Medicare Benefits Schedule - Item 63563

Search Results for Item 63563

View Associated Notes

Category 5 - DIAGNOSTIC IMAGING SERVICES

63563

63563 - Additional Information

Item Start Date:
01-Nov-2022
Description Updated:
01-Nov-2022
Schedule Fee Updated:
01-Nov-2022

Group
I5 - Magnetic Resonance Imaging
Subgroup
20 - Scans Of Pelvis And Upper Abdomen - For Specified Conditions

MRI scan of the pelvis or abdomen, if the request for the scan identifies that the investigation is for:

(a) sub‑fertility that requires one or more of the following:

(i) an investigation of suspected Mullerian duct anomaly seen in pelvic ultrasound or hysterosalpingogram;

(ii) an assessment of uterine mass identified on pelvic ultrasound before consideration of surgery;

(iii) an investigation of recurrent implantation failure in IVF (2 or more embryo transfer cycles without viable pregnancy); or

(b) surgical planning of a patient with known or suspected deep endometriosis involving the bowel, bladder or ureter (or any combination of the bowel, bladder or ureter), where the results of pelvic ultrasound are inconclusive

Applicable not more than once in a 2 year period (R) (Contrast)

Bulk bill incentive

(Anaes.)

Fee: $409.65 Benefit: 75% = $307.25 85% = $348.25

(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

Meaning of the term ‘scan’ in MRI items

In items 63001 to 63563 and 63740 to 63743, scan means a minimum of 3 sequences.

Eligible services

Items in Subgroups 1 to 21 (other than items 63541 and 63543) apply to an MRI or MRA service performed:

(a)   on request by a recognised specialist or consultant physician, where the request made in writing identifies the clinical indication for the service;

(b)   under the professional supervision of an eligible provider; and

(c)   with fully eligible equipment.

For information on what constitutes fully eligible equipment, please refer to ‘MRI equipment eligibility’ below.

Items 63395 to 63397 and the items in Subgroups 19, 20 and 21 (other than item 63461) apply to an MRI service performed:

(a)   on request by a recognised specialist or consultant physician, where the request made in writing identifies the clinical indication for the service;

(b)   under the professional supervision of an eligible provider; and

(c)   with partially eligible equipment.

For information on what constitutes partially eligible equipment, please refer to ‘MRI equipment eligibility’ below.

Items in Subgroup 22 apply to an MRI or MRA service performed:

(a)   on request by a medical practitioner, where the request made in writing identifies the clinical indication for the service;

(b)   under the professional supervision of an eligible provider; and

(c)   with fully eligible equipment or partially eligible equipment.

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

(a)   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;

(b)   under the professional supervision of an eligible provider; and

(c)   with fully eligible equipment or partially eligible equipment.

Prostate Multiparametric MRI items 63541 and 63543 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 which includes being rendered under the professional supervision of an eligible provider unless it is performed in an emergency or in a remote location because of medical necessity (please refer to ‘Permissible circumstances for performance of service’ below); and

(c)   using fully eligible equipment or partially eligible equipment.

See also note IN.5.2 for specific conditions relating to items 63541 and 63543.

Requests

A request must identify the clinical indications for the service.

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

  • 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 and 63397 (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

Benefits are only payable for MRI when performed as follows:

(a)   both

- 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

- reported by an eligible provider; or

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

- in an emergency; or

- because of medical necessity, in a remote location (refer to IN.0.6).

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 63397), an eligible provider is a specialist in diagnostic radiology who satisfies the Chief Executive Medicare (Services Australia) that he or she is a participant of the RANZCR Quality and Accreditation Program.

For cardiac MRI items 63395 to 63397, 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 RANZCR and the Cardiac Society of Australia and New Zealand (CSANZ).

