Medicare Benefits Schedule - Note IN.0.12

Specialist radiologists - services other than MRI

Benefits are not payable for consultations rendered by specialist radiologists in conjunction with one of the following diagnostic imaging services:

·  All musculoskeletal ultrasound – Group I1, Subgroup 6 (items 55812 – 55895)

·  Diagnostic radiology items as follows: 

- Group I3, Subgroup 1 – Radiographic Examination of the Extremities - items 57506 to 57527
- Group I3, Subgroup 2 – Radiographic Examination of Shoulder and Pelvis - items 57700 to 57721
- Group I3, Subgroup 3 – Radiographic Examination of the Head - items 57901 to 57969
- Group I3, Subgroup 4 – Radiographic Examination of the Spine - items 58100 to 58121
- Group I3, Subgroup 5 – Bone Age Study and Skeletal Survey - items 58300 and 58306
- Group I3, Subgroup 6 – Radiographic Examination of Thoracic Region - items 58500 to 58527
- Group I3, Subgroup 7 – Radiographic Examination of Urinary Tract - items 58700 to 58721
- Group I3, Subgroup 8 – Radiographic Examination of Alimentary Tract and Biliary System - items 58900 and 58903
- Group I3, Subgroup 9 – Radiographic Examination of Localisation of Foreign Bodies - item 59103 

Radiologists may claim consultation items when they attend the patient before, during or after the rendering of other diagnostic imaging services.  However, consultation items should only be claimed where the attendance on the patient is meaningful. That is:

- the radiologist utilises their medical knowledge, clinical acumen, technical skills and personal experience in clinical radiology to consult with a patient so as to alter, or potentially alter, the course of the patient's management in the best interests of the patient.
- the radiologist takes primary clinical responsibility for the management decisions made during the consultation (even if the decision is to proceed with the planned course of management).
- the consultation itself includes components of history taking; physical examination; discussion with the patient; formulation of management plans; and referral for additional opinion or tests.

Not all the components need be present in any one consultation, but presence of at least some indicates that a meaningful consultation occurred. 

To claim a specialist referred consultation (item 104 or 105), the specialist radiologist must have received a valid referral (not simply a request for a diagnostic imaging service) from a medical practitioner for the investigation, opinion, treatment and/or management of a condition or problem of a patient or for the performance of a specific examination(s) or test(s).  The requesting practitioner must have undertaken a professional attendance with the patient and turned their mind to the patient's need for referral and have communicated relevant information about the patient to the specialist or consultant physician (this need not mean an attendance on the occasion of the referral) – see note GN.6.16.

A request for the undertaking of a diagnostic imaging service in the absence of the other elements of a referral as noted above does not constitute a valid referral for a specialist referred consultation.  

The new consultation co-claiming rules do not apply to consultant physicians, other specialists and specialist radiologists who are also specialists in other medical disciplines. However, where a specialist radiologist has more than one qualification, co-claiming is only permitted where the patient has been referred to the provider in their non-radiologist capacity. 

Where a specialist or consultant physician receives a request for diagnostic imaging service only, for example, a request to a cardiologist to do an echocardiogram, a consultation should not be claimed. 

In addition, consultations must not be claimed in place of claiming a diagnostic imaging service. 

Consultations with MRI services

Benefits are not payable for consultations rendered by any credentialled MRI provider in conjunction with MRI services unless the providing practitioner determines that a consultation is necessary for the treatment or management of the patient’s condition. A consultation has to be meaningful. The definition of a meaningful consultation is the same as shown under the heading 'Specialist radiologists - services other than MRI' and the valid referral requirements for specialist referred consultations as noted under that heading also apply.

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