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Determinations/Health as made
This instrument amends the Health Insurance (Section 3C Diagnostic Imaging Services – Cardiac Services) Determination 2020 and the Health Insurance (Section 3C General Medical Services – Cardiac Services) Determination 2020 to update existing cardiac items and to list six new items for cardiac services.
Administered by: Health
Registered 11 Sep 2020
Table of contents.

Commonwealth Coat of Arms of Australia

 

Health Insurance Legislation Amendment (Section 3C – Cardiac Services) Determination 2020

I, Paul McBride, delegate of the Minister for Health, make the following Determination.

Dated   10 September 2020

Paul McBride

First Assistant Secretary

Medical Benefits Division

Health Resourcing Group

Department of Health

 

 

 


Contents

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

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

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

4  Schedules............................................................................................................................... 1

Schedule 1— Amendments                                                                                          2

Health Insurance (Section 3C Diagnostic Imaging Services – Cardiac Services) Determination 2020     2

Health Insurance (Section 3C General Medical Services – Cardiac Services) Determination 2020           22

 

 


1  Name

                        This instrument is the Health Insurance Legislation Amendment (Section 3C – 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  

15 September 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                Note:        This table relates only to the provisions of this instrument as originally made.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  Schedules

                        Each instrument that is specified in a Schedule to this instrument is amended or repealed as set out in the applicable items in the Schedule concerned, and any other item in a Schedule to this instrument has effect according to its terms.


 

Schedule 1— Amendments

Health Insurance (Section 3C Diagnostic Imaging Services – Cardiac Services) Determination 2020

 

1 Subsection 6(24) 

Repeal the subsection, substitute:

 

(24)   Clause 2.4.1 of the diagnostic imaging services table shall have effect as if items 61321, 61324, 61325, 61329, 61345, 61349, 61357, 61394, 61398, 61406, 61410 or 61414 were also specified in clause 2.4.1.

 

2 Division 1.1 of Schedule 1 (subclause 1.1.1(3))

Repeal the subclause, substitute:

 

(3)   For any particular patient, item 55141, 55143, 55145 or 55146 applies if one or more of the following is applicable:

(a)    if the patient displays one or more of the following symptoms of typical or atypical angina:

(i)            constricting discomfort in the:

a.         front of the chest; or

b.        neck; or

c.         shoulders; or

d.        jaw; or

e.         arms; or

(ii)          the patient’s symptoms, as described in subparagraph (3)(a)(i), are precipitated by physical exertion; or

(iii)        the patient’s symptoms, as described in subparagraph (3)(a)(i), are relieved by rest or glyceryl trinitrate within 5 minutes or less; or

(b)   if the patient has known coronary artery disease and displays one or more symptoms that are suggestive of ischaemia:

(i)            which are not adequately controlled with medical therapy; or

(ii)          have evolved since the last functional study; or

(c)    if the patient qualifies for one or more of the following indications:

(i)                  assessment of myocardial ischaemia with exercise is required if a patient with congenital heart lesions has undergone surgery and reversal of ischemia is considered possible; or

(ii)                assessment indicates that resting 12 lead electrocardiogram changes are consistent with coronary artery disease or ischaemia, in a patient that is without known coronary artery disease; or

(iii)             coronary artery disease related lesions, of uncertain functional significance, which have previously been identified on computed tomography coronary angiography or invasive coronary angiography; or

(iv)             an assessment by a specialist or consultant physician indicates that the patient has potential non-coronary artery disease, where a stress echocardiography study is likely to assist the diagnosis; or

(v)               assessment indicates that the patient has undue exertional dyspnoea of uncertain aetiology; or

(vi)             a pre-operative assessment of a patient with functional capacity of less than 4 metabolic equivalents confirming that surgery is intermediate to high risk, and the patient has at least one of following conditions:

a.       ischaemic heart disease or previous myocardial infarction; or

b.      heart failure; or

c.       stroke or transient ischaemic attack; or

d.      renal dysfunction (serum creatinine greater than 170umol/L or 2 mg/dL or a creatinine clearance of less than 60 mL/min); or

e.       diabetes mellitus requiring insulin therapy: or

(vii)           assessment before cardiac surgery or catheter-based interventions is required to:

a.       increase the cardiac output to assess the severity of aortic stenosis; or

b.      determine whether valve regurgitation worsens with exercise and/or correlates with functional capacity; or

c.       correlate functional capacity with the ischaemic threshold; or

(viii)         for patients where silent myocardial ischaemia is suspected, or due to the patient’s cognitive capacity or expressive language impairment, it is not possible to accurately assess symptom frequency based on medical history.