MRI equipment eligibility

Fully eligible equipment is equipment which:

(a)   is located at premises of a comprehensive practice in Modified Monash Areas 2 to 7; OR

(b)   is located at premises:
         (i) of a comprehensive practice in Modified Monash Areas 1; and

                (ii) is made available to the practice by a person:
                   - who is subject to a deed with the Commonwealth that relates to the equipment

                (iii) is not identified as partial eligible equipment in the deed

 Partially eligible equipment is equipment which:

(a)   is located at premises of a comprehensive practice; and

(i)   is made available to the practice by a person:

- who is subject to a deed with the Commonwealth that relates to the equipment; and

(ii)   is identified as partial eligible equipment in the deed

A comprehensive practice for MRI services

The Health Insurance (Diagnostic Imaging Services Table) Regulations defines a comprehensive practice as a medical practice, or a radiology department of a hospital, that provides X‑ray, ultrasound and computed tomography services (whether or not it provides other services).

The location of Medicare-eligible MRI machines is available at the Department of Health's website at www.health.gov.au by searching for “MRI Unit Locations”.

 Limitation period for certain Medicare eligible MRI services

Item MRI or MRA items Limitation Period Maximum number of services
1 63040 to 63073 12 months 3
2 63101 12 months 3
3 63125 to 63131 12 months 3
4 63161 to 63185 12 months 3
5 63219 to 63243 12 months 3
6 63271 to 63280 12 months 3
7 63322 to 63340 12 months  3
8 63361 12 months 2
9 63385 to 63391 12 months 2
10 63395  12 months 1
11 63397 36 months 1
12 63401 to 63404 12 months
13 63416 12 months
14 63425 to 63428 12 months 
15 63461 to 63467 12 months 
15A 63541 12 months 1
* 63545 12 months 1
16 63547  patient's lifetime 
17 63482  12 months 
18 63507 to 63522 and 63551 to 63560 12 months
19 63563 24 months 1

Please note the # indicates restriction is included in the item descriptor.

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

MRI items for the staging of histologically diagnosed cervical cancer at FIGO stage 1B or greater (63470 or 63473)

Items 63470 or 63473 in subgroup 20 may be claimed only once ever. After either 63470 or 63473 is claimed the patient is no longer eligible for Medicare benefits under either item.

MRI items for Crohn’s disease (63740 to 63743)

Medicare benefits are only payable once in a 12 month period for item 63740, where it is provided for assessment of change to therapy in a patient with small bowel Crohn’s disease. The 12 month limitation does not apply to this item otherwise.

Medicare benefits are only payable once in a 12 month period for item 63743, where it is provided for assessment of change to therapy of pelvis sepsis and fistulas from Crohn’s disease. The 12 month limitation does not apply to this item otherwise.

MRI Subgroup 22 Modifying Items and eligible MRI and MRA service

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

Restrictions when applied to bilateral anatomical sites

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.

For example, item 63328 provides for an MRI scan for derangement of the knee or its supporting structures and 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 as clinically required.

Co-claiming head and spine MRI scans – items 63001-63131 and 63151 to 63280

Benefits are payable for only one head MRI scan at the same attendance. The items that will restrict with each other are in the range 63001 to 63131.

Benefits are payable for only one spine MRI scan at the same attendance. The items that will restrict with each other are in the range 63151 to 63280.

The head or spine item with the highest schedule fee can be claimed where indications spanning two or more service have been requested.

More than one item can be claimed where the clinical need for the additional service is:

  • stated in the request for the service; and
  • appropriately documented in the record of the service.

These rules clarify the policy intent for the items, that is, only one item should be claimable for a scan irrespective of the:

  • number of clinical conditions being investigated; and
  • the number of sequences required to complete the scan.

Where a request form seeks an investigation of more than one clinical condition, the item to claim is the item with the highest schedule fee. If the items have the same schedule fee, the item to be claimed is the item applicable to the first mentioned indication on the request form.

More than one item can be claimed where the request for the scan states that there is a clinical need for the additional service, and this is appropriately documented in the diagnostic imaging record for the patient. This does not mean different clinical indications listed in a request, rather it means that the requester is seeking separate and distinct scans.

Providers will need to indicate on the claim that separate and distinct scans have been requested.

