Medicare Benefits Schedule - Item 63544

Search Results for Item 63544

View Associated Notes

Category 5 - DIAGNOSTIC IMAGING SERVICES

63544

63544 - Additional Information

Item Start Date:
01-Jul-2018
Description Start Date:
01-Jul-2018
Schedule Fee Start Date:
01-Jul-2018

Group
I5 - Magnetic Resonance Imaging
Subgroup
19 - Scan Of Body - For Specified Conditions

Multiparametric Magnetic Resonance Imaging scan of the prostate for the assessment of cancer, if the patient is referred by an urologist, radiation oncologist, or medical oncologist and:

 the request for the scan identifies: 
(i) the patient is under active surveillance following a confirmed diagnosis of prostate cancer by biopsy histopathology; and
(ii) the patient is not planning or undergoing treatment for prostate cancer.
using a standardised image acquisition protocol involving T2 Weighted Imaging, Diffusion Weighted Imaging, and Dynamic Contrast Enhancement (unless contraindicated)
(R) (NK)

Note: Benefits are payable at the time of diagnosis of prostate cancer, 12 months following diagnosis and then every 3rd year thereafter or at any time, if there is a clinical concern, including PSA progression.  This item is not to be used for the purposes of treatment planning or for monitoring after treatment

Bulk bill incentive

(Anaes.)

Fee: $225.00 Benefit: 75% = $168.75 85% = $191.25

(See para IN.0.18, IN.0.19 of explanatory notes to this Category)


Associated Notes

Category 5 - DIAGNOSTIC IMAGING SERVICES

IN.0.18

Group I5 - Magnetic Resonance Imaging

Itemisation

MRI items in Group I5 are divided into subgroups defined according to the area of the body to be scanned, (ie head, spine, musculoskeletal system, cardiovascular system or body) and the number of occasions in a defined period in which Medicare benefits may be claimed by a patient. Subgroups are divided into individual items, with each item being for a specific clinical indication.

Eligible services

Items in Subgroups 1 to 21 of Group I5 (other than items 63541 to 63544) apply to a MRI or MRA service performed:

  1. on request by a recognised specialist or consultant physician, where the request made in writing identifies the clinical indication for the service;
  2. under the professional supervision of an eligible provider; and
  3. with eligible equipment.

Items 63395 to 63398 and the items in Subgroups 19, 20 and 21 (other than items 63455 and 63461) of Group I5 apply to a MRI service performed:

  1. on request by a recognised specialist or consultant physician, where the request made in writing identifies the clinical indication for the service;
  2. under the professional supervision of an eligible provider; and
  3. with partial eligible equipment.

Items in Subgroup 22 of Group I5 apply to a MRI or MRA service performed:

  1. on request by a medical practitioner, where the request made in writing identifies the clinical indication for the service;
  2. under the professional supervision of an eligible provider; and
  3. with eligible equipment or partial eligible equipment.

Items in Subgroups 33 and 34 of Group I5 apply to a MRI service performed

  1. on request by a medical practitioner other than a specialist or consultant physician, where the request made in writing identifies the clinical indication for the service;
  2. under the professional supervision of an eligible provider; and
  3. with eligible equipment or partial eligible equipment.

Prostate Multiparametric MRI items 63541 to 63544 apply to a service performed:

a.    at the request of a specialist in the speciality of urology, radiation oncology, or medical oncology; and
b.    in a permissible circumstance; and
c.    using:
      (i) eligible equipment; or
      (ii) partial eligible equipment.

Requests

A request must be in writing and identify the clinical indications for the service.

MRI services can only be requested by a recognised specialist medical practitioner or consultant physician for the purpose of the Health Insurance Act 1973. However, there are exceptions to this provision for a limited number of MRI:

  • All dental specialists, prosthodontists, oral and maxillofacial surgeons, oral medicine specialists and oral pathology specialists may request item 63334 - scan of musculoskeletal system for derangement of the temporomandibular joint (s); and
  • Oral and maxillofacial surgeons and oral medicine and oral pathology specialists can also request item 63007 - scan of the head for skull base or orbital tumour; and
  • Items in subgroup 33 and 34 may only be requested by a medical practitioner other than a specialist or a consultant physician.

For cardiac MRI items 63395 to 63398 (scan for diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC)), the request must specify that ARVC is suspected on the basis of diagnostic criteria endorsed by the Cardiac Society of Australia and New Zealand (CSANZ), in force at the time the service is requested.

