Medicare Benefits Schedule - Item 71121

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Category 6 - PATHOLOGY SERVICES

71121

71121 - Additional Information

Item Start Date:
01-Sep-1992
Description Updated:
01-Jul-1994
Schedule Fee Updated:
01-Jan-2013

Group
P4 - Immunology

Detection of 2 antibodies specified in item 71119

Fee: $20.80 Benefit: 75% = $15.60 85% = $17.70

(See para PN.0.33 of explanatory notes to this Category)


Associated Notes

Category 6 - PATHOLOGY SERVICES

PN.0.33

Pathology Services Table

Rules for the Interpretation of the Pathology Services Table

Please note that in the Health Insurance (Pathology Services Table) Regulations 2010 (effective 1 November 2010) rules and sub-rules are referred to as clauses and sub-clauses.  In addition in the Regulations a rule that refers to specific items within a pathology group, for example Group P1 Haemotology, is listed directly above the Schedule of Services for that group.  A table cross referencing the following rules with the clauses in the Regulations is at the end of this section. 

1. (1)          In this table

patient episode means:

(a) a pathology service or pathology services (other than a pathology service to which paragraph 1 (1) (b) refers) provided for a single patient whose need for the service or services was determined under section 16A of the Act:

(i)      on the same day; or

(ii)     if more than 1 test is performed on the 1 specimen within 14 days ‑ on the same or different days; 

whether the services:

(iii)       are requested by 1 or more practitioners; or

(iv)       are described in a single item or in more than 1 item; or

(v)        are rendered by 1 approved pathology practitioner or more than 1 approved pathology practitioner; or

(vi)       are rendered on the same or different days; or 

(b) a pathology service to which rule 4 refers that is provided in the circumstances set out in that rule that relates to the service. 

receiving APP means an approved pathology practitioner in an approved pathology authority who performs one or more pathology services in respect of a single patient episode following receipt of a request for those services from a referring APP. 

recognised pathologist means a medical practitioner recognised as a specialist in pathology by a determination under section 3D, 3DB or 3E of the Act. 

referring APP means an approved pathology practitioner in an approved pathology authority who:

(i) has been requested to render 1 or more pathology services, all of which are requested in a single patient episode; and

(ii) is unable, because of the lack of facilities in, or expertise or experience of the staff of, the laboratory of the authority, to render 1 or more of the pathology services; and

(iii) requests an approved pathology practitioner (the receiving APP) in another approved pathology authority to render the pathology service or services that the referring APP is unable to render; and

(iv) renders each pathology service (if any) included in that patient episode, other than the pathology service or services in respect of which the request mentioned in subparagraph (iii) is made. 

serial examinations means a series of examinations requested on 1 occasion whether or not:

(a) the materials are received on different days by the approved pathology practitioner; or

(b) the examinations or cultures were requested on 1 or more request forms by the treating practitioner. 

the Act means the Health Insurance Act 1973. 

1. (2)          In these rules, a reference to a request to an approved pathology practitioner includes a reference to a request for a pathologist‑determinable service to which subsection 16A (6) of the Act applies. 

1. (3)          A reference in this table by number to an item that is not included in this table is a reference to the item that has that number in the general medical services table or the diagnostic imaging services table, as the case requires. 

1. (4)          A reference to a Group in the table includes every item in the Group and a reference to a Subgroup in the table includes every item in the Subgroup. 

Precedence of items

2. (1)          If a service is described:

(a) in an item in general terms; and

(b) in another item in specific terms;

only the item that describes the service in specific terms applies to the service. 

2. (2)          Subject to subrule (3), if:

(a) subrule (1) does not apply; and

(b) a service is described in 2 or more items;

only the item that provides the lower or lowest fee for the service applies to the service. 

2. (3)          If an item is expressed to include a pathology service that is described in another item, the other item does not apply to the service in addition to the first‑mentioned item, whether or not the services described in the 2 items are requested separately. 

Application of item 74990 and 74991

2. (4)          Despite subrules (1), (2) and (3):

(a) if the pathology service described in item 74991 is provided to a person, either that item or item 74990, but not both those items, applies to the service; and

(b) if item 74990 or 74991 applies to a pathology service, the fee specified in that item applies in addition to the fee specified in any other item in the table that applies to the service. 

