Medicare Benefits Schedule - Item 45530

Breast reconstruction (unilateral), using a latissimus dorsi or other large muscle or myocutaneous flap, including repair of secondary skin defect, if required, excluding repair of muscular aponeurotic layer, other than a service associated with a service to which item 30165, 30168, 30171, 30172, 30176, 30177 or 30179 applies

(H)

Multiple Operation Rule

(Anaes.) (Assist.)

Fee: $1,162.25 Benefit: 75% = $871.70

(See para TN.8.8, TN.8.97 of explanatory notes to this Category)

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Lipectomy is not intended as a primary bariatric procedure to correct obesity. MBS benefits are not available for surgery performed for cosmetic purposes. 

For the purpose of informing patient eligibility for lipectomy items (30165-30172, 30177, 30179) that are for the management of significant weight loss (SWL), SWL is defined as a weight loss equivalent of at least five BMI units. Weight must be stable for at least six months following significant weight loss prior to lipectomy. For significant weight loss that has occurred following pregnancy, the products of conception must not be included in the calculation of baseline weight to measure weight loss against. 

Multiple lipectomies of redundant non-abdominal skin and fat as a direct consequence of mass weight loss (for example on both buttocks and both thighs), attracts a Medicare benefit only once against the relevant item (30171 or 30172). The schedule fee for multiple lipectomies for excision of redundant non-abdominal skin and fat following massive weight loss is the same regardless of the number of excisions. 

The lipectomy items cannot be claimed in association with items 45564, 45565 or 45530. Where the abdomen requires surgical closure with reconstruction of the umbilicus following free tissue transfer (45564, 45565) or breast reconstruction (45530), item 45569 is to be claimed. 

In the context of eligibility for item 30175, acceptable examples of conservative non-surgical treatment include symptomatic management with pain medication, lower back braces, lifestyle changes, physiotherapy and/or exercise.

Diagnostic imaging, documented symptoms of pain and discomfort, and documented failure to respond to non-surgical conservative treatment must all be documented in patient notes. 

Related Items: 30165 30168 30171 30172 30176 30177 30179 30651 30655 45530 45533 45564 45565 45584 45585

When a prosthesis is inserted in conjunction with this operation, benefit would be attracted under Item 45527, the multiple operation rule applying. Benefits would also be payable for nipple reconstruction (Item 45545) when performed. 

When claiming item 45530 for a rectus abdominis flap; item 45569 should be claimed  for closure of the abdomen and reconstruction of the umbilicus, and item 45570 may be claimed if repair of the musculoaponeurotic layer is required. When claiming item 45530 for a latissimus dorsi flap, no item for the closure of the musculoaponeurotic layer should be claimed as it is expected that repair will be by direct suture. In the small number of cases, when a latissimus dorsi flap is used, and  repair by means other than direct suture is required, use of item 45203 would be appropriate. 

Items 30165-30179 (lipectomy items) should not be claimed in association with item 45530 as stated in the Health Insurance (General Medical Services Table) Regulations.

Related Items: 45530