 

3 Division 1.1 of Schedule 1 (below clause 1.1.2)

Repeal the table, substitute:

 

Group I1 - Ultrasound

Subgroup 7 – Transthoracic Echocardiogram and Stress Echocardiogram

Column 1

Item

Column 2

Description

Column 3

Fee ($)

55126

Initial real time echocardiographic examination of the heart with real time colour flow mapping from at least 3 acoustic windows, with recordings on digital media:

(a)    for the investigation of any of the following:

(i)            symptoms or signs of cardiac failure; or

(ii)          suspected or known ventricular hypertrophy or dysfunction; or

(iii)        pulmonary hypertension; or

(iv)        valvular, aortic, pericardial, thrombotic or embolic disease; or

(v)          heart tumour; or

(vi)        symptoms or signs of congenital heart disease; or

(vii)      other rare indications; and

(b)   if the service involves all of the following, where possible:

(i)            assessment of left ventricular structure and function including quantification of systolic function using M-mode, 2-dimensional or 3-dimensional imaging and diastolic function; and

(ii)          assessment of right ventricular structure and function with quantitative assessment; and

(iii)        assessment of left and right atrial structure including quantification of atrial sizes; and

(iv)        assessment of vascular connections of the heart including the great vessels and systemic venous structures; and

(v)          assessment of pericardium and assessment of any haemodynamic consequences of pericardial abnormalities; and

(vi)        assessment of all present valves including structural assessment and measurement of blood flow velocities across the valves using pulsed wave and continuous wave doppler techniques with quantification of stenosis or regurgitation; and

(vii)      assessment of additional haemodynamic parameters including the assessment of pulmonary pressures; and

(c)    not being a service associated with a service to which another item in this Subgroup (except items 55137, 55141, 55143, 55145 and 55146), or an item in Subgroup 1 (except item 55054), or an item in Subgroup 2 (except items 55118 and 55130), or an item in Subgroup 3 applies; and

(d)   cannot be claimed within 24 months if a service associated with a service to which item 55127, 55128, 55129, 55132, 55133 or 55134 is provided

For any particular patient, applicable not more than once in 24 months (R)

234.15

55127

Repeat serial real time echocardiographic examination of the heart with real time colour flow mapping from at least 3 acoustic windows, with recordings on digital media, for the investigation of known valvular dysfunction, if:

(a)    the service involves all of the following, where possible:

(i)            assessment of left ventricular structure and function including quantification of systolic function using M-mode, 2-dimensional or 3-dimensional imaging and diastolic function; and

(ii)          assessment of right ventricular structure and function with quantitative assessment; and

(iii)        assessment of left and right atrial structure including quantification of atrial sizes; and

(iv)        assessment of vascular connections of the heart including the great vessels and systemic venous structures; and

(v)          assessment of pericardium and assessment of any haemodynamic consequences of pericardial abnormalities; and

(vi)        assessment of all present valves including structural assessment and measurement of blood flow velocities across the valves using pulsed wave and continuous wave doppler techniques with quantification of stenosis or regurgitation; and

(vii)      assessment of additional haemodynamic parameters including the assessment of pulmonary pressures; and

(b)   the service is requested by a specialist or consultant physician; and

(c)    not being a service associated with a service to which another item in this Subgroup (except items 55137, 55141, 55143, 55145 and 55146), or an item in Subgroup 1 (except item 55054), or an item in Subgroup 2 (except items 55118 and 55130), or an item in Subgroup 3 applies (R)

234.15

55128

Repeat serial real time echocardiographic examination of the heart with real time colour flow mapping from at least 3 acoustic windows, with recordings on digital media, for the investigation of known valvular dysfunction, if:

(a)    the service involves all of the following, where possible:

(i)            assessment of left ventricular structure and function including quantification of systolic function using M-mode, 2-dimensional or 3-dimensional imaging and diastolic function; and

(ii)          assessment of right ventricular structure and function with quantitative assessment; and

(iii)        assessment of left and right atrial structure including quantification of atrial sizes; and

(iv)        assessment of vascular connections of the heart including the great vessels and systemic venous structures; and

(v)          assessment of pericardium and assessment of any haemodynamic consequences of pericardial abnormalities; and

(vi)        assessment of all present valves including structural assessment and measurement of blood flow velocities across the valves using pulsed wave and continuous wave doppler techniques with quantification of stenosis or regurgitation; and

(vii)      assessment of additional haemodynamic parameters including the assessment of pulmonary pressures; and

(b)   the service is requested by a medical practitioner (other than a specialist or consultant physician) at, or from, a practice location in:

(i)            a Modified Monash 3 area; or

(ii)          a Modified Monash 4 area; or

(iii)        a Modified Monash 5 area; or

(iv)        a Modified Monash 6 area; or

(v)          a Modified Monash 7 area; and

(c)    not being a service associated with a service to which another item in this Subgroup (except items 55137, 55141, 55143, 55145 and 55146), or an item in Subgroup 1 (except item 55054), or an item in Subgroup 2 (except items 55118 and 55130) or an item in Subgroup 3 applies (R)

234.15

55129

Repeat serial real time echocardiographic examination of the heart with real time colour flow mapping from at least 3 acoustic windows, with recordings on digital media, excluding valvular dysfunction (when valvular dysfunction is the primary condition):

(a)    for the investigation of any of the following:

(i)            symptoms or signs of cardiac failure; or

(ii)          suspected or known ventricular hypertrophy or dysfunction; or

(iii)        pulmonary hypertension; or

(iv)        aortic, thrombotic, embolic disease or pericardial disease (excluding isolated pericardial effusion or pericarditis); or

