Medicare Benefits Schedule - Item 38307

Search Results for Item 38307

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Category 3 - THERAPEUTIC PROCEDURES

38307

38307 - Additional Information

Item Start Date:
01-Jul-2021
Description Updated:
09-Jul-2021
Schedule Fee Updated:
01-Jul-2021

Group
T8 - Surgical Operations
Subgroup
6 - Cardio-Thoracic
Subheading
3 - Endovascular Interventional Procedures

Note: (acute coronary syndrome - 1 coronary territory with selective coronary angiography)  the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.2 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17A; and

(ii) for whom selective coronary angiography has not been completed in the previous 3 months; and

(b) including selective coronary angiography and all associated imaging, catheter and contrast; and

(c) including either or both:

(i) percutaneous angioplasty;

(ii) transluminal insertion of one or more stents; and

(d) performed on one coronary vascular territory; and

(e) excluding aftercare;

other than a service associated with a service to which item 38200, 38203, 38206, 38244, 38247, 38248, 38249, 38251, 38252, 38308, 38310, 38311, 38313, 38314, 38316, 38317, 38319, 38320, 38322 or 38323 applies 

Multiple Operation Rule

(Anaes.) (Assist.)

Fee: $1,844.60 Benefit: 75% = $1,383.45 85% = $1,756.70

(See para TN.8.217, TN.8.225, TR.8.2, TR.8.5 of explanatory notes to this Category)


Associated Notes

Category 3 - THERAPEUTIC PROCEDURES

TN.8.217

Staging rules for PCI for acute

Staging

  • If a staged procedure is appropriately performed over multiple days, items 38316, 38317 or 38319 must be used for subsequent stages.
  • For subsequent stages of an acute percutaneous coronary intervention completed up to 3 months after the initial procedure, it is expected that the patient would receive the subsequent stage/s of the intervention based on the qualifying indication for the initial procedure

Vascular Territories

  • The item number claimed should reflect the number of coronary vascular territories (Left Anterior Descending, Circumflex or Right Coronary Artery distribution) that are treated during the procedure, not the total number of treated territories the patient has received to date.
  • For isolated Left Main (no involvement of the bifurcation), a single territory should be claimed but if the treated segment involves the bifurcation then 2 territories should be claimed.
  • The Intermediate Artery when treated in isolation is single territory, when treated with the Left Anterior Descending or Circumflex or both, should be claimed as two territories.
  • A single lesion in a bypass graft should be claimed as single territory regardless of how many vascular territories are supplied by that graft. If the graft has multiple lesions and those lesions are in separate skip portions to a different territory, then an additional territory may be claimed.

Related Items: 38307 38308 38310 38316 38317 38319

Category 3 - THERAPEUTIC PROCEDURES

TN.8.225

Percutaneous Coronary Intervention (PCI) Acute/Unstable

Staging of acute/unstable PCI

  • Staging of acute PCI is permissible when clinically appropriate.
  • An example of appropriate Acute Coronary Syndrome (ACS) staging could include intervention on an occluded proximal lesion in the context of an ST elevation myocardial infarction (STEMI) and a decision is made not to intervene on a distal lesion as it is difficult to determine whether it is a real lesion (possibly a thrombus) or the patient’s haemodynamic status remains compromised (clinically unsafe to continue).

Requirements of subsequent stages of a staged acute/unstable PCI

  • The qualifying indication for the initial procedure is to be used as the qualifier for the relevant subsequent stages.
  • Subsequent stages are required to be completed within 3 months of the initial procedure otherwise the patient will need to requalify under the appropriate indication (if applicable).
  • It would generally be expected that subsequent stages would be completed as soon as is practicable proceeding the initial intervention.
  • For subsequent stages of an acute/unstable PCI it is implied that diagnostic angiography has been completed in the previous 3 months and therefore it is only permissible to claim items 38316, 38317 or 38319 for subsequent stages.

Multiple Providers of one episode of care (acute/unstable or stable) PCI – Separate interventional sites or Same interventional site

One of  the primary intentions of the changes to selective coronary angiography and PCI items, is to encourage the provision of the entire intervention in a single episode of care. Therefore, the provider should consider that there will be a reasonable need to intervene (revascularise), noting that in some cases intervention is not required (e.g. pressure testing – FFR result does not support the need for stenting).