2. (5)          For items 74990 and 74991:

bulk-billed, in relation to a pathology service, means:

(a) a medicare benefit is payable to a person in respect of the service; and

(b) under an agreement entered into under section 20A of the Act:

(i)      the person assigns to the practitioner by whom, or on whose behalf, the service is provided, his or her right to the payment of the medicare benefit; and

(ii)     the practitioner accepts the assignment in full payment of his or her fee for the service provided. 

Commonwealth concession card holder means a person who is a concessional beneficiary within the meaning given by subsection 84(1) of the National Health Act 1953

unreferred service means a pathology service that:

(a) is provided to a person by, or on behalf of, a medical practitioner, being a medical practitioner who is not a consultant physician, or specialist, in any speciality (other than a medical practitioner who is, for the purposes of the Act, both a general practitioner and a consultant physician, or specialist, in a particular speciality); and

(b) has not been referred to the medical practitioner by another medical practitioner or person with referring rights. 

2. (6)          For item 74991:

ASGC means the document titled Australian Standard Geographical Classification (ASGC) 2002, published by the Australian Bureau of Statistics, as in force on 1 July 2002. 

practice location, in relation to the provision of a pathology service, means the place of practice in respect of which the practitioner by whom, or on whose behalf, the service is provided, has been allocated a provider number by the Commission. 

Regional, rural or remote area means an area classified as RRMAs 3-7 under the Rural, Remote and Metropolitan Areas Classification. 

Rural, Remote and Metropolitan Areas Classification has the meaning given by subrule 3 (1) of Part 2 of Schedule 1 to the general medical services table. 

SLA means a Statistical Local Area specified in the ASGC. 

SSD mean a Statistical Subdivision specified in the ASGC. 

Circumstances in which services rendered following 2 requests to be taken to have been rendered following 1 request 

3. (1)          In subrule 3(2), service  includes assay, estimation and test. 

3. (2)          Two or more pathology services (other than services to which, under rule 4, this rule does not apply) rendered for a patient following 2 or more requests are taken to have been rendered following a single request if: 

(a) the services are listed in the same item; and

(ab)  that item is not item 74990 or 74991; and

(b)    the patient's need for the services was determined  under subsection 16A (1) of the Act on the same day even if the services are rendered by an approved pathology practitioner on more than one  day. 

Services to which rule 3 does not apply 

4. (1)          Rule 3 does not apply to a pathology service described in item 65060, 65070, 65120, 65123, 65126, 65129, 65150, 65153, 65156, 66500, 66503, 66506, 66509, 66512, 66584 or 66800, if:

(a) the service is rendered in relation to one or more specimens taken on each of not more than 6 separate occasions in a period of 24 hours; and

(b) the service is rendered to an inpatient in a hospital; and

(c)  each service must be rendered as soon as possible after collection and after authorization of the result of the previous specimen; and

(d) the account for the service is endorsed 'Rule 3 Exemption'. 

4. (2)          Rule 3 does not apply to any of the following pathology services:

(a) estimation of prothrombin time (INR) in respect of a patient undergoing anticoagulant therapy;

(b) quantitative estimation of lithium in respect of a patient undergoing lithium therapy;

(c)  a service described in item 65070 in relation to a patient undergoing chemotherapy for neoplastic disease or immunosuppressant therapy;

(d) a service described in item 65070 in relation to clozaril, ticlopidine hydrochloride, methotrexate, gold, sulphasalazine or penicillamine therapy of a patient;

(e)  a service described in item 66500 - 66512 in relation to methotrexate or leflunomide therapy of a patient;

(f)  quantitative estimation of urea, creatinine and electrolytes in relation to:

(i)   cis‑platinum or cyclosporin therapy of a patient; or

(ii)  chronic renal failure of a patient being treated in a dialysis program conducted by a recognised hospital;

(g) quantitative estimation of albumin and calcium in relation to therapy of a patient with vitamin D, its metabolites or analogues;

(h) quantitative estimation of calcium, phosphate, magnesium, urea, creatinine and electrolytes in cancer patients receiving bisphosphonate infusions. 

                   if: 

(i)   under a request for a service, other than a request for a service described in paragraph (a), no more than 6 tests are requested; and

(ii)  the tests are performed within 6 months of the request; and

(iii) the account for the service is endorsed "Rule 3 Exemption". 