(v)          heart tumour; or

(vi)        structural heart disease; or

(vii)      other rare indications; and

(b)   if the service involves all of the following, where possible:

(i)            assessment of left ventricular structure and function including quantification of systolic function using M-mode, 2-dimensional or 3-dimensional imaging and diastolic function; and  

(ii)          assessment of right ventricular structure and function with quantitative assessment; and

(iii)        assessment of left and right atrial structure including quantification of atrial sizes; and

(iv)        assessment of vascular connections of the heart including the great vessels and systemic venous structures; and

(v)          assessment of pericardium and assessment of any haemodynamic consequences of pericardial abnormalities; and

(vi)        assessment of all present valves including structural assessment and measurement of blood flow velocities across the valves using pulsed wave and continuous wave doppler techniques with quantification of stenosis or regurgitation if present; and

(vii)      assessment of additional haemodynamic parameters including the assessment of pulmonary pressures when possible; and

(c)    the service is requested by a specialist or consultant physician; and

(d)   not being a service associated with a service to which another item in this Subgroup (except items 55137, 55141, 55143, 55145 and 55146), or an item in Subgroup 1 (except item 55054), or an item in Subgroup 2 (except items 55118 and 55130) or an item in Subgroup 3 applies (R)

234.15

55132

Serial real time echocardiographic examination of the heart with real time colour flow mapping from at least 4 acoustic windows, with recordings on digital media, for the investigation of a patient who is under 17 years of age, or a patient of any age with complex congenital heart disease, if:

(a)    the service involves the all of the following, where possible:

(i)            assessment of ventricular structure and function including quantification of systolic function (if the ventricular configuration allows accurate quantification) using at least one of M-mode, 2-dimensional or 3-dimensional imaging; and

(ii)          assessment of diastolic function; and

(iii)        assessment of atrial structure including quantification of atrial sizes; and

(iv)        assessment of vascular connections of the heart including the great vessels and systemic venous structures; and

(v)          assessment of pericardium and assessment of any haemodynamic consequences of pericardial abnormalities; and

(vi)        assessment of all present valves including structural assessment and measurement of blood flow velocities across the valves using relevant Doppler techniques with quantification; and

(vii)      subxiphoid views where recommended for congenital heart lesions; and

(viii)    additional haemodynamic parameters relevant to the clinical condition under review; and

(b)   the service is performed by a specialist or consultant physician practising in the speciality of cardiology; and

(c)    not being a service associated with a service to which another item in this Subgroup (except items 55137, 55141, 55143, 55145 and 55146), or an item in Subgroup 1 (except item 55054), or an item in Subgroup 2 (except items 55118 and 55130) or an item in Subgroup 3 applies (R)

234.15

55133

Frequent repetition serial real time echocardiographic examination of the heart with real time colour flow mapping from at least 3 acoustic windows, with recordings on digital media:

(a)  for the investigation of a patient:

(i)            with isolated pericardial effusion or pericarditis; or

(ii)          who has commenced medication for non-cardiac purposes that have cardiotoxic side effects, and if the patient has a normal baseline study which requires echocardiograms to comply with the requirements of the Pharmaceutical Benefits Scheme; and

(b)  the service involves all of the following, where possible:

(i)            assessment of left ventricular structure and function including quantification of systolic function using M-mode, 2-dimensional or 3-dimensional imaging and diastolic function; and

(ii)          assessment of right ventricular structure and function with quantitative assessment; and

(iii)        assessment of left and right atrial structure including quantification of atrial sizes; and

(iv)        assessment of vascular connections of the heart including the great vessels and systemic venous structures; and

(v)          assessment of pericardium and assessment of any haemodynamic consequences of pericardial abnormalities; and

(vi)        assessment of all present valves including structural assessment and measurement of blood flow velocities across the valves using pulsed wave and continuous wave doppler techniques with quantification of stenosis or regurgitation; and

(vii)      assessment of additional haemodynamic parameters including the assessment of pulmonary pressures; and

(c)   not being a service associated with a service to which another item in this Subgroup (except items 55137, 55141, 55143, 55145 and 55146), or an item in Subgroup 1 (except item 55054), or an item in Subgroup 2 (except items 55118 and 55130) or an item in Subgroup 3 applies (R)

210.75

55134

Repeat real time echocardiographic examination of the heart with real time colour flow mapping from at least 3 acoustic windows, with recordings on digital media, for rare cardiac pathologies, if:

(a)    the service involves all of the following, where possible:

(i)            assessment of left ventricular structure and function including quantification of systolic function using M-mode, 2-dimensional or 3-dimensional imaging and diastolic function; and

(ii)          assessment of right ventricular structure and function with quantitative assessment; and

(iii)        assessment of left and right atrial structure including quantification of atrial sizes; and

(iv)        assessment of vascular connections of the heart including the great vessels and systemic venous structures; and

(v)          assessment of pericardium and assessment of any haemodynamic consequences of pericardial abnormalities; and

