SCHEDULE FOR 1 NOVEMBER 2019 Stakeholder Forum Tuesday, 17 - - PowerPoint PPT Presentation

CHANGES TO THE MEDICARE BENEFITS SCHEDULE FOR 1 NOVEMBER 2019

Stakeholder Forum Tuesday, 17 September 2019

17 September, 2019 1

Agenda

17 September, 2019 2

Time Item Presenter 10.30am – 10.50 Welcome and overview

• f the MBS Review

Mr Andrew Simpson, Assistant Secretary, MBS Reviews 10.50am – 12.00pm Anaesthesia changes Dr Andrew Singer, Medical Advisor 12.00pm – 12.45pm Lunch 12.45pm – 1.45pm Colonoscopy changes Professor Fin Macrae Member, Gastroenterology Clinical Committee Mr Ransome Mclean A/g Director, MBS Reviews 1.45pm – 2.00pm Other MBS changes

• Eating Disorders
• GP telehealth
• Diagnostic Imaging
• Amended Medicare

items Mr Andrew Simpson, Assistant Secretary, MBS Reviews Ms Mary Warner, Director, Medical Specialist Services Section 2.00pm – 2.30pm Q&A

Welcome and overview of the MBS Review

17 September, 2019 3

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

Stakeholder Forum

• Changes are coming to the MBS on November 1 2019.
• Combination of new items, amendments and deletions.
• Complex, covering specialist services and primary care.
• Purpose of today is to give an overview of changes coming on

November 1

• Discuss the rationale for changes
• Provide detail on the changes
• Answer questions and prepare for a smooth transition on November 1.

4 17 September, 2019

The MBS Review

• The MBS has not been reviewed in 30 years
• The MBS Review Taskforce was established in 2015
• The MBS Review aims to improve quality care and ensure services funded though 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

5 17 September, 2019

The MBS Review cont.

• Over 70 clinical committees and many more working groups

established

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

Taskforce to Government by the completion of the MBS Review

• The Review is clinician led
• Over 700 clinicians, consumer and health system experts involved in

the Review

6 17 September, 2019

The MBS Review Process

• The process of reviewing and implementing changes to items taking

approximately 2 years

• More than 30 reports have been delivered to government
• 5 phases of activity
• Initial Review
• Consultation
• Consideration by Government
• Implementation
• Evaluation

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

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

17 September, 2019 11

Presenter: Dr Andrew Singer, Medical Advisor MBS Reviews

The MBS Review of Anaesthesia

17 September, 2019 12

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

Taskforce was established in 2016

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

67 recommendations

• Consultation was undertaken on the ACC recommendations

between 2016 and 2018

• The report was amended as a result of consultation
• The Taskforce endorsed the final report in late 2018

The Anaesthesia changes – 1 November 2019

17 September, 2019 13

• From 1 November 2019, MBS items for anaesthesia

services are changing to reflect contemporary anaesthesia practice

• These changes are a result of the Taskforce

recommendations and extensive consultation with stakeholders

• Billing practices from 1 November 2019 will need to

be adjusted to reflect these changes

Summary of Changes

17 September, 2019 14

• 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 15

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 16

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

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

Regional nerve blocks – epidural injection cont.

17 September, 2019 17

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

the intention of the items TN.10.7 The administration of epidural anaesthesia during labour is covered by Item 18216 or 18219 in Group T7 of the Schedule whether administered by the medical practitioner undertaking the confinement or by another medical

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

For the purposes of items 18216 and 18226 items, one attendance means that the medical practitioner cannot claim either of these items if the additional attendance is to optimise the initial treatment. Optimise means extension or improvement in analgesic quality of an existing block, without the insertion of a new block as a separate procedure.

Regional nerve blocks – epidural injection

17 September, 2019 18

Anaesthesia for Eye Surgeries

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

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

reflect the anaesthesia complexity

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

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

17 September, 2019 19

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

TN.10.8 - Additional Services Performed in Connection with Anaesthesia - Subgroup 19 These items (with the exception of peri-operative nerve blocks (22030-22042) and perfusion services (22055-22075) have also been retained in the MBS in the non-RVG format, for use by practitioners who provide these services other than in association with anaesthesia. Item 22042: This item can be co-claimed with item 20142 (anaesthesia for lens surgery), when anaesthesia or sedation was also provided by the same anaesthetist. Item 22042 cannot be co-claimed with item 20142, 20144, 20145 and 20147 when a general anaesthetic is the primary anaesthetic approach.