4. (3)      Rule 3 does not apply to a pathology service described in items 65109 or 65110 if: 

(a) The service is rendered on not more than 5 separate occasions in the case of item 65109 and 2 separate occasions in the case of item 65110 in a period of 24 hours; and

(b) The service is rendered in response to a written request separated in time from the previous request; and

(c) The account for the service is endorsed "Rule 3 Exemption". 

Item taken to refer only to the first service of a particular kind 

5. (1)          For an item in Group P1 (Haematology):

(a) if pathology services of a kind referred to in item 65090 or 65093 are rendered for a patient during a period when the patient is in hospital, the item applies only to the first pathology service of that kind rendered for the patient during the period; and

(b) if:

(i)      tests (except tests mentioned in item 65099, 65102, 65105 and 65108) are carried out in relation to a patient episode; and

(ii)     specimen material from the patient episode is stored; and

(iii)    in response to a request made within 14 days of the patient episode, further tests (except tests mentioned in item 65099, 65102, 65105 and 65108) are carried out on the stored material; the later tests and the earlier tests are taken to be part of one patient episode. 

5. (2)          Benefits for items 65102 and 65108 are payable only if a minimum of 6 units are issued for the patient's care in any 1 day. 

5.(3)           For items 65099 and 65102:

compatibility tests by crossmatch means that, in addition to all the tests described in paragraphs (a) and (b) of the item, donor red cells from each unit must have been tested directly against the serum of the patient by 1 or more accepted crossmatching techniques. 

Certain items not to apply to a service referred by one pathology practitioner to another

6. (1)      In this rule: 

designated pathology service means a pathology service in respect of tests relating to a single patient episode that are tests of the kind described in item 65150, 65175, 66650, 66695, 66711, 66722, 66785, 66800, 66812, 66819, 66825, 69384, 69494, 71089, 71153 or 71165. 

6. (2)      This rule applies in respect of a designated pathology service where:

               (a)          an approved pathology practitioner (practitioner A) in an approved pathology authority:

(i)                has been requested to render the designated pathology service; and

(ii)               is unable, because of the lack of facilities in, or expertise or experience of the staff of, the laboratory of the authority, to render 1 or more of the tests included in the service; and

(iii)              requests an approved pathology practitioner (practitioner B) in another approved pathology authority to render the test or tests that practitioner A is unable to render; and

(iv)              renders each test (if any) included in the service, other than the test or tests in respect of which the request mentioned in subparagraph (iii) is made; and

(b)            the tests mentioned in subparagraph (a) (iv) that practitioner A renders are not tests constituting a service described in item 65156, 65179, 66653, 66712, 66734, 66788, 66806, 66815, 66822, 66828,  69496, 71093, 71159 or 71168. 

6. (3)      If this rule applies in respect of a designated pathology service:

(a)            item 65150, 65153, 65175, 65176, 65177, 65178, 66650, 66695, 66698, 66701, 66704, 66707, 66711, 66722, 66725, 66728, 66731, 66785, 66800, 66803, 66812, 66819, 66825, 69384, 69387, 69390, 69393, 69396, 69494, 69495, 71089, 71091, 71153, 71155, 71157, 71165, 71166 or 71167 (as the case requires) applies in respect of the test or tests rendered by practitioner A; and 

(b)            where practitioner B renders a service under a request referred to in subparagraph (2) (a) (iii) and: 

(i)              practitioner A has rendered one or more of the tests that the service comprises - subject to subrule (4), the amount specified in item 65158, 65181, 66652, 66697, 66715, 66724, 66790, 66805, 66817, 66821, 66827, 69401, 69498, 71092, 71156 or 71170 (as the case requires) shall be taken to be the fee for each test that the service comprises; or 

                              (ii)          practitioner A has not rendered any of the tests that the service comprises -

(A)  the amount specified in item 65157, 65180, 66651, 66696, 66714, 66723, 66789, 66804, 66816, 66820, 66826, 69400, 69497, 71090, 71154 or 71169 (as the case requires) shall be taken to be the fee for the first test that the service comprises; and 

(B)  subject to subrule (4), the amount specified in item 65158, 65181, 66652, 66697, 66715, 66724, 66790, 66805, 66817, 66821, 66827, 69401, 69498, 71092, 71156 or 71170 (as the case requires) shall be taken to be the fee for each subsequent test that the service comprises. 

