Medicare Benefits Schedule - Note IN.0.1

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Category 5 - DIAGNOSTIC IMAGING SERVICES

IN.0.1

Requests of Diagnostic Imaging Services

Request requirements 

Medicare benefits are not payable for diagnostic imaging services that are classified as R-type (requested) services unless prior to commencing the relevant service, the practitioner receives a signed and dated request from a requesting practitioner who determined the service was necessary.

There are exemptions to the request requirements in specified circumstances.  These circumstances are detailed below under 'Exemptions from the written request requirements for R-type diagnostic imaging services'. 

Form of a diagnostic imaging request

A request for a diagnostic imaging service does not have to be in a particular form, however, the legislation provides that a request must be in writing and contain sufficient information, in terms that are generally understood by the profession, to clearly identify the item/s of service requested.

A request to a medical imaging specialist for a diagnostic imaging service should include sufficient clinical information to assist the service provider to accurately provide the diagnostic imaging service requested and:

  1. ensure compliance with the MBS item descriptors, and
  2. where the requested service involves ionising radiation (x-ray, CT etc.), make a decision whether to expose the patient to radiation, consistent with the diagnostic imaging providers’ obligations under the International Commission on Radiological Protection’s (ICRP) doctrine of radiation protection.

Unless sufficient clinical information is provided, the requesting practitioner may be asked to provide additional information to the diagnostic imaging provider, which could result in delays for the patient.

The following should be provided on a request for a diagnostic imaging service:

(a) - A clear and legible request - a request must be in writing, dated and be legible so that all information contained is transferred between requestor and provider without loss of content or meaning, or risk of misinterpretation. The use of abbreviations should be avoided. Where permitted, verbal referrals should ensure clear communication between the requestor and provider.

  • Under the Electronic Transactions Act 1999, this information can be provided in electronic form.

(b) - Identity of the patient – a request should include details which confirm the identity of the patient, including their contact details.

(c) - Identity of the requestor – a request should include the identity and contact details of the requesting practitioner, including their Medicare provider number, to ensure effective and timely communication.

(d) - Clinical detail - a request should include a clinical justification for each examination requested and performed to support the performance of the diagnostic imaging examination.

  • Requests should contain information to enable the provider to confirm that the requested diagnostic imaging modality and examination are appropriate to that individual patient's presentation and circumstances, to answer the referrer's diagnostic question with the least number of diagnostic steps (with due regard for patient safety, radiation dose, local expertise and cost).
  • Where the request is for diagnostic imaging involving ionising radiation (e.g. x-ray, CT) the request should include clinical information for the provider to determine whether the expected clinical benefit to the patient of being exposed to diagnostic radiation outweighs the risk of  radiation exposure ('justification for medical radiation exposure').

The provider must have sufficient information to justify and approve a medical radiation procedure. Where known, this information should include pregnancy status for women of child-bearing age.

Before requesting a diagnostic imaging service, the requesting practitioner must turn their mind to the clinical relevance of the request and determine that the service is necessary. For example, an ultrasound to determine the sex of a foetus is generally not a clinically relevant service, unless there is an indication this service will determine further courses of treatment (e.g. where there is a genetic risk of a sex-related disease or condition).

The requestor should consider whether:

- they are duplicating recent tests,

- the results would change the diagnosis, affect patient management or do more harm than good.

- The Royal Australian and New Zealand College of Radiologists’ Education Modules for Appropriate Imaging Referrals contains decision support tools for select clinical scenarios

- The Australian Radiation Protection and Nuclear Safety Agency’s Radiation Protection of the Patient Module provides information about diagnostic imaging for medical practitioners, to ensure radiation use is justified, and may aid in communicating benefits and risks of diagnostic imaging modalities to patients.

- the benefits and risks to the patient or carer have been communicated, including any alternatives available, and

- there is information available to the patient about the tests requested. Consumer resources available include the:

- NPS MedicineWise Choosing Wisely program
- Consumers Health Forum’s Why do I even need this test? A Diagnostic Imaging and Informed Consent Consumer Resource
- The Royal Australian and New Zealand College of Radiologists’ Inside Radiology website.

(e) - MBS requirements - a request should meet any specific MBS item requirements. Failure to provide this information may mean that a Medicare benefit is not paid for the service. 

Who may request a diagnostic imaging service 

The following practitioners may request a diagnostic imaging service: 

- Specialists and consultant physicians can request any diagnostic imaging service.