Anaesthesia for Eye Surgeries cont.

17 September, 2019 20

Anaesthesia for Nose Surgery

Amended item 20160 Nose

Item Descriptor 20160 Initiation of the management of anaesthesia for intranasal

• r accessory sinuses, not being a service to which another

item in this Subgroup applies 20162 Initiation of the management of anaesthesia for intranasal surgery for malignancy or for intranasal ablation

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

nose or accessory sinuses

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

nose and sinus surgeries

• No change to fees

17 September, 2019 21

Electrical conversion of arrhythmias

Item Descriptor Proposed Fee 20410 Initiation of management of anaesthesia for electrical conversion

• f arrhythmias (no change).

$100.50 5 units $80.40 4 units

• Fee reduction to better reflect the anaesthetic complexity

17 September, 2019 22

Abdominal procedures

Item Descriptor Proposed fee 20706 Initiation of the management of anaesthesia for laparoscopic procedures in the upper abdomen, including laparoscopic cholecystectomy, not being a service to which another item in this Subgroup applies $140.70 (no change) 20745 Initiation of the management of anaesthesia for either

• r both of the following:

(a) upper gastrointestinal endoscopic procedures in association with acute gastrointestinal haemorrhage; (b) endoscopic retrograde cholangiopancreatography $140.70 7 units $120.60 6 units. 20750 Initiation of the management of anaesthesia for hernia repairs to the upper abdominal wall, other than a service to which another item in this Subgroup applies $100.50 5 units $80.40 4 units

• These items have been amended to reflect contemporary surgical and

anaesthesia practice and anaesthetic complexity

17 September, 2019 23

Abdominal procedures cont.

Item Descriptor 20790* Initiation of the management of anaesthesia for procedures within the peritoneal cavity in upper abdomen, including any of the following: (a) open cholecystectomy; (b) gastrectomy; (c) laparoscopically assisted nephrectomy; (d) bowel shunts 20840* Initiation of the management of anaesthesia for all open procedures within the lower abdominal peritoneal cavity, including appendicectomy, not being a service to which another item in this Subgroup applies 20902 Initiation of the management of anaesthesia for anorectal procedures (including surgical haemorrhoidectomy, but not banding of haemorrhoids)

• Banding of haemorrhoids can be claimed under MBS item 20810
• No change to fees
• * denotes that the GMST wording differs but the intent of the descriptor is the same

17 September, 2019 24

Item Descriptor Proposed fee 21922 Initiation of the management of anaesthesia for computerised axial tomography scanning, magnetic resonance scanning or digital subtraction angiography scanning $120.60 6 units (no change) 21926 Initiation of the management of anaesthesia for fluoroscopy (no change). $80.40 4 units $100.50 5 units 21936 Initiation of the management of anaesthesia for heart - 2 dimensional real time transoesophageal examination (no change). $100.50 5 units $120.60 6 units 21952 Initiation of the management of anaesthesia for diagnostic muscle biopsy to assess for malignant hyperpyrexia. $80.40 4 units $201.00 10 units.

Anaesthesia for Diagnostic & Biopsy procedures

• Fee reductions to better reflect the anaesthetic complexity
• Minor amendment to 21952 to clarify the procedure

17 September, 2019 25

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

• f pressure for a patient:

(a) when performed in association with the management of anaesthesia for the patient; and (b) other than a service to which item 13876 applies (c) is categorised as having a high risk of complications or during the procedure develops either complications or a high risk of complications

Anaesthesia for Therapeutic and Diagnostic Services

• The changes to item 22002 better reflects current clinical practice
• Items 22012, 22014 and 22025 descriptors have been amended to better

describe the intention of the item and patient population

• No change to the fees

17 September, 2019 26

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

• f 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

• f 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 27

• 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

• r 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.

