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Determinations/Health as made
This instrument introduces 10 new Medicare Benefits Schedule items for cardiac investigation services from 1 August 2020.
Administered by: Health
Registered 16 Jul 2020
Table of contents.

Commonwealth Coat of Arms of Australia

 

Health Insurance (Section 3C General Medical Services – Cardiac Services) Determination 2020

I, Andrew Simpson, delegate of the Minister for Health, make the following determination.

Dated               14 July 2020

Andrew Simpson

Assistant Secretary

MBS Review Unit
Medical Benefits Division

Health Financing Group

Department of Health

 


Contents

1  Name.................................................................................................. 1

2  Commencement................................................................................. 1

3  Authority............................................................................................ 1

4.  Definitions........................................................................................ 1

5.  Treatment and effect of relevant services......................................... 2

6.  Application of provisions of the general medical services table....... 3

7.  Application of items.......................................................................... 3

8.  Restriction of items........................................................................... 3

Schedule 1 – Relevant services.............................................................. 6


1  Name

              This instrument is the Health Insurance (Section 3C General Medical Services – Cardiac Services) Determination 2020.

2  Commencement

(1)          Each provision of this instrument specified in column 1 of the table commences, or is taken to have commenced, in accordance with column 2 of the table. Any other statement in column 2 has effect according to its terms.

 

Commencement information

Column 1

Column 2

Column 3

Provisions

Commencement

Date/Details

1.  The whole of this instrument.

1 August 2020

 

Note:          This table relates only to the provisions of this instrument as originally made. It will not be amended to deal with any later amendments of this instrument.

(2)          Any information in column 3 of the table is not part of this instrument. Information may be inserted in this column, or information in it may be edited, in any published version of this instrument.

3  Authority

This instrument is made under subsection 3C(1) of the Health Insurance Act 1973.

4.  Definitions

Act means the Health Insurance Act 1973.

admitted patient means a person who is receiving a service that is provided:

(a)     as part of an episode of hospital treatment; or

(b)     as part of an episode of hospital-substitute treatment in respect of which the person to whom the treatment is provided choses to receive a benefit from a private health insurer.

attendance means an item listed in Part 2 of the general medical services table.

clinical notes means a written report commenting on the significance of the trace findings and their relationship to clinical decision making for the patient in their clinical context. This interpretation does not include interpretation based solely on measurements or diagnoses automatically generated from the trace.

formal report means a written report that entails interpretation of the trace, (including indicators for the investigation) commenting on the significance of the trace findings and their relationship to clinical decision making for the patient in their clinical context, and may include a copy of the trace and any measurements taken or automatically generated.

relevant provisions means all provisions, of the Act and regulations made under the Act, and the National Health Act 1953 and regulations made under the National Health Act 1953, relating to medical services, professional services or items.

relevant service means a health service, as defined in subsection 3C(8) of the Act, that is specified in a Schedule.

requesting practitioner means the medical practitioner making the request for the service who is not the medical practitioner rendering the service.

Schedule means a Schedule to this instrument.

Note:     The following terms are defined in subsection 3(1) of the Act:

·          clinically relevant service;

·          diagnostic imaging services table;

·          general medical services table;

·          hospital-substitute treatment;

·          hospital treatment;

·          item;

·          professional service.

trained in exercise testing means the person is capable of safely performing exercise or pharmacological stress monitoring and recording, which must include the ability to recognise the symptoms and signs of cardiac disease.

(2)    Unless the contrary intention appears, a reference in this instrument to a provision of the Act or the National Health Act 1953 or regulations made under the Act or under the National Health Act 1953 as applied, adopted or incorporated in relation to specifying a matter is a reference to those provisions as in force from time to time and any other reference to provisions of an Act or regulations is a reference to those provisions as in force from time to time.

5.  Treatment and effect of relevant services

(1)        For subsection 3C(1) of the Act, a relevant service, provided in accordance with this instrument and as a clinically relevant service, is to be treated, for the relevant provisions, as if:

(a)           it were both a professional service and a medical service; and

(b)          there were an item in the general medical services table that:

(i)                 related to the service; and

(ii)               specified for that service a fee in relation to each State, being the fee specified in the item relating to the service set out in Schedule 1 to this instrument.

 

6.  Application of provisions of the general medical services table

(1)        Clauses 1.2.6 and 1.2.7 of the general medical services table shall have the effect as if items 11705 and 11731 of this instrument were specified in subclauses 1.2.6(1) and 1.2.7(1).

(2)        Clause 1.2.11 of the general medical services table shall have effect as if items 11704, 11705, 11707, 11714, 11716, 11717, 11723, 11729 and 11730 of this instrument were specified in subclause 1.2.11(1).

7.  Application of items

(1)        Items 11716, 11717, 11723 or 11729 do not apply to a service unless:

(a)           the patient is referred to the specialist or consultant physician; or

(b)           the service is requested by a requesting practitioner.