Permissible circumstances for performance of service

Group I5 items must be performed as follows:

(a) both:

  1. under the professional supervision of an eligible provider who is available to monitor and influence the conduct and diagnostic quality of the examination, including, if necessary, by personal attendance on the patient; and
  2. reported by an eligible provider; or

(b) if paragraph (a) is not complied with:

  1. in an emergency; or
  2. because of medical necessity, in a remote location (refer to DID).

Note: Practitioners do not have to apply for a remote area exemption in these circumstances.

Eligible providers

For items in Group I5 (excluding cardiac MRI items 63395 to 63398), an eligible provider is a specialist in diagnostic radiology who satisfies the Chief Executive Medicare (Department of Human Services) that he or she is a participant of the Royal Australian and New Zealand College of Radiologists' (RANZCR) Quality and Accreditation Program.

For cardiac MRI items 63395 to 63398, an eligible provider is a specialist in diagnostic radiology or a consultant physician, who is recognised by the Conjoint Committee for Certification in Cardiac MRI.  The conjoint committee is comprised of specialists from the Royal Australian and New Zealand College of Radiologists (RANZCR) and the Cardiac Society of Australia and New Zealand (CSANZ).

Eligible Provider declaration

The specialist must give the Department of Human Services a statutory declaration:

  1. stating that he or she is enrolled in the RANZCR Quality and Accreditation Program (except for providers only providing cardiac MRI (items 63395 to 63398));
  2. specifying the location of the MRI equipment;
  3. specifying the kinds of diagnostic imaging equipment offered at the location;
  4. stating the date of installation of the equipment (and the time of installation if this occurred on 12 May 1998); and
  5. if the equipment had not been installed before 7.30pm on 12 May 1998 (Eastern Standard Time), the specialist must also give the Department of Human Services a copy of the contract for the purchase or lease of the equipment.

In addition the Department of Human Services may request further supporting documentation or information. Specialists or consultant physicians are advised to contact the Provider Liaison Section, the Department of Human Services on 132 150 prior to lodging a declaration.

Eligible equipment is equipment which is:

  1. is located at premises of a comprehensive practice; and
  2. is made available to the practice by a person:
    1. who is subject to a deed with the Commonwealth that relates to the equipment; and
    2. for whom the deed has not been terminated; and
  3. is not identified as partial eligible equipment in the deed

Partial eligible equipment is equipment which is:
Equipment that:

  1. is located at premises of a comprehensive practice; and
  2. is made available to the practice by a person:
    1. who is subject to a deed with the Commonwealth that relates to the equipment; and
    2. for whom the deed has not been terminated; and
  3. is identified as partial eligible equipment in the deed

The location of Medicare-eligible MRI machines is available at the Department of Health's website at http://www.health.gov.au

Number of eligible services

Services in subgroups 1, 4, 6, 8, 11 and 18 have no frequency restriction.

For other MRI subgroups frequency restrictions on services are as follows:

 MRI or MRA items   Limitation period  Maximum number of services 
63040 to 63085 12 months 3
63101 and 63104  12 months 3
63125 to 63136 12 months 3
63161 to 63194 12 months 3
63219 to 63265 12 months 3
63271 to 63285 12 months 3
63322 to 63348 12 months 3
63361 and 63364 12 months  2
63385 to 63394 12 months 2
63395 and 63396 12 months 1
63397 and 63398 36 months 1
63401 to 63408 12 months 3
63416 and 63419 12 months 1
63425 to 63433 12 months 2
63455 to 63467 12 months 1
63547 and 63548 patient’s lifetime 1
63482 and 63486 12 months 3
63507 to 63523 and 63551 to 63561 12 months 3

Items 63470 or 63473 in subgroup 20 may be claimed only once in a patient's lifetime.

Items in subgroup 22 (modifying items) may only be ordered in conjunction with an eligible MRI/MRA service.

Items 63501 and 63502 in subgroup 32 may only be claimed once in any 12-month period, and items 63504 and 63505 have no restrictions. 