6. (4)      For paragraph (3) (b), the maximum number of tests to which item 65158, 65181, 66652, 66697, 66715, 66724, 66790, 66805, 66817, 66821, 66827, 69401, 69498, 71092, 71156 or 71170 applies is:              

(a)         for item 66652, 66715, 66790, 66817, 66821 or 66827:

2 - X; and

               (b)          for item 65158, 66805, 69498 or 71092:

3 - X; and

               (c)          for item 71156 or 71170:

4 - X; and

               (d)          for item 65181 or 66724:

5 - X; and          

where X is the number of tests rendered by practitioner A in relation to the designated pathology service in respect of which the request mentioned in that paragraph is made. 

6. (5)      Items in Group P10 (Patient episode initiation) do not apply to the second mentioned approved pathology practitioner in subrule (2). 

Items not to be split 

7. Except as stated in rule 6, the amount specified in an item is payable only to one approved pathology practitioner in respect of a single patient episode. 

Creatinine ratios - Group P2 (chemical) 

8.                A pathology service mentioned in an item (except item 66500) in Group P2 (chemical) that:

(a) involves the measurement of a substance in urine; and

(b) requires calculation of a substance/creatinine ratio;

                   is taken to include the measurement of creatinine necessary for the calculation. 

Thyroid function testing 

9. (1)          For item 66719:

abnormal level of TSH means a level of TSH that is outside the normal reference range in respect of the particular method of assay used to determine the level. 

9. (2)          Except where paragraph (a) of item 66719 is satisfied, the amount specified in the item is not payable in respect of a pathology service described in the item unless the pathologist who renders the service has a written statement from the medical practitioner who requested the service that satisfies subrule (3). 

9. (3)          The written statement from the medical practitioner must indicate: 

(a) that the tests are required for a particular purpose, being a purpose specified in paragraph (b) of item 66719; or

(b) that the medical practitioner who requested the tests suspects the patient has pituitary dysfunction; or

(c) that the patient is on drugs that interfere with thyroid hormone metabolism or function. 

Meaning of "serial examinations or cultures" 

10.             For an item in Group P3 (Microbiology):

(a) serial examinations or cultures means a series of examinations or cultures requested on 1 occasion whether or not:

(i)   the materials are received on different days by the approved pathology practitioner; or

(ii)  the examinations or cultures were requested on 1 or more request forms by the treating practitioner; and 

(b)      if:

(i)   tests are carried out in relation to a patient episode; and

(ii)  specimen material from the patient episode is stored; and

(iii)in response to a request made within 14 days of the patient episode, further tests are carried out on the stored material;

the later tests and the earlier tests are taken to be part of one patient episode. 

Investigation for hepatitis serology 

11.             A medicare benefit is not payable in respect of more than one of items 69475, 69478 and 69481 in a patient episode. 

Tests in Group P4 (Immunology) relating to antibodies 

12.             For items in Group P4 (Immunology), in items 71119, 71121, 71123 and 71125, if:

(a) tests are carried out in relation to a patient episode; and

(b) specimen material from the patient episode is stored; and

(c)  in response to a request made within 14 days of the patient episode, further tests are carried out on the stored material;

                   the later tests and the earlier tests are taken to be part of one patient episode. 

Tests on biopsy material ‑ Group P5 (Tissue pathology) and Group P6 (Cytology) 

13. (1)       For items in Group P5 (Tissue pathology):

(a) biopsy material means all tissue received by the Approved Pathology Practitioner:

(i)   from a medical procedure or group of medical procedures performed on a patient at the same time; or

(ii)  after being expelled spontaneously from a patient.