- Other medical practitioners can request any service and specific Magnetic Resonance Imaging Services - see Note IN.0.18.

- A medical practitioner, on behalf of the treating practitioner, for example, by a resident medical officer at a hospital on behalf of the patient's treating practitioner.

- Dental Practitioners, Physiotherapists, Chiropractors, Osteopaths and Podiatrists registered or licensed under State or Territory laws

- Participating nurse practitioners and participating midwives. 

All dental practitioners may request the following items: 

57509, 57515, 57521, 57523, 57527, 57540, 57901, 57902, 57903, 57906, 57909, 57912, 57915, 57918, 57921, 57924, 57927, 57930, 57933, 57939, 57942, 57945, 57960, 57963, 57966, 57969, 58100, 58300, 58503, 58903, 59733, 59739, 59751, 60500, 60503. 

Oral and maxillofacial surgeons, prosthodontists, dental specialists (periodontists, endodontists, pedeodontists, orthodontists) and specialists in oral medicine and oral pathology are also able to request the following items: 

Oral and maxillofacial surgeons (without medical specialist registration)  

55005, 55008, 55011, 55028, 55030, 55032, 56001 to 56220, 56224, 56227, 56230, 56259, 56301 to 56507, 56541, 56547, 56801 to 57007, 57041, 57047, 57341, 57345, 57703, 57705, 57709, 57711, 57712, 57714, 57715, 57717, 58103 to 58115, 58117, 58123, 58124, 58306, 58308, 58506, 58508, 58521 to 58527, 58529, 58909, 58911, 59103, 59104, 59703, 59704, 60000 to 60010, 60506, 60507, 60509, 60510, 61109, 61110, 61372, 61421, 61425, 61429, 61430, 61433, 61434, 61446, 61449, 61450, 61453, 61454, 61457, 61462, 61672, 61690, 61691, 61693, 61694, 61695, 61696, 61702, 61703, 61704, 61705, 61706, 61707, 61710, 63007, 63016, 63334 and 63346. 

Oral and maxillofacial surgeons (with medical specialist registration) 

Oral and maxillofacial surgeons who also have a medical qualification and are registered as medical specialist can request any item in the Diagnostic Imaging Services Table, subject to their scope of practice and any clauses or requirements relevant to the individual item. 

Prosthodontists 

55005, 55028, 56013, 56016, 56022, 56028, 56053, 56056, 56062, 56068, 57362, 57363, 58306, 58308, 61421, 61425, 61429, 61430, 61433, 61434, 61446, 61449, 61450, 61453, 61454, 61457, 61462, 61690, 61691, 61693, 61694, 61695, 61696, 61702, 61703, 61704, 61705, 61706, 61707, 61710, 63334 and 63346. 

Dental specialists (periodontists, endodontists, pedeodontists, orthodontists). 

56022, 56062, 57362, 57363, 58306, 58308, 61421, 61454, 61457, 61690, 61706, 61707, 63334, 63346. 

Specialists in oral medicine and/or oral pathology 

55005, 55008, 55011, 55028, 55030, 55032, 56001, 56007, 56010, 56013, 56016, 56022, 56028, 56041, 56047, 56050, 56053, 56056, 56062, 56068, 56101, 56107, 56141, 56147, 56301, 56307, 56341, 56347, 56401, 56407, 56441, 56447, 57341, 57345, 57362, 57363, 58306, 58308, 58506, 58508, 58909, 58911, 59103, 59104, 59703, 59704, 60000 to 60010, 60506, 60507 60509, 60510, 61109, 61110,  61372, 61421, 61425, 61429, 61430, 61433, 61434, 61446, 61449, 61450, 61453, 61454, 61457, 61462, 61672, 61690, 61691, 61693, 61694, 61695, 61696, 61702, 61703, 61704, 61705, 61706, 61707, 61710, 63007, 63016, 63334, and 66346. 

Chiropractors may request:

57712, 57714, 57715, 57717, 58100 to 58106 (inclusive), 58109, 58111, 58112, 58117 and 58123.

See para IN.0.17 of explanatory notes 

Physiotherapists and Osteopaths may request:

57712, 57714, 57715, 57717, 58100 to 58106 (inclusive), 58109, 58111, 58112, 58117, 58120, 58121, 58123, 58126 and 58127.

See para IN.0.17 of explanatory notes 

Podiatrists may request:

55836, 55837, 55840, 55841, 55844, 55845, 57521, 57523, 57527, 57536, 57540, 57539. 

