General Explanatory Notes
Services which do not attract Medicare benefits
Services not attracting benefits
(a) telephone consultations (with the exception of COVID-19 telehealth services);
(b) issue of repeat prescriptions when the patient does not attend the surgery in person;
(c) group attendances (unless otherwise specified in the item, such as items 170, 171, 172, 342, 344 and 346);
(d) non-therapeutic cosmetic surgery;
(e) euthanasia and any service directly related to the procedure. However, services rendered for counselling/assessment about euthanasia will attract benefits.
Medicare benefits are not payable where the medical expenses for the service
(a) are paid/payable to a public hospital;
(b) are for a compensable injury or illness for which the patient's insurer or compensation agency has accepted liability. (Please note that if the medical expenses relate to a compensable injury/illness for which the insurer/compensation agency is disputing liability, then Medicare benefits are payable until the liability is accepted.);
(c) are for a medical examination for the purposes of life insurance, superannuation, a provident account scheme, or admission to membership of a friendly society;
(d) are incurred in mass immunisation (see General Explanatory Note 12.3 for further explanation).
Unless the Minister otherwise directs
Medicare benefits are not payable where:
(a) the service is rendered by or on behalf of, or under an arrangement with the Australian Government, a State or Territory, a local government body or an authority established under Commonwealth, State or Territory law;
(b) the medical expenses are incurred by the employer of the person to whom the service is rendered;
(c) the person to whom the service is rendered is employed in an industrial undertaking and that service is rendered for the purposes related to the operation of the undertaking; or
(d) the service is a health screening service.
(e) the service is a pre-employment screening service
Current regulations preclude the payment of Medicare benefits for professional services rendered in relation to or in association with:
(a) chelation therapy (that is, the intravenous administration of ethylenediamine tetra-acetic acid or any of its salts) other than for the treatment of heavy-metal poisoning;
(b) the injection of human chorionic gonadotrophin in the management of obesity;
(c) the use of hyperbaric oxygen therapy in the treatment of multiple sclerosis;
(d) the removal of tattoos;
(e) the transplantation of a thoracic or abdominal organ, other than a kidney, or of a part of an organ of that kind; or the transplantation of a kidney in conjunction with the transplantation of a thoracic or other abdominal organ, or part of an organ of that kind;
(f) the removal from a cadaver of kidneys for transplantation;
(g) the administration of microwave (UHF radio wave) cancer therapy, including the intravenous injection of drugs used in the therapy.
Pain pumps for post-operative pain management
The cannulation and/or catheterisation of surgical sites associated with pain pumps for post-operative pain management cannot be billed under any MBS item.
The filling or re-filling of drug reservoirs of ambulatory pain pumps for post-operative pain management cannot be billed under any MBS items.
Non Medicare Services
No MBS item applies to a service mentioned in the item if the service is provided to a patient at the same time as, or in connection with, an injection of blood or a blood product that is autologous.
No MBS item applies to a service mentioned in the item if the service is provided to a patient at the same time as, or in connection with, the harvesting, storage, in vitro processing or injection of non‑haematopoietic stem cells.
An item in the range 1 to 10943 does not apply to the service described in that item if the service is provided at the same time as, or in connection with, any of the services specified below:
(a) endoluminal gastroplication, for the treatment of gastro-oesophageal reflux disease;
(b) gamma knife surgery;
(c) intradiscal electro thermal arthroplasty;
(d) intravascular ultrasound (except where used in conjunction with intravascular brachytherapy);
(e) intro-articular viscosupplementation, for the treatment of osteoarthritis of the knee;
(f) low intensity ultrasound treatment, for the acceleration of bone fracture healing, using a bone growth stimulator;
(g) lung volume reduction surgery, for advanced emphysema;
(h) photodynamic therapy, for skin and mucosal cancer;
(i) placement of artificial bowel sphincters, in the management of faecal incontinence;
(j) selective internal radiation therapy for any condition other than hepatic metastases that are secondary to colorectal cancer;
(k) specific mass measurement of bone alkaline phosphatase;
(l) transmyocardial laser revascularisation;
(m) vertebral axial decompression therapy, for chronic back pain;
(n) autologous chondrocyte implantation and matrix-induced autologous chondrocyte implantation;
(o) extracorporeal magnetic innervation.
Health Screening Services
Unless the Minister otherwise directs Medicare benefits are not payable for health screening services. A health screening service is defined as a medical examination or test that is not reasonably required for the management of the medical condition of the patient. Services covered by this proscription include such items as:
(a) multiphasic health screening;
(b) mammography screening (except as provided for in Items 59300/59303);
(c) testing of fitness to undergo physical training program, vocational activities or weight reduction programs;
(d) compulsory examinations and tests to obtain a flying, commercial driving or other licence;
(e) entrance to schools and other educational facilities;
(f) for the purposes of legal proceedings;
(g) compulsory examinations for admission to aged persons' accommodation and pathology services associated with clinical ecology.