(b) cytology means microscopic examination of 1 or  more stained preparations of cells separated naturally or artificially from their normal environment by methods recognised as adequate to demonstrate their structure to a degree sufficient to enable an opinion to be formed about whether they are likely to be normal,  abnormal but benign, or abnormal and malignant but, in accordance with customary laboratory practice, does not include examination of a blood film and a bone marrow aspirate; and

(c)  separately identified specimen means an individual specimen collected, identified so that it is clearly distinguished from any other specimen, and sent for testing by or on behalf of the treating practitioner responsible for the procedure in which the specimen was taken. 

13. (2)       For Groups P5 and P6 of the pathology services table, services in Group P6 include any services described in Group P5 on the material submitted for a test in Group P6. 

13. (3)       For subrule (2), any sample submitted for cytology from which a cell block is prepared does not qualify for a Group P5 item. 

13.(4)        If more than 1 of the services mentioned in items 72813, 72816, 72817, 72818, 72823, 72824, 72825, 72826, 72827, 72828, 72830, 72836 and 72838 are performed in a single patient episode, only the fee for  the item performed having the highest specified fee is applicable to the services. 

13.(5)        If more than 1 histopathological examinations are performed on separate specimens, of different complexity levels, from a single patient episode, a medicare benefit is payable only for the examination that has the highest schedule fee. 

13.(6)        In items 72813, 72816, 72817, 72818, 72823, 72824, 72825, 72826, 72827, 72828, 72830, 72836 and 72838 a reference to a complexity level is a reference to the level given to a specimen type mentioned in Part 4 of this Table. 

13.(7)        If more than 1 of the services mentioned in items 72846, 72847, 72848; 72849 and 72850 or 73059, 73060, 73061, 73064 and 73065 are performed in a single patient episode, a medicare benefit is payable only for the item performed that has the highest scheduled fee. 

13.(8)        If more than 1 of the services mentioned in items 73049, 73051, 73062, 73063, 73066 and 73067 are performed in a single patient episode, only the fee for the item performed having the higher or highest specified fee applies to the services. 

Items in Groups P10 (Patient episode initiation) and P11 (Specimen referred) not to apply in certain circumstances 

14. (1)       For this rule and items in Groups P10 (Patient episode initiation) and P11 (Specimen referred): 

approved collection centre has the same meaning as in Part IIA of the Act. 

institution means a place at which residential accommodation or day care is, or both residential accommodation and day care are, made available to:

(a) disadvantaged children; or

(b) juvenile offenders; or

(c)  aged persons; or

(d) chronically ill psychiatric patients; or

(e)  homeless persons; or

(f)  unemployed persons; or

(g)  persons suffering from alcoholism; or

(h) persons addicted to drugs; or

(i)   physically or mentally handicapped persons;

but does not include:

(j)  a hospital; or

(k) a residential aged care home; or

(l)   accommodation for aged persons that is attached to a residential aged care home or situated within a residential aged care home. 

prescribed laboratory means a laboratory operated by:

(a) the Australian Government; or

(b) an authority of the Commonwealth; or

(c)  a State or internal Territory; or

(d) an authority of a State or internal Territory; or

(e)  an Australian tertiary education institution. 

specimen collection centre has the same meaning as in Part IIA of the Act. 

treating practitioner has the same meaning as in paragraph 16A(1)(a) of the Act. 

14. (2)       If a service described in an item in Group P10 is rendered by, or on behalf of, an approved pathology practitioner who is a recognised pathologist, the relevant one of those items does not apply to the service if: 

(a) the service is rendered upon a request made in the course of a service provided to a public patient in a recognised hospital or when attending an outpatient service of a recognised hospital. 

14. (3)       An item in Group P10 or P11 does not apply to a pathology service to which subsection 16A(7) of the Act applies. 

14. (4)       An item in Group P10 or P11 does not apply to a pathology service unless at least 1 item in Groups P1 to P8 also applies to the service. 

14. (5)       Subject to subrule (7), if one item in Group P10 applies to a patient episode, no other item in the Group applies to the patient episode. 