Example: Item 63271 in subgroup 10 can be claimed by a patient on three occasions in any 12 month period. If the patient had claimed Medicare benefits for the following:

Item Date of Service
63271 10/12/04
63271 18/4/05
63271 16/10/05
63271 11/12/05

The following table provides examples of further dates of service would, and would not, be eligible:

Date of service Claimable? Why?
12/3/05 No Between 10/12/04 and 9/12/05, the patient would have had 4 x 63271 in 12 months - 10/12/04, 12/3/05, 18/4/05 and 16/10/05
4/3/06 No Between 5/3/05 and 4/3/06, the patient would have had 4 x 63271 in 12 months - 18/4/05, 16/10/05, 11/12/05 and 4/3/06
20/4/06 Yes Between 21/4/05 and 20/4/06, the patient would  have had 3x 63271 in 12 months - 16/10/05, 11/12/05 and 20/4/06

The frequency restrictions are therefore considered to be rolling restrictions and not based on calendar or financial years.

In addition, restrictions on the number of services of the kind described in subgroup 12 apply to specific anatomical sites. Where an item description applies to more than one anatomical site the restriction on the number of services applies to each site.

Item 63328, MRI scan for derangement of the knee or its supporting structures, applies to two specific anatomical sites, ie, right knee and left knee. Each anatomical site may be scanned up to 3 times in any 12-month period.

Prostate Multiparametric MRI items 63541 and 63542 are applicable not more than once in a 12 month period.

Prostate Multiparametric MRI items 63543 and 63544 may be claimed:

  1. at the time of diagnosis of prostate cancer; and
  2. 12 months following diagnosis; and
  3. every third year thereafter; or
  4. at any time if there is clinical concern from the specialist requesting the service.

Clinical concern means a clinical decision that the prostate cancer has progressed, and includes prostate specific antigen progression.

Items 63543 and 63544 are not applicable for the purposes of treatment planning or for monitoring after treatment of prostate cancer.

Related Items: 63395 63396 63397 63398 63507 63508 63510 63511 63513 63514 63516 63517 63519 63520 63522 63523 63541 63542 63543 63544 63547 63548 63551 63552 63554 63555 63557 63558 63560 63561

Category 5 - DIAGNOSTIC IMAGING SERVICES

IN.0.19

Bulk Billing Incentive

To provide an incentive to bulk-bill, for out of hospital services that are bulk billed the schedule fee is reduced by 5% and rebates paid at 100% of this revised fee (except for item 61369, and all items in Group I5 - Magnetic Resonance Imaging).  For items in Group I5 - Magnetic Resonance Imaging, the bulk billing incentive for out of hospital services is 100% of the Schedule Fee listed in the table.

