Medicare Benefits Schedule - Item 35751

Hysterectomy, laparoscopic, by any approach, including any endometrial sampling, with or without removal of the tubes, not being a service associated with a service to which item 35595 applies (H) 

Multiple Operation Rule

(Anaes.) (Assist.)

Fee: $893.85 Benefit: 75% = $670.40

(See para TN.8.2, TN.8.229, TN.8.231 of explanatory notes to this Category)

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The fees for two or more operations, listed in Group T8 (other than Subgroup 12 of that Group), performed on a patient on the one occasion  are calculated by the following rule:‑

-               100% for the item with the greatest Schedule fee

plus 50% for the item with the next greatest Schedule fee

plus 25% for each other item.

Note:

(a)           Fees so calculated which result in a sum which is not a multiple of 5 cents are to be taken to the next higher multiple of 5 cents.

(b)           Where two or more operations performed on the one occasion have Schedule fees which are equal, one of these amounts shall be treated as being greater than the other or others of those amounts.

(c)           The Schedule fee for benefits purposes is the aggregate of the fees calculated in accordance with the above formula.

(d)           For these purposes the term "operation" only refers to all items in Group T8 (other than Subgroup 12 of that Group). 

This rule does not apply to an operation which is one of two or more operations performed under the one anaesthetic on the same patient if the medical practitioner who performed the operation did not also perform or assist at the other operation or any of the other operations, or administer the anaesthetic.  In such cases the fees specified in the Schedule apply. 

Where two medical practitioners operate independently and either performs more than one operation, the method of assessment outlined above would apply in respect of the services performed by each medical practitioner. 

If the operation comprises a combination of procedures which are commonly performed together and for which a specific combined item is provided in the Schedule, it is regarded as the one item and service in applying the multiple operation rule. 

There are a number of items in the Schedule where the description indicates that the item applies only when rendered in association with another procedure. The Schedule fees for such items have therefore been determined on the basis that they would always be subject to the "multiple operation rule". 

Where the need arises for the patient to be returned to the operating theatre on the same day as the original procedure for further surgery due to post-operative complications, which would not be considered as normal aftercare - see note TN.8.4, such procedures would generally not be subject to the "multiple operation rule".  Accounts should be endorsed to the effect that they are separate procedures so that a separate benefit may be paid. 

Extended Medicare Safety Net Cap 

The Extended Medicare Safety Net (EMSN) benefit cap for items subject to the multiple operations rule, where all items in that claim are subject to a cap are calculated from the abated (reduced) schedule fee. 

For example, if an item has a Schedule fee of $100 and an EMSN benefit cap equal to 80 per cent of the schedule fee, the calculated EMSN benefit cap would be $80.  However, if the schedule fee for the item is reduced by 50 per cent in accordance with the multiple operations rule provisions, and all items in that claim carry a cap, the calculated EMSN benefit cap for the item is $40 (50% of $100*80%). 

Related Items: 13241 31537 32222 32223 32224 32225 32226 32227 32228 32229 35591 35592 35609 35610 35631 35632 35668 35669 35671 35721 35724 35751 36504 36505 36507 36508 36836 37226

Appropriate documentation, ideally with photographic and/or histological evidence, is to be collected and retained to demonstrate the complexity of the procedure performed. Where photographic evidence is not retained, the reasons for this should be clearly documented.

Related Items: 35631 35632 35637 35641 35658 35750 35751 35753 35754 35756

Procedure may be undertaken using laparoscopy with any number of ports or by any approach as clinically indicated.

A laparoscopically assisted vaginal hysterectomy is defined as the introduction of the laparoscope to assess the pelvis and commence the procedure taking the round ligaments, adnexal attachments as indicated and to the level of the uterine arteries with the uterine arteries and uterosacral pedicles secured vaginally. 

A total laparoscopic hysterectomy is defined as the introduction of the laparoscope to assess the pelvis and complete the procedure laparoscopically including securing the uterine arteries and uterosacral pedicles. 

The complex hysterectomy items 35753 and 35754 are intended to cover procedures with increased complexity. 35753 is to be used for the excision of moderate endometriosis. 35754 is to be used for the excision of extensive endometriosis and when side wall dissection is required.

Related Items: 35750 35751 35753 35754 35756