14. (6)       An item in Group P11 applies only to the approved pathology practitioner or approved pathology authority to whom the specimen mentioned in the item was referred. 

14. (7)       If, in respect of the same patient episode:

(a) services referred to in 1 or more items in Group P5 and 1 or more of Groups P1, P2, P3, P4, P6, P7 and P8 are rendered by an approved pathology practitioner in the laboratory of another approved pathology authority; or

(b) services referred to in 1 or more items in Group P6 and 1 or more of Groups P1, P2, P3, P4, P5, P7 and P8 are rendered by another approved pathology practitioner in the laboratory of another approved pathology authority;

the fee specified in the applicable item in Group P10 is payable to both approved pathology practitioners. 

14. (8)       If more than one specimen is collected from a person on the same day for the provision of pathology services:

(a) in accordance with more than 1 request; and

(b) in or by a single approved pathology authority;

                   the fee specified in the applicable item in Group P10 applies once only to the services unless an exemption listed in Rule 4 applies or an exemption has been granted under Rule 3 "S4B(3)". 

14. (9)       The amount specified in item 73940 is payable only once in respect of a single patient episode. 

Application of an item in Group P11 (Specimen referred) to a service excludes certain other items 

15.             If item 73940 applies to a patient episode, none of the items in Group P10 applies to any pathology service rendered by the approved pathology authority or approved pathology practitioner who claimed item 73940 in respect of the patient episode. 

Circumstances in which an item in Group P11 (Specimen referred) does not apply 

16. (1)          An item in Group P11 does not apply to a referral if: 

(a) a service in respect of the same patient episode has been carried out by the referring approved pathology authority; and

(b) the approved pathology authority to which the referral is made is related to the referring approved pathology authority. 

16. (2)       An approved pathology authority is related to another approved pathology authority for subrule (1) if:

(a) both approved pathology authorities are employed (including employed under contract) by the same person, whether or not the person is also an approved pathology authority; or

(b) either of the approved pathology authorities is employed (including employed under contract) by the other; or

(c)  both approved pathology authorities are corporations and are related corporations within the meaning of the Corporations Act; or

(d) the approved pathology authorities are partners (whether or not either or both of the approved pathology authorities are individuals and whether or not other persons are in partnership with either or both of the approved pathology authorities; or

(e)  both approved pathology authorities are operated by the Commonwealth or an authority of the Commonwealth; or

(f)  both approved pathology authorities are operated by the same State or internal Territory or an authority of the same State or internal Territory. 

16. (3)       An item in Group P11 does not apply to a referral if the following common tests are referred either singly or in combination (except if the following items are referred in combination with other items not similarly specified): 65060, 65070, 65120, 66500, 66503, 66506, 66509, 66512, 66536, 66596, 69300, 69303, 69333 or 73527. 

Abbreviations 

17. (1)       The abbreviations in Part 4 of this table may be used to identify particular pathology services or groups of pathology services. 

17. (2)       The names of services or drugs not listed in Part 4 of this table must be written in full. 

Certain pathology services to be treated as 1 service 

18. (1)       In this rule:

general practitioner means a medical practitioner who:

                     (a)    is not a consultant physician in any specialty; and

                     (b)    is not a specialist in any specialty.

set of pathology services means a group of pathology services:

                     (a)    that consists of services that are described in at least 4different items; and

                     (b)    all of which are requested in a single patient episode; and

                      (c)    each of which relates to a patient who is not an admitted patient of a hospital; and

                     (d)    excludes services referred to in an item in Group P10, Group P11, Group P12 or

Group P13, items 66900, 69484, 73070, 73071, 73072, 73073, 73074, 73075 or 73076; and

                      (e)    excludes services described in the following items:

65079, 65082, 65157, 65158, 65166, 65180, 65181, 66606, 66610, 66639, 66642, 66651, 66652, 66663, 66666, 66696, 66697, 66714, 66715, 66723, 66724, 66780, 66783, 66789, 66790, 66792, 66804, 66805, 66816, 66817, 66820, 66821, 66826, 66827, 66832, 66834, 66837, 69325, 69328, 69331, 69379, 69383, 69400, 69401, 69451, 69500, 69484, 69489, 69492, 69497, 69498, 71076, 71090, 71092, 71096, 71148, 71154, 71156, 71169, 71170, 73309, 73312, 73315, 73318, 73321 and 73324;

where those services are performed by an approved pathology practitioner in an accredited pathology laboratory of an approved pathology authority following referral by another approved pathology practitioner in an accredited pathology laboratory of an approved pathology authority which is not related to the first mentioned approved pathology authority.