However, it is recognised that some providers of interventional cardiology services only provide selective coronary angiography (diagnostic) and require a secondary provider to undertake angioplasty, stenting and/or atherectomy.
 

Non-interventional – selective angiography providers (clinical assessment suggests intervention required)

Acute/Unstable patients

  • Acute/Unstable patients should undergo both selective coronary angiography and PCI by an accredited PCI provider in a single episode of care, unless staging is clinically required.
  • Rare exceptions might include rural or remote sites that offer diagnostic angiography as a triage service prior to limited availability PCI.
  • It would be expected that the non-interventional cardiologist (non-PCI accredited) has a limited role in the management of acute/unstable patients.

Separate hospital/procedural sites (Acute/Unstable or Stable)

  • The first provider undertakes the diagnostic angiography and either makes an independent decision or following discussion with the interventional cardiologist  refers to the secondary provider at another site  for the purposes of revascularisation (e.g. referral from a rural or regional hospital to a metropolitan hospital); therefore 
  • In this scenario there is a clear delineation between the angiography and revascularisation services due to the different geographical locations (separate episodes of care). Example claiming is as follows:

Acute (ACS) - claiming example

  • Provider 1 – site 1 (diagnostic angiography) claims item 38244 (ACS – selective angiography). Provider 2 – site 2 (PCI) claims item 38316 (ACS – PCI single territory)

Abandoned T8 Surgical Procedures and Acute or Stable Percutaneous Coronary Intervention (PCI) – Excluding appropriate staging

The new acute PCI items 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) the PCI and rescue PCI needs to be conducted by another provider, item 30001 is claimed. This will allow claiming by the provider who subsequently completes the rescue PCI, taking into consideration the time restrictions for each of the selective angiography items.

The new stable PCI items do not have time restrictions. However, it is important for the patient that if a provider cannot complete (abandoned) the PCI and rescue PCI needs to be conducted by another provider, item 30001 is claimed. This will allow claiming by the provider who subsequently completes the rescue PCI, taking into consideration the time restrictions for each of the selective angiography items.

 

 

Related Items: 38307 38308 38310 38316 38317 38319

Category 3 - THERAPEUTIC PROCEDURES

TR.8.2

Selective Coronary Angiography Indications

Clause 5.10.17A Items 38244, 38247, 38307, 38308, 38310, 38316, 38317 and 38319—patient eligibility and timing

(1) A patient is eligible for a service to which item 38244, 38247, 38307, 38308, 38310, 38316, 38317 or 38319 applies if:

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

(b) a service to which the item applies has not been provided to the patient in the previous 3 months, unless:

(i) the patient experiences a new acute coronary syndrome or angina, as described in paragraph (2)(a), (b) or (c), in that period; or

(ii) for a service to which item 38316, 38317 or 38319 applies—the service was provided to the patient in that period as a subsequent stage following an initial primary percutaneous coronary intervention procedure.

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

(a) an acute coronary syndrome evidenced by any of the following:

(i) ST segment elevation;

(ii) new left bundle branch block;

(iii) troponin elevation above the local upper reference limit;

(iv) new resting wall motion abnormality or perfusion defect;

(v) cardiogenic shock;

(vi) resuscitated cardiac arrest;

(vii) ventricular fibrillation;

(viii) sustained ventricular tachycardia; or

(b) unstable angina or angina equivalent with a crescendo pattern, rest pain or other high-risk clinical features, such as hypotension, dizziness, pallor, diaphoresis or syncope occurring at a low threshold; or

(c) either of the following, detected on computed tomography coronary angiography:

(i) significant left main coronary artery disease with greater than 50% stenosis or a cross-sectional area of less than 6 mm2;

(ii) severe proximal left anterior descending coronary artery disease (with stenosis of more than 70% or a cross-sectional area of less than 4 mm2 before the first major diagonal branch).

Related Items: 38244 38247 38307 38308 38310 38316 38317 38319 57364

Category 3 - THERAPEUTIC PROCEDURES

TR.8.5

Selective Coronary Angiography and Percutaneous Coronary Intervention - Documentation Requirements

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


Legend

  • Assist - Addition/Deletion of (Assist.)
  • Amend - Amended Description
  • Anaes - Anaesthetic Values Amended
  • Emsn - EMSN Change
  • Fee - Fee Amended
  • Renum - Item Number Change (renumbered)
  • New - New Item
  • NewMin - New Item (previous Ministerial Determination)
  • Qfe - QFE Change