Participating Nurse Practitioners may request:

55014, 55036, 55059, 55061, 55070, 55076, 55600, 55601, 55768, 55769, 55800, 55801, 55804, 55805, 55808, 55809, 55812, 55813, 55816, 55817, 55820, 55821, 55824, 55825, 55828, 55829, 55832, 55833, 55836, 55837, 55840, 55841, 55844, 55845, 55848, 55849, 55850, 55851, 55852, 55853, 57509, 57515, 57521, 57523, 57527, 57530, 57533, 57536, 57540, 57703, 57705, 57709, 57711, 57712, 57714, 57715, 57717, 57721, 58503 to 58527 (inclusive) and 58529

Participating Midwives may request: 

55700, 55701, 55704, 55706, 55707, 55710, 55713, 55714, 55718, 55722.

Form of a request

Responsibility for the adequacy of requesting details rests with the requesting practitioner. A request for a diagnostic imaging service does not have to be in a particular form. However, the legislation provides that a request must be in writing and contain sufficient information, in terms that are generally understood by the profession, to clearly identify the item/s of service requested. This includes, where relevant, noting on the request the clinical indication(s) for the requested service. The provision of additional relevant clinical information can often assist the service provider and enhance the overall service provided to the patient. As such, this practice is actively encouraged. 

A written request must be signed and dated and contain the name and address or name and provider number in respect of the place of practice of the requesting practitioner. 

Referral to specified provider not required 

It is not necessary that a written request for a diagnostic imaging service be addressed to a particular provider or that, if the request is addressed to a particular provider, the service must be rendered by that provider.  Request forms containing relevant information about a diagnostic imaging provider supplied, or made available to, a requesting practitioner by a diagnostic imaging provider on, or after, 1 August 2012 must include a statement that informs the patient that the request may be taken to a diagnostic imaging provider of the patient's choice. 

Request for more than one service and limit on time to render services 

The requesting practitioner may use a single request to order a number of diagnostic imaging services.  However, all services provided under this request must be rendered within seven days after the rendering of the first service. 

Contravention of request requirements 

A practitioner who, without reasonable excuse makes a request for a diagnostic imaging service that does not include the required information in his or her request or in a request made on his or her behalf is guilty of an offence under the Health Insurance Act 1973 punishable, upon conviction, by a fine of $1000.

A practitioner who renders "R-type" diagnostic imaging services and who, without reasonable excuse, provides either directly or indirectly to a requesting practitioner a document to be used in the making of a request which would contravene the request information requirements is guilty of an offence under the Health Insurance Act 1973 punishable, upon conviction, by a fine of $1000. 

Exemptions from the written request requirements for R-type diagnostic imaging services 

There are exemptions from the general written request requirements (R-type) diagnostic imaging services and these are outlined as follows: 

Consultant physician or specialist 

A consultant physician or specialist is a medical practitioner recognised for the purposes of the Health Insurance Act 1973 as a specialist or consultant physician, in a particular specialty. 

A written request is not required for the payment of Medicare benefits when the diagnostic imaging service is provided by or on behalf of a consultant physician or a specialist (other than a specialist in diagnostic radiology) in his or her specialty and after clinical assessment he/she determines that the service was necessary.  For details required for accounts/receipts see Note IN.0.7. 

However, if in the referral to the consultant physician or specialist, the referring practitioner specifically requests a diagnostic imaging service (eg to a cardiologist to perform an echocardiogram) the service provided is a requested, not self-determined service.  If further services are subsequently provided, these further services are self-determined - see "Additional services". 

Additional services 

A written request is not required for a diagnostic imaging service if that service was provided after one which has been formally requested and the providing practitioner determines that, on the basis of the results obtained from the requested service, that an additional service was necessary.  However, the following services cannot be self- determined as "additional services": 

- MRI services;

- PET services; and

- services not otherwise able to be requested by the original requesting practitioner.

For details required for accounts/receipts see Note IN.0.7. 

Substituted services 

- A provider may substitute a service for the service originally requested when:

- the provider determines, from the clinical information provided on the request, that the substituted service would be more appropriate for the diagnosis of the patient's condition; and

- the provider has consulted with the requesting practitioner or taken all reasonable steps to do so before providing the substituted service; and

- the substituted service was one that would be accepted as a more appropriate service in the circumstances by the practitioner's speciality group. 

However, the following services cannot be substituted:

- MRI services;

- PET services; and

- services not otherwise able to be requested by the original requesting practitioner. 

For details required for accounts/receipts see Note IN.0.7. 