Anaesthesia for Therapeutic and Diagnostic Services

17 September, 2019 28

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 29

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

• f 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 30

• Amended age requirements to better reflect the anaesthetic complexity.
• No fee change

Anaesthesia/Perfusion Modifying Units & Assistant for epidural blood patch

Item Descriptor 25015* Anaesthesia, perfusion or assistance in the management of anaesthesia, where the patient is less than 12 months of age or 70 years or greater for a patient less than 4 years or 75 years or older Item Descriptor Proposed fee 18297 Assistance at the administration of an epidural blood patch (a service to which item 18233 applies) by another medical practitioner $60.30 3 Units

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

epidural blood patch

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

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

17 September, 2019 31

Anaesthesia / perfusion time units

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

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

result of consolidating items to reflect 15 minutes time increments

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

creation of seven substitute items

17 September, 2019 32

Consolidated items

• Items 22040, 22045 and 22050 are being deleted.
• A new item has been introduced which combines the services previously

claimed under these items

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

the anaesthetic complexity Item Descriptor Schedule fee 22041* Perioperative introduction of a plexus or nerve block proximal to the lower leg or forearm for post

• perative pain management.

$40.20 2 Units

17 September, 2019 33

Deleted items

Item Descriptor Comment

20705 Initiation of the management of anaesthesia for diagnostic laparoscopy procedures Services under this item are expected to be claimed under item 20706. 20805 Initiation of the management of anaesthesia for diagnostic laparoscopic procedures Services under this item are expected to be claimed under item 20806. 20953 Initiation of the management of anaesthesia for endometrial ablation or resection in association with hysteroscopy Services under this item are expected to be claimed under item 20952. 21927 Initiation of the management of anaesthesia for barium enema or other opaque study of the small bowel This item is considered obsolete. 22001 Collection of blood for autologous transfusion

• r when homologous blood is required for

immediate transfusion in an emergency situation, when performed in association with the administration of anaesthesia This item has been deleted the service is considered part of normal clinical practice. Reference to this item has been removed from the Health Insurance (General Medical Services Table) Regulations 2019.

17 September, 2019 34

Deleted items

Item Descriptor Comment

22018 Measurement of the mechanical or gas exchange function of the respiratory system, using measurements of parameters that incorporate serial arterial blood gas analysis and include at least 2 of the following parameters: (a) pressure; (b) volume; (c) flow; (d) gas concentration in inspired or expired air; (e) alveolar gas or blood; performed in association with the management of anaesthesia, and for which a written record of the results is prepared, other than a service associated with a service to which item 11503 applies This item has been deleted the service is considered part

• f normal clinical practice.

As a result of this deletion reference to 22018 has been removed from items 11507 and 11512. 22070 Cardioplegia, blood or crystalloid, administration by any route, that is: (a) a service to which item 22060 applies; and (b) not a service associated with a service to which an item in Subgroup 21 applies This item has been deleted the service is considered part

• f normal clinical practice.

Any questions

35 17 September, 2019

COLONOSCOPY MBS ITEM CHANGES

17 September, 2019 36

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

Why do we need to review colonoscopy items?

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

• In 2018-19:
• 311,364 colonoscopies without polypectomy (MBS item 32090)
• 310,015 colonoscopies with polypectomy (MBS item 32093)
• From 2008 to 2018:
• 26.4% increase in colonoscopies without polypectomy (MBS item 32090)
• 140.5 % increase in colonoscopies with polypectomy (MBS item 32093)
• Continue to increase with ageing population and impact of National

Bowel Cancer Screening Program

37 17 September, 2019

38 $0 $20,000,000 $40,000,000 $60,000,000 $80,000,000 $100,000,000 $120,000,000 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Medicare Benefits for items 32090 and 32093

Item 32290 Item 32093

17 September, 2019

Why do we need to review colonoscopy items?

• Australian Atlas of Healthcare Variation 2015:
• The Atlas mapped colonoscopies by where people lived, age

standardized the data and provided the results in deciles.

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

Atlas also showed:

• Large variations in colonoscopy rates
• Highest rate 30 times that of the lowest
• Rates higher in metropolitan areas, and higher in high SES populations
• Inadequate access to services in certain parts of the country
• Significant waiting lists

39 17 September, 2019

MBS Colonoscopies performed

17 September, 2019 40

41

MBS Colonoscopies performed

17 September, 2019

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.

43 17 September, 2019

Summary of agreed changes to colonoscopy items

44 17 September, 2019

1

Reimbursement should be aligned with best clinical practice for colonoscopy agreed across relevant medical specialties.

2

Items should be restructured to reflect clinical indications and surveillance intervals for colonoscopy. A new suite of items is recommended.

3

Current colonoscopy items require examination ‘beyond the hepatic flexure’. This should be amended ‘to the caecum’ to emphasise the importance of a complete colonoscopy. For patients post right hemicolectomy this examination should be to the anastomosis.