MRI scan of the pelvis for pregnancy - 18 weeks gestation – suspected fetal abnormality (MBS item 63454) 

Clinical Notes and Diagnostic Imaging Request

For item 63454 the requesting specialist practising in the specialty of obstetrics is to record in their clinical notes and the imaging request:

·         the pregnancy is at, or after, 18 weeks gestation; and

·         fetal abnormality is suspected; and

·         an ultrasound has been previously performed and the diagnosis of fetal abnormality is indeterminate or requires further examination of the patient.

Providers

The service can only be requested by a specialist practising in the specialty of obstetrics.

Gestation period

For item 63454, “at or after 18 weeks gestation” means from 18 weeks 0 days of pregnancy onwards as confirmed by an ultrasound.

MRI scan of both breast for detection of cancer – younger than 60 years (MBS Item 63464)[HL2] 

Clinical Notes and Diagnostic Imaging Request

For item 63464 the requesting specialist or consultant physician is to record in their clinical notes and the imaging request:

  • the patient is asymptomatic; and
  • the patient is younger than 60 years of age; and
  • the patient is at a high risk of developing breast cancer due to one or more of the clinical indicators contained in the item descriptor. Reference the relevant clinical indicator/s in the clinical notes and request.

Clinically Relevant Evaluation Algorithm

A clinically relevant evaluation algorithm referenced in item 63464(c)(v) is considered to be the Tyrer‑Cuzick (IBIS Risk Evaluator) algorithm version 8 (or later version). The lifetime risk estimation is one of a number of clinical indicators contained in the item descriptor which can support a patient being eligible to claim item 63464. 

Restrictions

For item 63464, the service is not to be performed with items 55076 or 55079.

The service can only be claimed once in any 12-month period.

Age requirements

The age references in item 63464 are as follows:

  • younger than 60 years of age refers to a patient who has not yet turned 60 years of age.
  • before the age of 50 years refers to the patient being up to and including 49 years of age.
  • at age 45 years or younger refers to the patient being up to and including 45 years of age.

MRI scan of the pelvis for multiple pregnancy - 18 weeks gestation – suspected fetal abnormality (MBS Item 63549) 

Clinical Notes and Diagnostic Imaging Request

For item 63549 the requesting specialist practising in the specialty of obstetrics is to record in their clinical notes and the imaging request:

  • the patient has a multiple pregnancy; and
  • the pregnancy is at, or after, 18 weeks gestation; and
  • fetal abnormality is suspected; and
  • an ultrasound has been previously performed and diagnosis of fetal abnormality is indeterminate or requires further examination of the patient.

Providers

The service can only be requested by a specialist practising in the specialty of obstetrics.

Gestation period

For item 63549, “at or after 18 weeks gestation” means from 18 weeks 0 days of pregnancy onwards as confirmed by an ultrasound.

MRI scan of the liver (MBS Item 63545) 

Clinical Notes and Diagnostic Imaging Request

For item 63545 the requesting specialist or consultant physician is to record in their clinical notes and the imaging request:

  • the patient has a confirmed extra-hepatic primary malignancy (other than hepatocellular carcinoma), with no persistent extra-hepatic disease and
  • computed tomography of the patient’s liver is negative or inconclusive for metastatic disease; and
  • the identification of liver metastases would change the patient’s treatment planning.

Restrictions

The service can only be claimed once in any 12 month period.

MRI scan of the pelvis for sub-fertility and deep endometriosis (MBS Item 63563)

Clinical Notes and Diagnostic Imaging Request

For item 63563 the requesting specialist or consultant physician is to record in their clinical notes and the imaging request that the scan is for the investigation of

  • sub-fertility requiring one or more of the following:

o    an investigation of suspected Mullerian duct anomaly seen in pelvic ultrasound or hysterosalpingogram;

o    an assessment of uterine mass identified on pelvic ultrasound before consideration of surgery;

o    an investigation of recurrent implantation failure in IVF (2 or more embryo transfer cycles without viable pregnancy); or

  • surgical planning of a patient with known or suspected deep endometriosis involving either the bowel, bladder or ureter, where the results of pelvic ultrasound are inconclusive.

Restrictions

The service can only be claimed once in any 2 year period.

Definitions

“Recurrent implantation failure” is defined as failure to establish clinical pregnancy following two or more embryo transfer cycles. The number of embryos per cycle can be one or more.

