Medicare Benefits Schedule - Item 63551

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Category 5 - DIAGNOSTIC IMAGING SERVICES

63551

63551 - Additional Information

Item Start Date:
01-Nov-2013
Description Start Date:
01-Nov-2013
Schedule Fee Start Date:
01-Nov-2013

Group
I5 - Magnetic Resonance Imaging
Subgroup
34 - Magnetic Resonance Imaging - For Specified Conditions

referral by a medical practitioner (excluding a specialist or consultant physician) for a scan of head for a patient  16 years or older for any of the following:


- unexplained seizure(s) (R) (Contrast) (Anaes.)

- unexplained chronic headache with suspected intracranial pathology (R) (Contrast) (Anaes.)

Bulk bill incentive

Fee: $403.20 Benefit: 75% = $302.40 85% = $342.75

(See para IN.0.18 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


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