(vi)        assessment of all present valves including structural assessment and measurement of blood flow velocities across the valves using pulsed wave and continuous wave doppler techniques with quantification of stenosis or regurgitation; and

(vii)      assessment of additional haemodynamic parameters including the assessment of pulmonary pressures; and

(b)   the service is requested by a specialist or consultant physician; and

(c)    not being a service associated with a service to which another item in this Subgroup (except items 55137, 55141, 55143, 55145 and 55146), or an item in Subgroup 1 (except item 55054), or an item in Subgroup 2 (except items 55118 and 55130) or an item in Subgroup 3 applies (R)

234.15

55137

Serial real time echocardiographic examination of the heart with real time colour flow mapping from at least 4 acoustic windows, with recordings on digital media:

(a)    for the investigation of a fetus with suspected or confirmed of one or more of the following:

(i)                 complex congenital heart disease; or

(ii)               functional heart disease; or

(iii)             fetal cardiac arrhythmia; or

(iv)             cardiac structural abnormality requiring confirmation; and

(b)   the service involves the assessment all of the following, where possible:

(i)                 ventricular structure and function; and

(ii)               atrial structure; and

(iii)             vascular connections of the heart including the great vessels and systemic venous structures; and

(iv)             pericardium and assessment of any haemodynamic consequences of pericardial abnormalities; and

(v)               all present valves including structural assessment and measurement of blood flow velocities across the valves using relevant doppler techniques with quantification; and

(c)    the service is performed by a specialist or consultant physician practising in the speciality of cardiology with advanced training and expertise in fetal cardiac imaging; and

(d)   not being a service associated with a service to which another item in this Subgroup (except items 55141, 55143, 55145 and 55146), or an item in Subgroup 1 (except item 55054), or an item in Subgroup 2 (except items 55118 and 55130) or an item in Subgroup 3 applies (R)

234.15

55141

Exercise stress echocardiography focused study if;

(a)    the service involves all of the following:

(i)     two-dimensional recordings before exercise (baseline) from at least 2 acoustic windows; and

(ii)   matching recordings at or immediately after peak exercise, which include at least parasternal short and long axis views, and apical 4-chamber and 2 chamber views; and

(iii) recordings on digital media with equipment permitting display of baseline and matching peak images on the same screen; and

(iv) resting electrocardiogram and continuous multi-channel electrocardiogram monitoring and recording during stress; and

(v)   blood pressure monitoring and the recording of other parameters (including heart rate); and

(b)   cannot be claimed if a service associated with a service to which item 55143, 55145 or 55146 applies is provided in the previous 24 months; and

(c)    not being a service associated with a service to which item 11704, 11705, 11707, 11714, 11729 or 11730 applies; and

(d)   not being a service associated with a service to which an item in Subgroup 1 (except item 55054) or an item in Subgroup 3 applies

For any particular patient, applicable not more than once in 24 months (R)

417.45

55143

Repeat pharmacological or exercise stress echocardiography if:

(a)    the patient has had a service associated with a service to which item 55141, 55145 or 55146 applies provided in the previous 24 months; and

(b)   the patient has symptoms of ischaemia that have evolved and are not adequately controlled with optimal medical therapy; and

(c)    the service is requested by a specialist or a consultant physician; and

(d)   not being a service associated with a service to which item 11704, 11705, 11707, 11714, 11729 or 11730 applies; and

(e)    not being a service associated with a service to which an item in Subgroup 1 (except item 55054) or an item in Subgroup 3 applies

For any particular patient, applicable not more than once in 12 months (R)

417.45

55145

Pharmacological stress echocardiography if:

(a)    the service involves all of the following:

(i)     two-dimensional recordings before drug infusion (baseline) from at least 2 acoustic windows; and

(ii)   matching recordings at least twice during drug infusion, including a recording at the peak drug dose, which include at least parasternal short and long axis views, and apical 4-chamber and 2 chamber views; and

(iii) recordings on digital media with equipment permitting display of baseline and matching peak images on the same screen; and

(iv) resting electrocardiogram and continuous multi-channel electrocardiogram monitoring and recording during stress; and

(v)   blood pressure monitoring and the recording of other parameters (including heart rate); and

(b)   a service to which item 55141, 55146 or 55143 applies has not been provided in the previous 24 months; and

(c)    not being a service associated with a service to which item 11704, 11705, 11707, 11714, 11729 or 11730 applies; and

(d)   not being a service associated with a service to which an item in Subgroup 1 (except item 55054) or an item in Subgroup 3 applies

For any particular patient, applicable not more than once in 24 months (R)

483.85

55146

Pharmacological stress echocardiography if:

(a)    the service involves all of the following:

(i)     two-dimensional recordings before drug infusion (baseline) from at least 2 acoustic windows; and

(ii)   matching recordings at least twice during drug infusion, including a recording at the peak drug dose, which include at least parasternal short and long axis views, and apical 4-chamber and 2 chamber views; and

(iii) recordings on digital media with equipment permitting display of baseline and matching peak images on the same screen; and

(iv) resting electrocardiogram and continuous multi-channel electrocardiogram monitoring and recording during stress; and