4

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

5

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

6

Restrictions should be introduced on the co-claiming of services 32090 and 32093 on the same day, same patient, during a single episode of sedation/anaesthesia.

7

Remove the treatment of radiation proctitis, angiodysplasia or post-polypectomy bleeding from the polyp removal colonoscopy item and create a separate item for this service. It is also recommended that specific reference to Argon Plasma Coagulation be removed to enable any therapy to be used.

8

New colonoscopy items for symptomatic patients/patients with iron deficiency; and for patients following a positive FOBT test.

Changes to the MBS

• Changes will be implemented on 1 November 2019.
• Eight new colonoscopy items will be added to MBS to replace four

current MBS items:

• NEW
• 32222, 32223, 32224, 32225, 32226, 32227, 32228, 32229
• DELETED
• 32088, 32089, 32090, 32093

17 September, 2019 45

17 September, 2019 46

NEW ITEM MBS item 32222

Item Item Descriptor Proposed Fee Explanatory Notes

1

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

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

17 September, 2019 47

NEW ITEM MBS item 32223

Item Item Descriptor Propose d Fee Explanatory Notes

2

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

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

17 September, 2019 48

NEW ITEM MBS item 32224

Item Item Descriptor Propose d Fee Explanatory Notes

3

Endoscopic examination of the colon to the caecum by colonoscopy, for a patient who has a moderate risk of colorectal cancer due to: (a) a history of adenomas, including an adenoma that: (i) was greater than 10 mm in diameter; or (ii) had villous features; or (iii) had high grade dysplasia; or (iv) was an advanced serrated adenoma; or (b) having had a previous colonoscopy that revealed 5 to 9 adenomas, each of which was less than 10 mm in diameter, had no villous features and had no high grade dysplasia Applicable only once in any 3-year period (Anaes.) $339.70

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

17 September, 2019 49

NEW ITEM MBS item 32225

Item Item Descriptor Proposed Fee Explanatory Notes

4

Endoscopic examination of the colon to the caecum by colonoscopy, for a patient who has a high risk of colorectal cancer due to having had a previous colonoscopy that: (a) revealed 10 or more adenomas; or (b) included a piecemeal, or possibly incomplete, excision of a large, sessile polyp Applicable not more than 4 times in any 12-month period (Anaes.) $339.70 MBS fee: $339.70 Benefit: 75% = $254.80 85% = $288.75

17 September, 2019 50

NEW ITEM MBS item 32226

Item Item Descriptor Proposed Fee Explanatory Notes

5

Endoscopic examination of the colon to the caecum by colonoscopy, for a patient who has a high risk of colorectal cancer due to: (a) a known or suspected familial condition, such as familial adenomatous polyposis, Lynch syndrome or serrated polyposis syndrome; or (b) a genetic mutation associated with hereditary colorectal cancer Applicable only once in any 12-month period (Anaes.) $339.70 MBS fee: $339.70 Benefit: 75% = $254.80 85% = $288.75

17 September, 2019 51

NEW ITEM MBS item 32227

Item Item Descriptor Proposed Fee Explanatory Notes

6

Endoscopic examination of the colon to the caecum by colonoscopy: (a) for the treatment of bleeding, including one or more of the following: (i) radiation proctitis; (ii) angioectasia; (iii) post-polypectomy bleeding; or (b) for the treatment of colonic strictures with balloon dilatation Applicable only once on a day under a single episode of anaesthesia or other sedation (Anaes.) $476.70 MBS fee: $476.70 Benefit: 75% = $357.55 85% = $405.20

17 September, 2019 52

NEW ITEM MBS item 32228

Item Item Descriptor Proposed Fee Explanatory Notes

7

Endoscopic examination of the colon to the caecum by colonoscopy, other than a service to which item 32222, 32223, 32224, 32225 or 32226 applies Applicable only once (Anaes.) $339.70 MBS fee: $339.70 Benefit: 75% = $254.80 85%=$288.75

17 September, 2019 53

NEW ITEM MBS item 32229

Item Item Descriptor Proposed Fee Explanatory Notes

8

Removal of one or more polyps during colonoscopy, in association with a service to which item 32222, 32223, 32224, 32225, 32226 or 32228 applies (Anaes.) $274.00 MBS fee: $274.00 Benefit: 75% = $205.50 85% = $232.90

Deleted MBS item

32088

FIBREOPTIC COLONOSCOPY examination of the colon beyond the hepatic flexure WITH or WITHOUT BIOPSY, following a positive faecal

• ccult 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

54 Stakeholder Forum - 17 September 2019

• Item will be obsolete due to

new item 32222 capturing colonoscopy following FOBT. This will be used for FOBT picked up via the National Bowel Screening Program.

