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Category 3 - THERAPEUTIC PROCEDURES
41626 - Additional Information
ABSCESS OR INFLAMMATION OF MIDDLE EAR, operation for (excluding aftercare)
Fee: $148.50 Benefit: 75% = $111.40 85% = $126.25
(See para TN.8.4 of explanatory notes to this Category)
Category 3 - THERAPEUTIC PROCEDURES
Aftercare (Post-operative Treatment)
Section 3(5) of the Health Insurance Act 1973 states that services included in the Schedule (other than attendances) include all professional attendances necessary for the purposes of post-operative treatment of the patient. For the purposes of this book, post-operative treatment is generally referred to as "aftercare".
Aftercare is deemed to include all post-operative treatment rendered by medical specialists and consultant physicians, and includes all attendances until recovery from the operation, the final check or examination, regardless of whether the attendances are at the hospital, private rooms, or the patient's home. Aftercare need not necessarily be limited to treatment given by the surgeon or to treatment given by any one medical practitioner.
If the initial procedure is performed by a general practitioner, normal aftercare rules apply to any post-operative service provided by the same practitioner.
The medical practitioner determines each individual aftercare period depending on the needs of the patient as the amount and duration of aftercare following an operation may vary between patients for the same operation, as well as between different operations.
Medicare will not normally pay for any consultations during an aftercare period as the Schedule fee for most operations, procedures, fractures and dislocations listed in the MBS item includes a component of aftercare.
There are some instances where the aftercare component has been excluded from the MBS item and this is clearly indicated in the item description.
There are also some minor operations that are merely stages in the treatment of a particular condition. As such, attendances subsequent to these services should not be regarded as aftercare but rather as a continuation of the treatment of the original condition and attract benefits. Likewise, there are a number of services which may be performed during the aftercare period for pain relief which would also attract benefits. This includes all items in Groups T6 and T7, and items 39013, 39100, 39115, 39118, 39121, 39127, 39130, 39133, 39136, 39324 and 39327.
Where there may be doubt as to whether an item actually does include the aftercare, the item description includes the words "including aftercare".
If a service is provided during the aftercare phase for a condition not related to the operation, then this can be claimed, provided the account identifies the service as 'Not normal aftercare', with a brief explanation of the reason for the additional services.
If a patient was admitted as a private patient in a public hospital, then unless the MBS item does not include aftercare, no Medicare benefits are payable for aftercare.
Medicare benefits are not payable for surgical procedures performed primarily for cosmetic reasons. However, benefits are payable for certain procedures when performed for specific medical reasons, such as breast reconstruction following mastectomy. Surgical procedures not listed on the MBS do not attract a Medicare benefit.
Where an initial or subsequent consultation relates to the assessment and discussion of options for treatment and, a cosmetic or other non-rebatable service are discussed, this would be considered a rebatable service under Medicare. Where a consultation relates entirely to a cosmetic or other non-Medicare rebatable service (either before or after that service has taken place), then that consultation is not rebatable under Medicare. Any aftercare associated with a cosmetic or non-Medicare rebatable service is also not rebatable under Medicare.
All care directly related to a public in-patient's care should be provided free of charge. Where a patient has received in-patient treatment in a hospital as a public patient (as defined in Section 3(1) of the Health Insurance Act 1973), routine and non-routine aftercare directly related to that episode of admitted care will be provided free of charge as part of the public hospital service, regardless of where it is provided, on behalf of the state or territory as required by the National Healthcare Agreement. In this case no Medicare benefit is payable.
Notwithstanding this, where a public patient independently chooses to consult a private medical practitioner for aftercare, then the clinically relevant service provided during this professional attendance will attract Medicare benefits.
Where a public patient independently chooses to consult a private medical practitioner for aftercare following treatment from a public hospital emergency department, then the clinically relevant service provided during this professional attendance will attract Medicare benefits.
Where the aftercare for fractures is delegated to a doctor at a place other than where the initial reduction was carried out, then Medicare benefits may be apportioned on a 50:50 basis rather than on the 75:25 basis for surgical operations.
Where the reduction of a fracture is carried out by hospital staff in the out-patient or emergency department of a public hospital, and the patient is then referred to a private practitioner for aftercare, Medicare benefits are payable for the aftercare on an attendance basis.
The following table shows the period which has been adopted as reasonable for the after‑care of fractures:‑
|Treatment of fracture of||After-care Period|
|Terminal phalanx of finger or thumb||6 weeks|
|Proximal phalanx of finger or thumb||6 weeks|
|Middle phalanx of finger||6 weeks|
|One or more metacarpals not involving base of first carpometacarpal joint||6 weeks|
|First metacarpal involving carpometacarpal joint (Bennett's fracture)||8 weeks|
|Carpus (excluding navicular)||6 weeks|
|Navicular or carpal scaphoid||3 months|
|Colles'/Smith/Barton's fracture of wrist||3 months|
|Distal end of radius or ulna, involving wrist||8 weeks|
|Both shafts of forearm or humerus||3 months|
|Clavicle or sternum||4 weeks|
|Pelvis (excluding symphysis pubis) or sacrum||4 months|
|Symphysis pubis||4 months|
|Fibula or tarsus (excepting os calcis or os talus)||8 weeks|
|Tibia or patella||4 months|
|Both shafts of leg, ankle (Potts fracture) with or without dislocation, os calcis (calcaneus) or os talus||4 months|
|Metatarsals - one or more||6 weeks|
|Phalanx of toe (other than great toe)||6 weeks|
|More than one phalanx of toe (other than great toe)||6 weeks|
|Distal phalanx of great toe||8 weeks|
|Proximal phalanx of great toe||8 weeks|
|Nasal bones, requiring reduction||4 weeks|
|Nasal bones, requiring reduction and involving osteotomies||4 weeks|
|Maxilla or mandible, unilateral or bilateral, not requiring splinting||6 weeks|
|Maxilla or mandible, requiring splinting or wiring of teeth||3 months|
|Maxilla or mandible, circumosseous fixation of||3 months|
|Maxilla or mandible, external skeletal fixation of||3 months|
|Spine (excluding sacrum), transverse process or bone other than vertebral body
requiring immobilisation in plaster or traction by skull calipers
|Spine (excluding sacrum), vertebral body, without involvement of cord, requiring
immobilisation in plaster or traction by skull calipers
|Spine (excluding sacrum), vertebral body, with involvement of cord||6 months|
Note: This list is a guide only and each case should be judged on individual merits.
- 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