Medicare Benefits Schedule - Item 57364

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

Computed tomography of the coronary arteries performed on a minimum of a 64 slice (or equivalent) scanner, if:

(a) the service is requested by a specialist or consultant physician; and

(b) at least one of the following apply to the patient:

(i) the patient has stable symptoms and newly recognised left ventricular systolic dysfunction of unknown aetiology;

(ii) the patient requires exclusion of coronary artery anomaly or fistula;

(iii) the patient will be undergoing non-coronary cardiac surgery;

(iv) the patient meets the criteria to be eligible for a service to which item 38247, 38249 or 38252 applies, but as an alternative to selective coronary angiography will require an assessment of the patency of one or more bypass grafts

(R) 

Bulk bill incentive

(Anaes.)

Fee: $758.30 Benefit: 75% = $568.75 85% = $659.60

(See para IN.0.19, IN.2.1, TR.8.2, TR.8.3, TR.8.6 of explanatory notes to this Category)

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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

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

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

Out-of-hospital services attract higher benefits when they are bulk billed by the provider.

For all diagnostic imaging items (except those in Group 6 – Management of Bulk Billed Services and items 61369, 61466, 61485) benefits for bulk billed services are payable at 95% of the schedule fee for the item.

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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