(v)   blood pressure monitoring and the recording of other parameters (including heart rate); and

(b)   the patient has had a service performed under item 55141 in the previous 4 weeks and the test has failed due to an inadequate heart rate response; and

(c)    a service to which item 55143 or 55145 applies has not been provided in the previous 24 months; and

(d)   not being a service associated with a service to which item 11704, 11705, 11707, 11714, 11729 or 11730 applies; and

(e)    not being a service associated with a service to which an item in Subgroup 1 (except item 55054) or an item in Subgroup 3 applies

For any particular patient, applicable not more than once in 24 months (R)

483.85

 

4 Division 1.2 of Schedule 1 (subclause 1.2.1(1))  

Repeal the subclause, substitute:

(1)      For any particular patient, item 61324, 61329, 61345, 61349, 61357, 61394, 61398, 61406, 61410 or 61414 applies if one or more of the following is applicable:

(a)      if the patient displays one or more of the following symptoms of typical or atypical angina:

(i)          constricting discomfort in the:

a.              front of the chest; or

b.             neck; or

c.              shoulders; or

d.             jaw; or

e.              arms; or

(ii)        the patient’s symptoms, as described in subparagraph (3)(a)(i), are precipitated by physical exertion; or

(iii)      the patient’s symptoms, as described in subparagraph (3)(a)(i), are relieved by rest or glyceryl trinitrate within 5 minutes or less; or

(b)     if the patient has known coronary artery disease, and displays one or more symptoms that are suggestive of ischaemia:

(i)       which are not adequately controlled with medical therapy; or

(ii)          which have evolved since the last functional study; or

(c)           if the patient qualifies for one or more of the following indications:

(i)                 assessment indicates that resting 12 lead electrocardiogram changes are consistent with coronary artery disease or ischaemia, in a patient that is without known coronary artery disease; or

(ii)               coronary artery disease related lesions, of uncertain functional significance, which have previously been identified on computed tomography coronary angiography or invasive coronary angiography; or

(iii)             an assessment by a specialist or consultant physician indicates that the patient has possible painless myocardial ischaemia, which includes undue exertional dyspnoea of uncertain aetiology; or

(iv)             a pre-operative assessment of a patient with functional capacity of less than 4 metabolic equivalents, confirming that surgery is intermediate to high risk, and the patient has at least one of following conditions:

a.         ischaemic heart disease or previous myocardial infarction; or

b.         heart failure; or

c.         stroke or transient ischaemic attack; or

d.         renal dysfunction (serum creatinine greater than 70umol/L or 2 mg/dL or a creatinine clearance of less than 60 mL/min); or

e.         diabetes mellitus requiring insulin therapy: or

(v)               quantification of extent and severity of myocardial ischaemia, before either percutaneous coronary intervention or coronary bypass surgery, to ensure the criteria for intervention are met; or

(vi)             assessment of relative amounts of ischaemic viable myocardium and non-viable (infarcted) myocardium, in patients with previous myocardial infarction; or

(vii)           assessment of myocardial ischaemia with exercise is required, if a patient with congenital heart lesions has undergone surgery and ischemia is considered possible; or

(viii)         assessment of myocardial perfusion in a person who is under 17 years old with coronary anomalies, before and after cardiac surgery for congenital heart disease, or where there is a probable or confirmed coronary artery abnormality; or

(ix)             for patients where myocardial perfusion abnormality is suspected but due to the patient’s cognitive capacity or expressive language impairment, it is not possible to accurately assess symptom frequency based on medical history.

 

5 Division 1.2 of Schedule 1 (subclause 1.2.1(2))

Repeal the subclause, substitute:

 

(1)      For any particular patient, the request for a service to be provided under item 61324, 61329, 61345, 61349, 61357, 61394, 61398, 61406, 61410 or 61414 must identify the symptom/s or clinical indications/s, as outlined in subclause 1.2.1(1).

 

6 Division 1.2 of Schedule 1 (subclause 1.2.1(3)) 

Omit “61349 or 61357”, substitute “61349, 61357, 61394, 61398, 61406, 61410 or 61414”

 

7 Division 1.2 of Schedule 1 (subclause 1.2.1(4)) 

Omit “61349 or 61357”, substitute “61349, 61357, 61394, 61398, 61406, 61410 or 61414”

 

8 Division 1.2 of Schedule 1 (subclause 1.2.2(1)) 

Repeal the subclause, substitute:

 

(1)   Item 61321, 61324, 61329, 61345, 61357, 61394, 61398, 61406 or 61414 are applicable not more than once in any 24 month period if the patient is 17 years old or older.