Deleted MBS item

32089

Endoscopic examination of the colon beyond the hepatic flexure by FIBREOPTIC COLONOSCOPY for the REMOVAL OF 1 OR MORE POLYPS, following a positive faecal occult blood test for a participant registered on the National Bowel Cancer Screening Program (Anaes.)

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

55 Stakeholder Forum - 17 September 2019

• Item will be obsolete due to

new item 32222 capturing colonoscopy following FOBT. This will be used for FOBT picked up via the National Bowel Screening Program.

Deleted MBS items

32090 Fibreoptic colonoscopy —examination of colon beyond the hepatic flexure with or without biopsy (Anaes.) 32093 Endoscopic examination of the colon beyond the hepatic flexure by fibreoptic colonoscopy for the removal of one or more polyps, or the treatment of radiation proctitis, angiodysplasia or post-polypectomy bleeding by argon plasma coagulation, one or more of (Anaes.) Services under these items are expected to be claimed under items 32222-32229.

56 Stakeholder Forum - 17 September 2019

• Replace items 32090 & 32093

with new items to align colonoscopy services with Australian clinical practice guidelines

• New items better describe

the indications for initial colonoscopy and ensure appropriate surveillance intervals for patients who are at increased risk of developing colorectal cancer

What does this mean for providers?

• The new items better describe the indications for initial colonoscopy

and ensure appropriate surveillance intervals of patients who are at increased risk of developing colorectal cancer

• Providers will need to familiarise themselves with the changes,

associated rules and explanatory notes

• Ensure services billed to Medicare meet eligibility requirements
• utlined in the legislation.

57 Stakeholder Forum - 17 September 2019

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

58 Stakeholder Forum - 17 September 2019

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

• For items 32223-32225, the most appropriate item to be billed is

determined by the previous history of the patient.

• The previous history for the purpose of these items is defined by

number, size and type of adenomas removed during ANY previous colonoscopy.

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

adenomas (<10mm with no high-risk histological features) is eligible a colonoscopy every five years under item 32223, the clinical guidelines indicate that colonoscopy every 10 years is sufficient.

59 Stakeholder Forum - 17 September 2019

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
• ccult blood tests for patients as a first line test for patients with a low

risk family history of colorectal cancer.

60 Stakeholder Forum - 17 September 2019

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.

61 Stakeholder Forum - 17 September 2019

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.

62 Stakeholder Forum - 17 September 2019

Any questions

63 17 September, 2019

NEW MEDICARE ITEMS FOR 1 NOVEMBER 2019

17 September, 2019 64

Mr Andrew Simpson, Assistant Secretary MBS Reviews

17 September, 2019 65

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 66

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

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

consultant psychiatrist and paediatrician preparation of eating disorders treatment and management plans.

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

paediatrician review of eating disorders treatment and management plans.

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

paediatrician provision of psychological treatment services.

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

health services.

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

Occupational Therapists and Social Workers provision of eating disorder psychological treatment services.

Overview of the Eating Disorders Treatment Pathway

17 September, 2019 67

GP Telehealth

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

areas (Modified Monash Model areas 6-7)

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

relationship with telehealth provider

• $33.5 million for new GP telehealth MBS items
• The new items align with draft recommendations of General Practice and

Primary Care Clinical Committee

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

General Practitioner (GP) Telehealth

17 September, 2019 68

Item Descriptor Proposed fee

2461 Professional attendance by video conference by a general practitioner for an obvious problem characterised by the straightforward nature of the task that requires a short patient history and, if required, limited examination and management—each attendance 17.50 2463 Professional attendance by video conference by a general practitioner, of less than 20 minutes in duration, including any of the following that are clinically relevant: (a) taking a patient history; (b) performing a clinical examination; (c) arranging any necessary investigation; (d) implementing a management plan; (e) providing appropriate preventive health care; for one or more health-related issues, with appropriate documentation—each attendance 38.20

Subgroup 5—General practitioner video conferencing consultation attendance for patients in rural and remote areas

17 September, 2019 69

Item Descriptor Proposed fee

2464 Professional attendance by video conference by a general practitioner,

• f at least 20 minutes in duration but less than 40 minutes, including any
• f 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 73.95 2465 Professional attendance by video conference by a general practitioner,

• f 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 108.85

Subgroup 5—General practitioner video conferencing consultation attendance for patients in rural and remote areas cont.