The Minister has directed that Medicare benefits be paid for the following categories of health screening:
(a) a medical examination or test on a symptomless patient by that patient's own medical practitioner in the course of normal medical practice, to ensure the patient receives any medical advice or treatment necessary to maintain their state of health. Benefits would be payable for the attendance and tests which are considered reasonably necessary according to patients individual circumstances (such as age, physical condition, past personal and family history). For example, a cervical screening test in a person (see General Explanatory note 12.3 for more information), blood lipid estimation where a person has a family history of lipid disorder. However, such routine check-up should not necessarily be accompanied by an extensive battery of diagnostic investigations;
(b) a pathology service requested by the National Heart Foundation of Australia, Risk Evaluation Service;
(c) age or health related medical examinations to obtain or renew a licence to drive a private motor vehicle;
(d) a medical examination of, and/or blood collection from persons occupationally exposed to sexual transmission of disease, in line with conditions determined by the relevant State or Territory health authority, (one examination or collection per person per week). Benefits are not paid for pathology tests resulting from the examination or collection;
(e) a medical examination for a person as a prerequisite of that person becoming eligible to foster a child or children;
(f) a medical examination being a requisite for Social Security benefits or allowances;
(g) a medical or optometrical examination provided to a person who is an unemployed person (as defined by the Social Security Act 1991), as the request of a prospective employer.
The National Policy for the National Cervical Screening Program (NCSP) is as follows:
(a) Cervical screening should be undertaken every five years in asymptomatic persons, using a primary human papillomavirus (HPV) test with partial genotyping and reflex liquid based cytology (LBC) triage;
(b) Persons who have ever been sexually active should commence cervical screening at 25 years of age;
(c) Persons aged 25 years or older and less than 70 years will receive invitations and reminders to participate in the program;
(d) Persons will be invited to exit the program by having a HPV test between 70 years or older and less than 75 years of age and may cease cervical screening if their test result is low risk;
(e) Persons 75 years of age or older who have either never had a cervical screening test or have not had one in the previous five years, may request a cervical screening test and can be screened;
(f) All persons, both HPV vaccinated and unvaccinated, are included in the program;
(g) Self collection of a sample for testing is available for persons who are aged 30 years and over and has never participated in the NCSP; or is overdue for cervical screening by two years or longer.
· Self collection must be facilitated and requested by a healthcare professional who also routinely offers cervical screening services;
· The self collection device and the HPV test, when used together, must meet the requirements of the National Pathology Accreditation Advisory Council (NPAAC) Requirements for Laboratories Reporting Tests for the NCSP; and
(h) Persons with intermediate and higher risk screening test results should be followed up in accordance with the cervical screening pathway and the NCSP: Guidelines for the management of screen detected abnormalities, screening women in specific populations and investigation of women with abnormal vaginal bleeding (2016 Guidelines) – endorsed by the Royal Australian College of General Practitioners, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the Royal College of Pathologists of Australasia, the Australian Society of Gynaecologic Oncologists and the Australian Society for Colposcopy and Cervical Pathology.
Note 1: As separate items exist for routine screening, screening in specific population and investigation of persons with abnormal vaginal bleeding, treating practitioners are asked to clearly identify on the request form, if the sample is collected as part of routine screening or for another purpose (see paragraph PP.16.11 of Pathology Services Explanatory Notes in Category 6).
Note 2: Where reflex cytology is performed following the detection of HPV in routine screening, the HPV test and the LBC test results must be issued as a combined report with the overall risk rating.
Note 3: See items 2501 to 2509, and 2600 to 2616 in Group A18 and A19 of Category 1 ‑ Professional Attendances and the associated explanatory notes for these items in Category 1 - Professional Attendances.
Services rendered to a doctor's dependants, practice partner, or practice partner's dependants
Medicare benefits are not paid for professional services rendered by a medical practitioner to dependants or partners or a partner's dependants.
A 'dependant' person is a spouse or a child. The following provides definitions of these dependant persons:
(a) a spouse, in relation to a dependant person means:
a. a person who is legally married to, and is not living, on a permanent basis, separately and apart from, that person; and
b. a de facto spouse of that person.
(b) a child, in relation to a dependant person means:
a. a child under the age of 16 years who is in the custody, care and control of the person or the spouse of the person; and
b. a person who:
(i) has attained the age of 16 years who is in the custody, care and control of the person of the spouse of the person; or
(ii) is receiving full time education at a school, college or university; and
(iii) is not being paid a disability support pension under the Social Security Act 1991; and
(iv) is wholly or substantially dependent on the person or on the spouse of the person.
- 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