          (1A)            An approved pathology authority is related to another approved pathology authority for the purposes of paragraph 18(1)(e) if that approved pathology authority would be related to the other approved pathology authority for the purposes of rule 16(2). 

18. (2)   If a general practitioner requests a set of pathology services, the pathology services in the set are to be treated as individual pathology services in accordance with this rule. 

18. (3)   If the fee specified in 1 item that describes any of the services in the set of pathology services is higher than the fees specified in the other items that describe the services in the set:

                     (a)    the pathology service described in the first‑mentioned item is to be treated as 1 pathology service; and

                     (b)    either:

                                   (i)         the pathology service in the set that is described in the item that specifies the second‑highest fee is to be treated as 1 pathology service; or

                                  (ii)         if 2 or more items that describe any of those services specify the second‑highest fee¿ the pathology service described in the item that specifies the second‑highest fee, and has the lowest item number, is to be treated as 1 pathology service; and

                      (c)    the pathology services in the set, other than the services that are to be treated as 1 pathology service under paragraphs (a) and (b), are to be treated as 1 pathology service.

18. (4)   If the fees specified in 2 or more items that describe any of the services in the set of pathology services are the same, and higher than the fees specified in the other items that describe the services in the set:

                     (a)    the pathology service in the set that is described in the item that specifies the highest fee, and has the lowest item number, is to be treated as 1 pathology service; and

                     (b)    the pathology service in the set that is described in the item that specifies the highest fee, and has the second‑lowest item number, is to be treated as 1 pathology service; and

                      (c)    the pathology services in the set, other than the services that are to be treated as 1 pathology service under paragraphs (a) and (b), are to be treated as 1 pathology service.

18. (5)   If pathology services are to be treated as 1 pathology service under paragraph (3)(c) or (4)(c), the fee for the 1 pathology service is the highest fee specified in any of the items that describe the pathology services that are to be treated as the 1pathology service. 

Hepatitis C viral RNA testing 

19.             For item 69499 and 69500:

Hepatitis C sero‑positive, for a patient, means 2 different assays of Hepatitis C antibodies are positive. 

serological status is uncertain, for a patient, means any result where 2 different assays of Hepatitis C antibodies are inconclusive. 

Haemochromatosis testing 

20.             For items 73317 and 73318:

                   elevated serum ferritin for a patient, means a level of ferritin above the normal reference range in respect of the particular method of assay used to determine the level. 

Nutritional and toxicity metals testing 

22. (1)       For this rule:

nutritional metals testing group means items 66819, 66820, 66821 and 66822.

metal toxicity testing group means items 66825, 66826, 66827, 66828, 66831 and 66832. 

22. (2)       An item in the nutritional metals testing group or the metal toxicity testing group does not apply in relation to a service performed if medicare benefits are paid or payable for tests that are performed for the same patient in 3 patient episodes requested within 6 months before the request for that service, under any of:

(a)    that item; or

(b)    the other item in the same group; or

(c)     an item in the other group. 

Antineutrophil Cytoplasmic Antibody 

23.             A request for Antineutrophil Cytoplasmic Antibody immunofluorescence test (ANCA) shall be deemed to include requests for antineutrophil proteinase 3 antibody test (PR-3 ANCA) and antimyeloperoxidase antibody test (MPO ANCA) where the immunofluorescence test for ANCA is abnormal, or has been abnormal, or those specific antibodies have been previously detected. 