 

9 Division 1.2 of Schedule 1 (below clause 1.2.2)

Repeal the table, substitute:

 

Group I4 – Nuclear Medicine Imaging

Subgroup 1 – Nuclear Medicine – Non-PET

Column 1

Item

Column 2

Description

Column 3

Fee ($)

61321

Single rest myocardial perfusion study for the assessment of extent and severity of viable and non-viable myocardium – with single photon emission tomography, which can include planar imaging, when performed on a patient who has left ventricular systolic dysfunction and probable or confirmed coronary artery disease, if:

(a)    using a single rest technetium-99m (Tc-99m) protocol; and

(b)   the service is requested by a specialist or a consultant physician; and

(c)    not being a service associated with a service to which item 11704, 11705, 11707, 11714, 11729, 11730, 61325, 61329, 61345, 61398 or 61406 applies (R)

329.00

61324

Single stress myocardial perfusion study – with single photon emission tomography, which can include planar imaging, if:

(a)    the patient has symptoms of cardiac ischaemia where at least one of the following applies:

(i)     the patient has body habitus or other physical condition/s (including heart rhythm disturbance) to the extent where a stress echocardiography would not provide adequate information; or

(ii)   the patient is unable to exercise to the extent where a stress echocardiography would not provide adequate information; or

(iii) the patient has had a failed stress echocardiography provided under a service to which items 55141, 55143, 55145 or 55146 applies; and

(b)   the service includes resting ECG, continuous ECG monitoring during exercise (with recording), blood pressure monitoring and the recording of other parameters (including heart rate); and

(c)    the service is requested by a specialist or consultant physician; and

(d)   not being a service associated with a service to which item 11704, 11705, 11707, 11714, 11729, 11730, 61321, 61325, 61329, 61345, 61357, 61394, 61398, 61406 or 61414 applies (R)

653.05

61325

Single rest myocardial perfusion study for the assessment of extent and severity of viable and non-viable myocardium – with single photon emission tomography, which can include planar imaging, when performed on a patient with left ventricular systolic dysfunction and probable or confirmed coronary artery disease, if:

(a)    using an initial rest study followed by redistribution study on the same day; and

(b)   using a thallous chloride-201 (Tl-201) protocol; and

(c)    the service is requested by a specialist or a consultant physician; and

(d)   not being a service associated with a service to which item 11704, 11705, 11707, 11714, 11729, 11730, 61321, 61329, 61345, 61398 or 61406  applies (R)

329.00

61329

Combined stress and rest, stress and re-injection or rest and redistribution myocardial perfusion study, including delayed imaging or re-injection protocol on a subsequent occasion – with single photon emission tomography, which can include planar imaging, if:

(a)    the patient has symptoms of cardiac ischaemia where at least one of the following applies:

(i)     the patient has body habitus or other physical condition/s (including heart rhythm disturbance) to the extent where a stress echocardiography would not provide adequate information; or

(ii)   the patient is unable to exercise to the extent where a stress echocardiography would not provide adequate information; or

(iii) the patient has had a failed stress echocardiography provided under a service to which item 55141, 55143, 55145 or 55146 applies; and

(b)   the service includes resting electrocardiograph, continuous electrocardiograph monitoring during exercise (with recording), blood pressure monitoring and the recording of other parameters (including heart rate); and

(c)    the service is requested by a medical practitioner (other than a specialist or consultant physician); and

(d)   not being a service associated with a service to which item 11704, 11705, 11707, 11714, 11729, 11730, 61321, 61324, 61325, 61345, 61357, 61394, 61398, 61406 or 61414 applies (R)

982.05

61345

Combined stress and rest, stress and re-injection or rest and redistribution myocardial perfusion study, including delayed imaging or re-injection protocol on a subsequent occasion – with single photon emission tomography, which can include planar imaging, if:

(a)    the patient has symptoms of cardiac ischaemia where at least one of the following applies:

(i)     the patient has body habitus or other physical condition/s (including heart rhythm disturbance) to the extent where a stress echocardiography would not provide adequate information; or

(ii)   the patient is unable to exercise to the extent where a stress echocardiography would not provide adequate information; or

(iii) the patient has had a failed stress echocardiography provided under a service to which item 55141, 55143, 55145 or 55146 applies; and

(b)   the service includes resting electrocardiograph, continuous electrocardiograph monitoring during exercise (with recording), blood pressure monitoring and the recording of other parameters (including heart rate); and

(c)    the service is requested by a specialist or consultant physician; and

(d)   not being a service associated with a service to which item 11704, 11705, 11707, 11714, 11729, 11730, 61321, 61324, 61325, 61329, 61357, 61394, 61398, 61406 or 61414 applies (R)

982.05

61349

Repeat combined stress and rest, stress and re-injection or rest and redistribution myocardial perfusion study, including delayed imaging or re-injection protocol on a subsequent occasion—with single photon emission tomography, which can include planar imaging, if:

(a)    in the previous 24 months, the patient has had a single stress or combined rest and stress myocardial perfusion study performed under item 61324, 61329, 61345, 61357, 61394, 61398, 61406 or 61414 and has undergone a revascularisation procedure; and

(b)   the patient has one or more of the following symptoms of cardiac ischaemia that have evolved and are not adequately controlled with optimal medical therapy, where at least one of the following applies;

(i)     the patient has body habitus or other physical condition/s (including heart rhythm disturbance) to the extent where a stress echocardiography would not provide adequate information; or

(ii)   the patient is unable to exercise to the extent where a stress echocardiography would not provide adequate information; or

