Medicare Benefits Schedule - Item 38249

Note: (stable coronary syndrome - graft) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.3 and TR.8.5

Selective coronary and graft angiography:

(a) for a patient who is eligible for the service under clause 5.10.17B; and

(b) as part of the management of the patient; and

(c) with placement of one or more catheters and injection of opaque material into native coronary arteries; and

(d) if free coronary grafts attached to the aorta or direct internal mammary artery grafts are present—with placement of one or more catheters and injection of opaque material into those grafts (irrespective of the number of grafts); and

(e) with or without left heart catheterisation, left ventriculography or aortography; and

(f) including all associated imaging;

other than a service associated with a service to which item 38200, 38203, 38206, 38244, 38247, 38248, 38251 or 38252 applies—applicable once each 3 months

Multiple Operation Rule

(Anaes.)

Fee: $1,559.20 Benefit: 75% = $1,169.40 85% = $1,460.50

(See para IN.2.1, TN.8.215, TN.8.216, TR.8.3, TR.8.5, TR.8.6 of explanatory notes to this Category)

• Previous - Item 38248
• Next - Item 38251

Discussions of the results

Discussions of the results, findings or interpretation of a study are reasonably expected to be part of a formal report. Discussion of these findings with a patient does not constitute a consult. Similarly, discussion(s) during the course of a study or to determine the safety or appropriateness of the study is part of the service and should not be claimed as a consult.

Abandoned T8 Surgical Procedures and Selective Coronary Angiography

The new selective coronary angiography items now have time restrictions applied whether claimed by the same or different providers. It is important for the patient that if a provider cannot complete (abandoned) a comprehensive diagnostic angiography that appropriately informs the diagnosis and treatment pathway or is discontinued due to the clinical status of the patient, item 30001 is claimed. This will allow claiming by the provider who subsequently completes the entire diagnostic angiography service taking into consideration the time restrictions for each of the selective angiography items.

Related Items: 38244 38247 38248 38249 38251 38252

Claiming Guidance

This item is only claimable when the patient has graft arteries present and has undergone angiographic investigation of the native coronary arteries and any graft arteries, which can include but is not limited to free coronary grafts attached to the aorta or direct internal mammary artery grafts.

Related Items: 38247 38249 38252

Clause 5.10.17B Items 38248 and 38249—patient eligibility

(1) A patient is eligible for a service to which item 38248 or 38249 applies if:

(a) subclause (2) applies to the patient; or

(b) the patient is recommended for coronary angiography as a result of a heart team conference that meets the requirements of subclause (3).

(2) This subclause applies to a patient who has:

(a) limiting angina or angina equivalent, despite an adequate trial of optimal medical therapy; or

(b) high risk features, including at least one of the following:

(i) myocardial ischaemia demonstrated on functional imaging;

(ii) ST segment elevation, sustained ST depression, hypotension or a Duke treadmill score of minus 11 or less, demonstrated by stress electrocardiogram testing;

(iii) computed tomography coronary angiography evidence of one or more coronary arteries with stenosis of 70% or more; or

(iv) left ventricular dysfunction with an ejection fraction of less than 40% or segmental wall motion abnormality at rest

(3) For the purposes of paragraph (1)(b), the requirements for a heart team conference are as follows:

(a) the conference must be conducted by a team of specialists or consultant physicians practising in the speciality of cardiology or cardiothoracic surgery, including each of the following:

(i) an interventional cardiologist;

(ii) a non-interventional cardiologist;

(iii) a specialist or consultant physician; and

(b) the team must:

(i) assess the patient’s risk and technical suitability to receive the service; and

(ii) make a recommendation about whether or not the patient is suitable for invasive coronary angiography; and

(c) a record of the conference must be created, and must include the following:

(i) the particulars of the assessment of the patient during the conference;

(ii) the recommendations made as a result of the conference;

(iii) the names of the members of the team making the recommendations.

Related Items: 38248 38249 57364

Clause 5.10.17D Restriction on items 38244, 38247, 38248, 38249, 38251, 38252, 38307, 38308, 38310, 38311, 38313, 38314, 38320, 38322, 38323, 38316, 38317 and 38319—reports and clinical notes

Items 38244, 38247, 38248, 38249, 38251, 38252, 38307, 38308, 38310, 38311, 38313, 38314, 38320, 38322, 38323, 38316, 38317 and 38319 apply to a service provided to a patient only if a report or clinical note:

(a) is prepared for the service; and

(b) includes documentation that demonstrates how the item applies to the service, including how the patient is eligible for the service.

Related Items: 38244 38247 38248 38249 38251 38252 38307 38308 38310 38311 38313 38314 38316 38317 38319 38320 38322 38323

Definition of a heart team conference: relevant to items 38248, 38249, 38311, 38313, 38320, 38322 and 57364

 (a)   A heart team conference is a team of 3 or more participants who are cardiac specialists; where:

1. the first participant is a specialist or consultant physician who is an interventional cardiologist; and
2. the second participant is a specialist or consultant who is a non-interventional cardiologist; and
3. the third participant is a specialist or consultant physician; and

(b)    the team assesses a patient’s risk and technical suitability to receive the service; and

(c)    the result of the heart team conference’s assessment is that the team makes a recommendation about whether or not the patient is suitable for selective coronary angiography (for items 38248, 38249, 38320) or percutaneous coronary intervention (for items 38311, 38313, 38320, 38322) ; and

(d)    the particulars of the assessment and recommendation/s, and the names of those providers making the recommendation/s are recorded in writing.

Note: For non-complex stable triple vessel disease, providers are encouraged to include a cardiothoracic surgeon in the heart team.

Related Items: 38248 38249 38311 38313 38320 38322 57364

Heart rate during CTCA should be less than 65 beats per minute wherever possible, and sublingual glyceryl trinitrate (GTN) should be administered immediately prior to scanning where clinically appropriate.

The presence of coronary calcium alone does not preclude CTCA.

Discussions of the results, findings or interpretation of a study are reasonably expected to be part of a formal report. Discussion of these findings with a patient does not constitute a separate consultation. Similarly, discussion(s) during the course of a study or to determine the safety or appropriateness of the study is part of the service and should not be claimed as a separate consultation.

Indication (b)(iv) of the item recognises the increasing role of CTCA as an alternative to selective coronary angiography (invasive) in the assessment of the coronary arteries (including bypass grafts).

The service only applies if the patient meets the requirements of Notes: TR.8.3 (item 38247), TR.8.2 (item 38249) or item 38252 if subclause (iv) of the item applies.

Related Items: 38247 38249 38252 57364