 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 50NEW 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 51NEW 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 52NEW 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 53Deleted 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 55Deleted 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 56What 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 60Why 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 64Eating 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 66General 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 68Subgroup 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 69Subgroup 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 70Subgroup 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 71Diagnostic 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 72Diagnostic 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 73Diagnostic 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 74Diagnostic 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 75Any questions 17 September, 2019 76
AMENDED MEDICARE ITEMS FOR 1 NOVEMBER 2019
Presenter:
Ms Mary Warner, Director,
Medical Specialist Services Section
17 September, 2019 77AMENDED 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 78Amended 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 79Amended 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 80Amended 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 81Communication 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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