(iii) the patient has had a failed stress echocardiography provided under service to which item 55141, 55143, 55145 or 55146 applies; and

(c)    the service is requested by a specialist or a consultant physician; and

(d)   not being a service associated with a service to which item 11704, 11705, 11707, 11714, 11729 11730 or 61410 applies; and

For any particular patient, applicable not more than once in 12 months (R)

982.05

61357

Single stress myocardial perfusion study – with single photon emission tomography, which can include planar imaging, if:

(a)    the patient has symptoms of cardiac ischaemia where at least one of the following applies:

(i)     the patient has body habitus or other physical condition/s (including heart rhythm disturbance) to the extent where a stress echocardiography would not provide adequate information; or

(ii)   the patient is unable to exercise to the extent where a stress echocardiography would not provide adequate information; or

(iii) the patient has had a failed stress echocardiography provided under a service to which items 55141, 55143, 55145 or 55146 applies; and

(b)   the service includes resting electrocardiograph, continuous electrocardiograph monitoring during exercise (with recording), blood pressure monitoring and the recording of other parameters (including heart rate); and

(c)    the service is requested by a medical practitioner (other than a specialist or consultant physician); and

(d)   not being a service associated with a service to which item 11704, 11705, 11707, 11714, 11729, 11730, 61321, 61324, 61325, 61329, 61345, 61394, 61398, 61406 or 61414 applies (R)

653.05

61394

Single stress myocardial perfusion study – with single photon emission tomography, which can include planar imaging, if:

(a)    the patient has symptoms of cardiac ischaemia; and

(b)    the service is provided at, or from, a practice location in:

(i)     a Modified Monash 3 area; or

(ii)   a Modified Monash 4 area; or

(iii) a Modified Monash 5 area; or

(iv) a Modified Monash 6 area; or

(v)   a Modified Monash 7 area; and

(c)    a stress echocardiography service is not available in the Modified Monash area where the service is provided; and

(d)   the service includes resting electrocardiograph, continuous electrocardiograph monitoring during exercise (with recording), blood pressure monitoring and the recording of other parameters (including heart rate); and

(e)    the service is requested by a specialist or consultant physician; and

(f)    not being a service associated with a service to which item 11704, 11705, 11707, 11714, 11729, 11730, 61321, 61325, 61329, 61345, 61357, 61394, 61398, 61406 or 61414 applies (R)

653.05

61398

Combined stress and rest, stress and re-injection or rest and redistribution myocardial perfusion study, including delayed imaging or re-injection protocol on a subsequent occasion – with single photon emission tomography, which can include planar imaging, if:

(a)    the patient has symptoms of cardiac ischaemia; and

(b)   the service is provided at, or from, a practice location in:

(i)     a Modified Monash 3 area; or

(ii)   a Modified Monash 4 area; or

(iii) a Modified Monash 5 area; or

(iv) a Modified Monash 6 area; or

(v)   a Modified Monash 7 area; and

(c)    a stress echocardiography service is not available in the Modified Monash area where the services is provided; and

(d)   the service includes resting electrocardiograph, continuous electrocardiograph monitoring during exercise (with recording), blood pressure monitoring and the recording of other parameters (including heart rate); and

(e)    the service is requested by a medical practitioner (other than a specialist or consultant physician); and

(f)    not being a service associated with a service to which item 11704, 11705, 11707, 11714, 11729, 11730, 61321, 61324, 61325, 61329, 61345, 61357, 61394, 61398, 61406 or 61414 applies (R)

982.05

61406

Combined stress and rest, stress and re-injection or rest and redistribution myocardial perfusion study, including delayed imaging or re-injection protocol on a subsequent occasion – with single photon emission tomography, which can include planar imaging, if:

(a)    the patient has symptoms of cardiac ischaemia; and

(b)   the service is provided at, or from, a practice location in:

(i)     a Modified Monash 3 area; or

(ii)   a Modified Monash 4 area; or

(iii) a Modified Monash 5 area; or

(iv) a Modified Monash 6 area; or

(v)   a Modified Monash 7 area; and

(c)    a stress echocardiography service is not available in the Modified Monash area where the services is provided; and

(d)   the service includes resting electrocardiograph, continuous electrocardiograph monitoring during exercise (with recording), blood pressure monitoring and the recording of other parameters (including heart rate); and

(e)    the service is requested by a specialist or consultant physician; and

(d)   not being a service associated with a service to which item 11704, 11705, 11707, 11714, 11729, 11730, 61321, 61324, 61325, 61329, 61345, 61357, 61394, 61398, 61406 or 61414 applies (R)

982.05

61410

Repeat combined stress and rest, stress and re-injection or rest and redistribution myocardial perfusion study, including delayed imaging or re-injection protocol on a subsequent occasion—with single photon emission tomography, which can include planar imaging, if:

(a)    in the previous 24 months, the patient has had a single stress or combined rest and stress myocardial perfusion study performed under item 61324, 61329, 61345, 61357, 61394, 61398, 61406 or 61414 and has undergone a revascularisation procedure; and

(b)   the patient has one or more symptoms of cardiac ischaemia that have evolved and are not adequately controlled with optimal medical therapy; and