 “Viable pregnancy” is defined as any pregnancy that results in a live birth.

 

 

Related Items: 63464 63549 63563

Category 5 - DIAGNOSTIC IMAGING SERVICES

IN.0.19

Bulk Billing Incentive

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 item 61369) benefits for bulk billed services are payable at 95% of the schedule fee for the item.

Related Items: 55028 55029 55030 55031 55032 55033 55036 55037 55038 55039 55048 55049 55054 55065 55066 55068 55070 55071 55073 55076 55079 55084 55085 55118 55126 55127 55128 55129 55130 55132 55133 55134 55135 55137 55141 55143 55145 55146 55238 55244 55246 55248 55252 55274 55276 55278 55280 55282 55284 55292 55294 55296 55600 55603 55700 55703 55704 55705 55706 55707 55708 55709 55712 55715 55718 55721 55723 55725 55729 55736 55739 55740 55741 55742 55743 55757 55758 55759 55762 55764 55766 55768 55770 55772 55774 55812 55814 55844 55846 55848 55850 55852 55854 55856 55857 55858 55859 55860 55861 55862 55863 55864 55865 55866 55867 55868 55869 55870 55871 55872 55873 55874 55875 55876 55877 55878 55879 55880 55881 55882 55883 55884 55885 55886 55887 55888 55889 55890 55891 55892 55893 55894 55895 56001 56007 56010 56013 56016 56022 56028 56030 56036 56101 56107 56219 56220 56221 56223 56224 56225 56226 56233 56234 56237 56238 56301 56307 56401 56407 56409 56412 56501 56507 56620 56622 56623 56626 56627 56628 56629 56630 56801 56807 57001 57007 57201 57341 57352 57353 57354 57360 57506 57509 57512 57515 57518 57521 57522 57523 57524 57527 57541 57700 57703 57706 57709 57712 57715 57721 57901 57902 57905 57907 57915 57918 57921 57924 57927 57930 57933 57939 57942 57945 57960 57963 57966 57969 58100 58103 58106 58108 58109 58112 58115 58300 58306 58500 58503 58506 58509 58521 58524 58527 58700 58706 58715 58718 58721 58900 58903 58909 58912 58915 58916 58921 58927 58933 58936 58939 59103 59300 59302 59303 59305 59312 59314 59318 59700 59703 59712 59715 59718 59724 59733 59739 59751 59754 59763 59970 60000 60003 60006 60009 60012 60015 60018 60021 60024 60027 60030 60033 60036 60039 60042 60045 60048 60051 60054 60057 60060 60063 60066 60069 60072 60075 60078 60500 60503 60506 60509 60918 60927 61109 61310 61313 61314 61321 61324 61325 61328 61329 61340 61345 61348 61349 61353 61356 61357 61360 61361 61364 61368 61372 61373 61376 61381 61383 61384 61386 61387 61389 61390 61393 61394 61397 61398 61402 61406 61409 61410 61413 61414 61421 61425 61426 61429 61430 61433 61434 61438 61441 61442 61445 61446 61449 61450 61453 61454 61457 61461 61462 61469 61473 61477 61480 61485 61495 61499 61505 61523 61524 61525 61529 61541 61553 61559 61563 61564 61565 61612 61620 61622 61628 61632 61647 61650 63001 63004 63007 63010 63040 63043 63046 63049 63052 63055 63058 63061 63064 63067 63070 63073 63101 63111 63114 63125 63128 63131 63151 63154 63161 63164 63167 63170 63173 63176 63179 63182 63185 63201 63204 63219 63222 63225 63228 63231 63234 63237 63240 63243 63271 63274 63277 63280 63301 63304 63307 63322 63325 63328 63331 63334 63337 63340 63361 63385 63388 63391 63395 63397 63401 63404 63416 63425 63428 63440 63443 63446 63454 63461 63464 63467 63470 63473 63476 63482 63491 63494 63496 63497 63498 63499 63501 63502 63504 63505 63513 63531 63533 63541 63543 63545 63546 63547 63560 63563 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