Related Items: 55005 55007 55008 55010 55011 55013 55014 55016 55017 55019 55023 55026 55028 55029 55030 55031 55032 55033 55036 55037 55038 55039 55048 55049 55054 55059 55060 55061 55062 55063 55064 55065 55067 55068 55069 55070 55073 55076 55079 55084 55085 55113 55114 55115 55116 55117 55118 55119 55120 55121 55122 55123 55125 55130 55131 55135 55136 55220 55221 55222 55223 55224 55226 55227 55228 55229 55230 55232 55233 55235 55236 55238 55244 55246 55248 55252 55274 55276 55278 55280 55282 55284 55292 55294 55296 55600 55601 55603 55604 55700 55701 55702 55703 55704 55705 55706 55707 55708 55709 55710 55711 55712 55713 55714 55715 55716 55717 55718 55719 55720 55721 55722 55723 55724 55725 55726 55727 55729 55730 55735 55736 55737 55739 55759 55760 55762 55763 55764 55765 55766 55767 55768 55769 55770 55771 55772 55773 55774 55775 55800 55801 55802 55803 55804 55805 55806 55807 55808 55809 55810 55811 55812 55813 55814 55815 55816 55817 55818 55819 55820 55821 55822 55823 55824 55825 55826 55828 55829 55830 55831 55832 55833 55834 55835 55836 55837 55838 55839 55840 55841 55842 55843 55844 55845 55846 55847 55848 55849 55850 55851 55852 55853 55854 55855 56001 56007 56010 56013 56016 56022 56028 56030 56036 56041 56047 56050 56053 56056 56062 56068 56070 56076 56101 56107 56141 56147 56219 56220 56221 56223 56224 56225 56226 56227 56228 56229 56230 56231 56232 56233 56234 56235 56236 56237 56238 56239 56240 56259 56301 56307 56341 56347 56401 56407 56409 56412 56441 56447 56449 56452 56501 56507 56541 56547 56619 56620 56625 56626 56659 56660 56665 56666 56801 56807 56841 56847 57001 57007 57041 57047 57201 57247 57341 57345 57350 57351 57355 57356 57360 57361 57506 57509 57512 57515 57518 57521 57522 57523 57524 57527 57529 57530 57532 57533 57535 57536 57537 57538 57539 57540 57700 57702 57703 57705 57706 57708 57709 57711 57712 57714 57715 57717 57721 57723 57901 57902 57903 57906 57909 57911 57912 57914 57915 57917 57918 57920 57921 57923 57924 57926 57927 57929 57930 57932 57933 57935 57938 57939 57941 57942 57944 57945 57947 57950 57953 57956 57959 57960 57962 57963 57965 57966 57968 57969 58100 58102 58103 58105 58106 58108 58109 58111 58112 58114 58115 58117 58123 58124 58126 58127 58300 58302 58306 58308 58500 58502 58503 58505 58506 58508 58509 58511 58521 58523 58524 58526 58527 58529 58700 58702 58706 58708 58715 58717 58718 58720 58721 58723 58900 58902 58903 58905 58909 58911 58912 58914 58915 58916 58917 58920 58921 58923 58927 58929 58933 58935 58936 58938 58939 58941 59103 59104 59300 59301 59302 59303 59304 59305 59306 59307 59309 59310 59312 59313 59314 59315 59318 59319 59700 59701 59703 59704 59712 59713 59715 59716 59718 59719 59724 59725 59733 59734 59739 59740 59751 59752 59754 59755 59763 59764 59903 59912 59925 59970 59971 59972 59973 59974 60000 60001 60003 60004 60006 60007 60009 60010 60012 60013 60015 60016 60018 60019 60021 60022 60024 60025 60027 60028 60030 60031 60033 60034 60036 60037 60039 60040 60042 60043 60045 60046 60048 60049 60051 60052 60054 60055 60057 60058 60060 60061 60063 60064 60066 60067 60069 60070 60072 60073 60075 60076 60078 60079 60500 60501 60503 60506 60509 60510 60918 60927 61109 61110 61302 61303 61306 61307 61310 61313 61314 61316 61317 61320 61328 61340 61348 61352 61353 61356 61360 61361 61364 61368 61372 61373 61376 61381 61383 61384 61386 61387 61389 61390 61393 61397 61401 61402 61405 61409 61413 61417 61421 61425 61426 61429 61430 61433 61434 61437 61438 61441 61442 61445 61446 61449 61450 61453 61454 61457 61458 61461 61462 61469 61473 61480 61484 61485 61495 61499 61505 61523 61529 61541 61553 61559 61565 61620 61622 61628 61632 61647 61650 61651 61652 61653 61654 61655 61656 61657 61658 61659 61660 61661 61662 61663 61664 61665 61666 61667 61668 61669 61670 61671 61672 61673 61674 61675 61676 61677 61678 61679 61680 61681 61682 61683 61684 61685 61686 61687 61688 61689 61690 61691 61692 61693 61694 61695 61696 61697 61698 61699 61700 61701 61702 61703 61704 61705 61706 61707 61708 61709 61710 61712 61713 61714 61715 61716 61717 61718 61719 61729 63001 63004 63007 63010 63013 63014 63016 63017 63040 63043 63046 63049 63052 63055 63058 63061 63064 63067 63070 63073 63074 63075 63076 63077 63078 63079 63080 63081 63082 63083 63084 63085 63101 63104 63111 63114 63117 63119 63125 63128 63131 63134 63135 63136 63151 63154 63157 63158 63161 63164 63167 63170 63173 63176 63179 63182 63185 63186 63187 63188 63189 63190 63191 63192 63193 63194 63201 63204 63207 63208 63219 63222 63225 63228 63231 63234 63237 63240 63243 63257 63258 63259 63260 63261 63262 63263 63264 63265 63271 63274 63277 63280 63282 63283 63284 63285 63301 63304 63307 63310 63311 63313 63322 63325 63328 63331 63334 63337 63340 63341 63342 63343 63345 63346 63347 63348 63361 63364 63385 63388 63391 63392 63393 63394 63395 63396 63397 63398 63401 63404 63407 63408 63416 63419 63425 63428 63432 63433 63440 63443 63446 63447 63448 63449 63455 63457 63458 63461 63464 63467 63470 63473 63476 63479 63481 63482 63484 63486 63491 63494 63497 63498 63499 63501 63502 63504 63505 63513 63514 63541 63542 63543 63544 63547 63548 63560 63561 64990 64991


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