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Determinations/Health as made
This instrument amends the Health Insurance (Section 3C Diagnostic Imaging Services – Cardiac Services) Determination 2020 to clarify that a co-claiming restriction between general ultrasound services and cardiac services is not required.
Administered by: Health
Registered 15 Sep 2020
Table of contents.

Commonwealth Coat of Arms of Australia

 

Health Insurance Legislation Amendment (Section 3C – Cardiac Services) Determination (No. 2) 2020

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

Dated   14 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

 

 


1  Name

                        This instrument is the Health Insurance Legislation Amendment (Section 3C – Cardiac Services) (No. 2) 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  

Immediately after the Health Insurance Legislation Amendment (Section 3C – Cardiac Services) Determination 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                Note:        This table relates only to the provisions of this instrument as originally made.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 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 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 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 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 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 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 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 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 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 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 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 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 3 applies

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

483.85