(2)        A service to which items 11716, 11717, 11723 or 11729 applies is considered to be referred if the specialist or consultant physician who renders the service:

(a)           manages the ongoing care of the patient; or

(b)           performs an attendance to determine that testing is necessary, where the need for the test has not otherwise been scheduled; or

(c)           performs an attendance immediately after the test has been performed, at which clinical management decisions are discussed with the patient.

(3)        A service to which items 11716, 11717, 11723 or 11729 applies is taken to be requested if rendered in circumstances other than described in subsection 7(2).

8.  Restriction of items

Restriction on items 11704, 11707, 11714, 11716, 11717 and 11723location of service

(1)        Items 11704, 11707, 11714, 11716, 11717 or 11723 do not apply to a service if the patient is an admitted patient.

Restriction on items 11704 and 11705—financial relationship

(2)      Items 11704 or 11705 do not apply to a service if the medical practitioner who renders the service has a financial relationship with the requesting practitioner.

Restriction on items 11729 and 11730—patient limitations

(3)        Items 11729 or 11730 do not apply to a service unless:

(a)           the patient’s body habitus, or other physical condition, is suitable for exercise stress testing or pharmacological induced stress testing; and

(b)           the patient can complete the exercise sufficiently or respond adequately to pharmacological induced stress, to take the required measurements/

(4)        Item 11729 does not apply to a service performed on a patient who:

(a)           is asymptomatic and has a normal cardiac examination; or

(b)           has a known cardiac disease but the absence of symptom evolution suggests the disease has not progressed and the service is used for monitoring; or

(c)           has an abnormal resting electrocardiography result which would prevent the interpretation of results.

(5)        Item 11730 does not apply to a service performed on a patient who is asymptomatic and has a normal cardiac examination.

Restriction on items 11729 and 11730—personnel limitations

(6)        Items 11729 or 11730 do not apply to a service unless one of the persons, as described in subparagraphs b(iv) and (v) of the descriptors of those items (column 2 of the table at Schedule 1), is a medical practitioner.

Restriction on items 11704 and 11705—services performed on the same day as an attendance

(7)        Item 11704 does not apply to a service if the specialist or consultant physician who performs the service has performed a service to which an attendance applies for the same patient on the same day.

(8)        Item 11705 does not apply to a service if the specialist or consultant physician who performs the service has performed a service to which an attendance applies for the same patient on the same day, unless exceptional circumstances exist.

(9)        For the purpose of subsection 8(8), exceptional circumstances means there has been a significant change in the patient’s clinical condition or care circumstances that necessitates the performance of the attendance.

Restriction on items 11716, 11717, 11723 or 11729 —requested services performed on the same day as an attendance

(10)    Where items 11716, 11717, 11723 or 11729 are requested, an item does not apply to a service if the medical practitioner has performed a service to which an attendance applies for the same patient on the same day.


 

Schedule 1 – Relevant services

 

Group D1Miscellaneous diagnostic procedures and investigations

Item

Service

Fee ($)

Subgroup 6Cardiovascular

11704

Twelve-lead electrocardiography to produce a trace and a formal report, by a specialist or a consultant physician, if:

(a)    the service is requested by a requesting practitioner; and

(b)   a copy of formal report is provided to the requesting practitioner

32.25

11705

Preparing a formal report only on an electrocardiography trace, by a specialist or a consultant physician, if:

(a)    the service is requested by a requesting practitioner; and

(b)   the formal report uses a trace provided from twelve-lead electrocardiography for the patient which has:

(i)     been provided with the request from the requesting practitioner; and

(ii)   not been previously been reported on; and

(c)    a copy of the formal report is provided to the requesting practitioner

For any particular patient, applicable no more than twice on the same day

19.00

11707

Twelve-lead electrocardiography to produce a trace only, by a medical practitioner, if the trace:

(a)    is required to inform clinical decision making; and

(b)   is reviewed in a clinically appropriate timeframe to identify potentially serious or life-threatening abnormalities; and

(c)    does not need to be fully interpreted or reported on

 

For any particular patient, applicable no more than twice on the same day

19.00

11714

Twelve-lead electrocardiography to produce a trace and a clinical note, by a specialist or consultant physician, if a copy of the clinical note is provided to the medical practitioner managing the patient’s care, if appropriate

For any particular patient, applicable no more than twice on the same day

25.00

11716

Continuous electrocardiogram recording of ambulatory patient for 12 or more hours with interpretation and report, by a specialist or consultant physician, if the service:

(a)    is indicated for the evaluation of a patient for:

(i)     syncope; or

(ii)   pre-syncopal episodes; or

(iii) palpitations where episodes are occurring greater than once a week; or

(iv)  another asymptomatic arrhythmia is suspected with an expected frequency of greater than once a week; or

(v)   surveillance following cardiac surgical procedures that have an established risk of causing dysrhythmia; and

(b)   utilises a system capable of superimposition and full disclosure printout of at least 12 hours of recorded electrocardiogram data, (including resting electrocardiogram and the recording of parameters) microprocessor based scanning analysis; and