17 September, 2019 70

Item Descriptor Proposed fee 2471 Professional attendance by video conference of not more than 5 minutes in duration by a medical practitioner who is not a general practitioner—each attendance 11.00 2472 Professional attendance by video conference of more than 5 minutes in duration but not more than 25 minutes by a medical practitioner who is not a general practitioner—each attendance 21.00 2475 Professional attendance by video conference of more than 25 minutes in duration but not more than 45 minutes by a medical practitioner who is not a general practitioner—each attendance 38.00 2478 Professional attendance by video conference of more than 45 minutes in duration by a medical practitioner who is not a general practitioner—each attendance 61.00 Subgroup 6—Other non referred video conferencing consultation attendance for patients in rural and remote areas

17 September, 2019 71

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 than 5 minutes in duration by a medical practitioner – each attendance 14.00 2481 Professional attendance by video conference of more than 5 minutes in duration but not more than 25 minutes by a medical practitioner – each attendance 30.55 2482 Professional attendance by video conference of more than 25 minutes in duration but not more than 45 minutes by a medical practitioner – each attendance 59.15 2483 Professional attendance by video conference of more than 45 minutes in duration who is not a medical practitioner – each attendance 87.10

17 September, 2019 72

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 73

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

Diagnostic Imaging Cont.

MRI Cont.

17 September, 2019 74

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

Diagnostic Imaging Cont.

Item Description of the new service Proposed fee 61524 Whole body 18F-FDG PET study where the patient is referred by a specialist or consultant physician, performed for the staging of locally advanced (Stage III) breast cancer in a patient considered potentially suitable for active therapy $953.00 61525 Whole body 18F-FDG PET study, where the patient is referred by a specialist or consultant physician, performed for the evaluation of suspected metastatic or suspected locally or regionally recurrent breast carcinoma in a patient considered suitable for active therapy $953.00

17 September, 2019 75

X-RAY

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

patients within residential aged care facilities

Diagnostic Imaging Cont.

Item Description of the new service Proposed fee 57541 The service must be requested by a medical practitioner who has attended the patient in person and the request must identify one or more of the following indications: (a) the patient has experienced a fall and one or more of the following items apply to the service: 57509, 57515, 57521, 57527, 57530, 57533, 57536, 57539 (x-rays of the extremities) 57703, 57705, 57709, 57711, 57712, 57714, 57715, 57717 (x-rays of the shoulder or pelvis), 58521, 58523, 58524, 58526, 58527, 58529 (x-rays of the ribs and sternum); or (b) pneumonia or heart failure is suspected and item 58503 or 58505 (chest x-rays) applies to the service; or (c) acute abdomen or bowel obstruction is suspected and item 58903

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

This item can be claimed once only per visit at a residential aged care facility irrespective of the number of patients x-rayed. $73.65 If the service is bulked billed, 95% of the fee is payable. The diagnostic imaging multiple services rules do not apply to this item.

Any questions

76 17 September, 2019

AMENDED MEDICARE ITEMS FOR 1 NOVEMBER 2019

17 September, 2019 77

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

AMENDED MEDICARE ITEMS FOR 1 NOVEMBER 2019

19 September, 2019 78

Minor Amendments for 1 November 2019

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

amendments to Medicare Benefits Schedule (MBS) items for the following services:

• Sleep Studies
• Spinal Surgery
• Ear Nose and Throat (ENT)
• Gene Testing
• Plastic and Reconstructive Surgery.
• These amendments will:
• clarify the policy intent of these services;
• address anomalies;
• make enhancements (including for data collection and

compliance purposes).

19 September, 2019 79

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.

Amended Medicare Items For 1 November 2019 cont.

19 September, 2019 80

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.

Amended Medicare Items For 1 November 2019 cont.

19 September, 2019 81

Post Implementation Reviews

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

following the implementation of MBS Review Taskforce recommendations (e.g. MBS changes for thoracic medicine).

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

Amended Medicare Items For 1 November 2019 cont.

17 September, 2019 82

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

Any questions

83 17 September, 2019