Remote areas 

A written request is not required for the payment of Medicare benefits for a R-type diagnostic imaging service rendered by a medical practitioner in a remote area provided: 

- the R-type service is not one for which there is a corresponding NR-type service; and

- the medical practitioner rendering the service has been granted a remote area exemption for that service. 

For details required for accounts/receipts see Note IN.0.7. 

Definition of remote area 

The definition of a remote area is one that is more than 30 kilometres by road from: 

a) a hospital which provides a radiology service under the direction of a specialist in the specialty of diagnostic radiology; and

b) a free-standing radiology facility under the direction of a specialist in the specialty of diagnostic radiology. 

Application for remote area exemption 

A medical practitioner, other than a consultant physician or specialist, who believes that he or she qualifies for exemption under the remote area definition, should obtain an application form from the Department of Human Services' website www.humanservices.gov.au or by contacting the Department of Human Services' Provider Eligibility Section, by email at sa.prov.elig@humanservices.gov.au or via phone on 1800 032 259 Monday to Friday, between 8.30 am and 5.00 pm, Australian Eastern Standard Time. 

Quality assurance requirement for remote area exemption 

Application for, or continuation of, a remote area exemption will be contingent on practitioners being enrolled in an approved continuing medical education and quality assurance program. For further information, please visit the Australian College of Rural and Remote Medicine (ACRRM) website at www.acrrm.org.au, or call the ACRRM on 1800 223 226. 

Emergencies 

The written request requirement does not apply if the providing practitioner determines that, because the need for the service arose in an emergency, the service should be performed as quickly as possible.

For details required for accounts/receipts see Note IN.0.7. 

Lost requests 

The written request requirement does not apply where:

- the person who received the diagnostic imaging service, or someone acting on that person's behalf, claimed that a  written request had been made for such a service but that the request had been lost; and

- the provider of the diagnostic imaging service or that provider's agent or employee obtained confirmation from the requesting practitioner that the request had been made. 

The lost request exemption is applicable only to services that the practitioner could originally request. 

For details required for accounts/receipts see Note IN.0.7. 

Pre-existing diagnostic imaging practices 

The legislation provides for exemption from the written request requirement for services provided by practitioners who have operated pre-existing diagnostic imaging practices.  The exemption applies to the services covered by the following Items: 57712, 57714, 57715, 57717, 57901, 57902, 57903, 57911, 57912, 57914, 57915, 57917, 57921, 57926, 57929, 57935, 58100 to 58115, 58117, 58123, 58124, 58521, 58523, 58524, 58526, 58527, 58529, 58700, 58702, 59103 and 59104. 

To qualify for this "grandparent" exemption the providing practitioner must:

a) be treating his or her own patient;

b) have determined that the service was necessary;

c) have rendered between 17 October 1988 and 16 October 1990 at least 50 services (which resulted in the payment of Medicare benefits) of the kind which have been designated "R-type" services from 1 May 1991;

d) provide the exempted services at the practice location where the services which enabled the practitioner to qualify for the "grandparent" exemption were rendered; and

e) be enrolled in an approved continuing medical education and quality assurance program from 1 January 2001.  For further information, please contact the Royal Australian College of General Practitioners (RACGP), at www.racgp.org.au, on 1800 472 247 or via email to racgp@racgp.org.au, or the Australian College of Rural and Remote Medicine (ACRRM), at www.acrrm.org.au or by calling 1800 223 226. 

Benefits are only payable for services exempted under these provisions where the service was provided by the exempted medical practitioner at the exempted location.  Exemptions are not transferable. 

For details required for accounts/receipts see Note IN.0.7. 

Retention of requests 

A medical practitioner who has rendered an R-type diagnostic imaging service in response to a written request must retain that request for a period of two years commencing on the day on which the service was rendered.  

A medical practitioner must, if requested by the Department of Human Services CEO, produce written requests retained by that practitioner for an R-type diagnostic imaging service as soon as practicable and in any case by the end of the day after the day on which the Department of Human Services CEO's request was made.  An employee of the Department of Human Services is authorised to make and retain copies of or take and retain extracts from written requests or written confirmations of lost requests.  

A medical practitioner who, without reasonable excuse, fails to comply with the above requirements is guilty of an offence under the Health Insurance Act 1973 punishable, upon conviction, by a fine of $1000. 

The Department of Health has developed a Health Practitioner Guideline to substantiate that a valid request existed (pathology or diagnostic imaging), which is located online at www.health.gov.au


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