(c)    is not in association with ambulatory blood pressure monitoring; and

(d)   is other than a service on a patient in relation to whom this item and any of the items 11704, 11705, 11707 or 11714 are rendered by a single medical practitioner on a single patient on a single day; and

(e)    is applicable once in a 4 week period

172.75

11717

Ambulatory electrocardiogram monitoring of a patient, by a specialist or consultant physician, if the service:

(a)    utilises a patient activated, single or multiple event memory recording device which is connected continuously to the patient for between 7 and 30 days and is capable of recording for at least 20 seconds prior to each activation and for 15 seconds after each activation; and

(b)   includes transmission, analysis, interpretation and reporting (including the indication for the investigation); and

(c)    is for investigation of recurrent episodes of:

(i)     unexplained syncope; or  

(ii)   palpitation; or

(iii) other symptoms where a cardiac rhythm disturbance is suspected and where episodes are infrequent has occurred; and

(d)   is applicable once in a 3 month period

101.50

11723

Conducting ambulatory electrocardiogram monitoring of a patient, by a specialist or consultant physician, if the service:

(a)    utilises a patient activated, single or multiple event recording, on a memory recording device which is connected continuously to the patient for up to 7 days and is capable of recording for at least 20 seconds prior to each activation and for 15 seconds after each activation; and

(b)   includes transmission, analysis, interpretation and formal report (including the indication for the investigation); and

(c)    is for investigation of recurrent episodes of:

(i)     unexplained syncope; or 

(ii)   palpitation; or

(iii) other symptoms where a cardiac rhythm disturbance is suspected and where episodes are infrequent has occurred; and

(d)   is applicable once in a 3 month period

53.55

11729

Multi channel electrocardiogram monitoring and recording during exercise (motorised treadmill or cycle ergometer capable of quantifying external workload in watts) or pharmacological stress, if:

(a)    the patient is aged 17 years or more; and:

(i)           has symptoms consistent with cardiac ischemia; or

(ii)         has other cardiac disease which may be exacerbated by exercise; or

(iii)       has a first degree relatives with suspected heritable arrhythmia; and

(b)   the exercise or pharmacological stress monitoring and recording:

(i)           is not less than 20 minutes in duration; and

(ii)         includes resting electrocardiogram; and

(iii)       is performed on premises equipped with standard resuscitation equipment; and

(iv)       a person trained in exercise testing and cardiopulmonary resuscitation is in continuous attendance during the monitoring and recording; and

(v)         a second person trained in cardiopulmonary resuscitation is located at the premise where the testing is performed and is immediately available to respond at the time the exercise test is performed on the patient, if required; and

(c)    a written report is produced by a medical practitioner that includes interpretation of the exercise or pharmacological stress monitoring and recording data, commenting on the significance of the data, and their relationship to clinical decision making for the patient in their clinical context; and

(d)   other than a service:

(i)           provided on the same occasion as a service described in any of items 11704, 11705, 11707 or 11714 of the general medical services table; or

(ii)         performed within 24 months of a service to which any of items 55141, 55143, 55145, 55146, 61324, 61329, 61345, 61349 or 61357 of the diagnostic imaging services table has applied

Applicable once in a 24 month period

156.95

11730

Multi channel electrocardiogram monitoring and recording during exercise (motorised treadmill or cycle ergometer capable of quantifying external workload in watts), if:

(a)    the patient is aged under 17 years; and:

(i)     has symptoms consistent with cardiac ischemia; or

(ii)   has other cardiac disease which may be exacerbated by exercise; or

(iii) has a first degree relatives with suspected heritable arrhythmia; and

(b)   the exercise or pharmacological stress monitoring and recording:

(i)     is not less than 20 minutes in duration; and

(ii)   includes resting electrocardiogram; and

(iii) is performed on premises equipped with standard resuscitation equipment; and

(iv) a person trained in exercise testing and cardiopulmonary resuscitation is in continuous attendance during the monitoring and recording; and

(v)   a second person trained in cardiopulmonary resuscitation is located at the premise where the testing is performed and is immediately available to respond at the time the exercise test is performed on the patient, if required; and

(c)    a written report is produced by a medical practitioner that includes interpretation of the exercise or pharmacological stress monitoring and recording data, commenting on the significance of the data, and their relationship to clinical decision making for the patient in their clinical context; and

(d)   other than a service:

(i)     provided on the same occasion as a service described in any of items 11704, 11705, 11707 or 11714 of the general medical services table; or

(ii)   performed within 24 months of a service to which any of items 55141, 55143, 55145, 55146, 61324, 61329, 61345, 61349 or 61357 of the diagnostic imaging services table has applied

Applicable once in a 24 month period

156.95

11731

Implanted electrocardiogram loop recording, by a medical practitioner, including reprogramming when required; retrieval of stored data, analysis, interpretation and report by a medical practitioner, if the service is:

(a)    an investigation for a patient with:

(i)     cryptogenic stroke; or

(ii)   recurrent unexplained syncope; and

(b)   not a service to which item 38285 of the general medical services table applies; and

(c)    applicable once in a 4 week period

35.85