Satisfying Requirements Described in Items 

24. Unless stated elsewhere in these rules, where an item contains a requirement, this requirement is satisfied if:

(a) The requirement/s as stipulated in the item descriptor are contained in the request form; or

(b) The requirement/s as stipulated in the item descriptor were supplied previously in writing to the APA and this documentation is retained by the APA; or

(c)  The results of other laboratory tests performed in the same episode meet the requirement/s as stipulated in the item descriptor; or

(d) The results of laboratory tests that meet the requirement/s as stipulated in the item descriptor are supplied on the request form; or

                   The results of laboratory tests that meet the requirement/s as stipulated in the item descriptor are contained in the APA's records. 

Limitation on certain items 

25.             (a) For any particular patient, items 66539, 66605, 66606, 66607, 66610, 69380, 69488, 69489, 71075, 71127, 71135 or 71137 is applicable not more than twice in a 12 month period.

                   (b) For any particular patient, item 66626 is applicable not more than 36 times in a 12 month period.

                   (c)  For any particular patient, items 66655, 66659, 66838, 66841, 69482, 69491, 69499 or 69500 are applicable not more than once in a 12 month period.

                   (d) For any particular patient, item 66750 or 66751 is applicable not more than once in a pregnancy.

                   (e)  For any particular patient, item 69336 is applicable not more than once in each period of 7 days.

                   (f)  For any particular patient, items 66551, 66660, 69445, 69451, 69483, 71079 or  73523 are applicable not more than 4 times in a 12 month period.

                   (g)  For any particular patient, items 66554, 66830 and 71077 are applicable not more than 6 times in a 12 month period.

                   (h) For any particular patient, item 66819, 66820, 66821, 66822, 66825, 66826, 66827 or 66828 is applicable not more than 3 times in a 6 month period.

                    (i)  For any particular patient, items 73339 and 73340 are applicable not more than once. 

Antigen Detection - Group P3 (Microbiology) 

26.          If the service listed in 69316, 69317, 69319, 69494, 69495, 69496, 69497 or 69498 is a pathologist determinable service the specialist pathologist is required to record the reasons for determining the need for this service. 

27. If the service rendered in 71148, 73320 or 73321 is a pathologist determinable service, the specialist pathologist is required to record the reason for determining the need for this service including the result of the service in 71147. 

Second Opinion morphology, limitations on items 72858 and 72859 

28.1       Items 72858 and 72859 apply:

                                    (a)     only to a service that is covered by:

                         (i)         item 65084 or 65087; or

                         (ii)        item 72813, 72816, 72817, 72818, 72823, 72824, 72825, 72826, 72827, 72828, 72830, 72836 or 72838; or

                         (iii)       an item in Group P6 (other than item 73070, 73071, 73072, 73073, 73074, 73075 or 73076); and

(b) only if the treating practitioner and the approved pathology practitioner who provided the original opinion on the patient specimen agree that a second opinion is reasonably necessary for diagnostic purposes. 

28.2        Items72858 and 72859 do not apply if the accredited pathology laboratory in which the second opinion is provided is the same laboratory in which the original opinion was provided.

 

 Table for Cross Referencing Rules and Clauses appearing in Regulations 

1 Nov 2010 MBS Book Rules

Health Insurance (Pathology Services Table) Regulations 2010 Clauses

1

Dictionary

         

2

1.2.1

2.12.1

       

3

1.2.2

         

4

1.2.3

2.1.1

2.2.2

     

5

2.1.2

         

6

1.2.4

         

7

1.2.5

         

8

2.2.1

         

9

2.2.5

         

10

2.3.1

         

11

2.3.3

         

12

2.4.2

         

13

2.5.1

2.6.1

       

14

2.10.1

2.11.1

       

15

2.11.2

         

16

2.11.3

         

17

1.1.1

         

18

1.2.6

         

18A

1.2.7

         

19

2.3.5

         

20

2.7.1

         

21

2.2.4

         

22

2.2.7

         

23

2.4.4

         

24

1.2.8

2.4.5

       

25

2.2.3

2.2.6

2.2.7

2.3.4

2.4.1

2.8.1

26

2.3.2

         

27

2.4.3

2.7.2

       
               

 

Related Items: 65060 65090 71119 71121 71123 71125 72858 72859 73529


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