(c)    the service is provided at, or from, a practice location in:

(i)     a Modified Monash 3 area; or

(ii)   a Modified Monash 4 area; or

(iii) a Modified Monash 5 area; or

(iv) a Modified Monash 6 area; or

(v)   a Modified Monash 7 area; and

(d)   a stress echocardiography service is not available in the Modified Monash area where the services is provided; and

(e)    not being a service associated with a service to which item 11704, 11705, 11707, 11714, 11729 or 11730 applies

For any particular patient, applicable not more than once in 12 months (R)

982.05

61414

Single stress myocardial perfusion study – with single photon emission tomography, which can include planar imaging, if:

(a)    the patient has symptoms of cardiac ischaemia; and

(b)   the service is provided at, or from, a practice location in:

(i)     a Modified Monash 3 area; or

(ii)   a Modified Monash 4 area; or

(iii) a Modified Monash 5 area; or

(iv) a Modified Monash 6 area; or

(v)   a Modified Monash 7 area; and

(c)    a stress echocardiography service is not available in the Modified Monash area where the services is provided; and

(d)   the service includes resting electrocardiograph, continuous electrocardiograph monitoring during exercise (with recording), blood pressure monitoring and the recording of other parameters (including heart rate); and

(e)    the service is requested by a medical practitioner (other than a specialist or consultant physician); and

(f)    not being a service associated with a service to which item 11704, 11705, 11707, 11714, 11729, 11730, 61321, 61324, 61325, 61329, 61345, 61357, 61394, 61398, 61406 or 61414 applies (R)

653.05

 

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

 

10 Subsection 6(2)

            Repeal the subsection, substitute:

(2)   Clause 1.2.11 of the general medical services table shall have effect as if items 11704, 11707, 11714, 11716, 11717, 11723, 11729, 11730 and 11735 of this instrument were specified in subclause 1.2.11(1).       

 

11 Section 7 (below the heading)

Repeal the section, substitute:

(1)        Items 11716, 11717, 11723, 11729 or 11735 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, 11729, or 11735 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, 11729 or 11735 applies is taken to be requested if rendered in circumstances other than described in subsection 7(2).

 

12 Subsection 8(1) (including the heading)

Repeal the subsection, substitute:

Restriction on items 11704, 11707, 11714, 11716, 11717, 11723 and 11735 location of service

(1)          Items 11704, 11707, 11714, 11716, 11717, 11723 or 11735 do not apply to a service if the patient is an admitted patient.

 

13 Subsection 8(10) (including the heading)

Repeal the subsection, substitute:

Restriction on items 11716, 11717, 11723, 11729 or 11735 —requested services performed on the same day as an attendance

(10)       Where items 11716, 11717, 11723, 11729 or 11735 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.

 

14 Schedule 1 (below the heading)

Repeal the table, substitute:

 

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; and

(c)    if the service is not associated with a service to which item 12203, 12204, 12205, 12207, 12208, 12210, 12213, 12215, 12217 or 12250 applies

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; and

(d)   the service is not associated with a service to which item 12203, 12204, 12205, 12207, 12208, 12210, 12213, 12215, 12217 or 12250 applies

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

 

Not associated with a service to which item 12203, 12204, 12205, 12207, 12208, 12210, 12213, 12215, 12217 or 12250 applies

 

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

 

Not associated with a service to which item 12203, 12204, 12205, 12207, 12208, 12210, 12213, 12215, 12217 or 12250 applies

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; and

(f)    is not associated with a service to which item 12203, 12204, 12205, 12207, 12208, 12210, 12213, 12215, 12217  12250, 11717, 11723 or 11735 applies

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; and

(e)    is not associated with a service to which item 12203, 12204, 12205, 12207, 12208, 12210, 12213, 12215, 12217, 12250, 11716, 11723 or 11735 applies

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; and

(e)    is not associated with a service to which item 12203, 12204, 12205, 12207, 12208, 12210, 12213, 12215, 12217, 12250, 11716, 11717 or 11735 applies

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, 61357, 61394, 61398, 61406, 61410 or 61414 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, 61357, 61394, 61398, 61406, 61410 or 61414 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

11735

Continuous electrocardiogram recording of an ambulatory patient for 7 days with interpretation and report, by a specialist or consultant physician, if the service:

(a)    utilises intelligent microprocessor based monitoring, with patient triggered recording and symptom reporting capability, real time analysis of electrocardiograms and alerts, and daily or live data uploads; and

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

(c)    is for the investigation of

(i)     episodes of suspected intermittent cardiac arrhythmia or episodes of syncope; or

(ii)   suspected intermittent cardiac arrhythmia in patients who:

A.     have had a previous cerebrovascular accident; or

B.     are at risk of cerebrovascular accident; or

C.     have had a previous transient ischemic attack/s; and

(d)   is not associated with a service to which item 11716, 11717, 11723, 12203, 12204, 12205, 12207, 12208, 12210, 12213, 12215, 12217 or 12250 applies

 

For any particular patient, applicable no more than four times in a 12 month period.

131.90