Category 5 - DIAGNOSTIC IMAGING SERVICES
Professional supervision for ultrasound services - R-type eligible services
Ultrasound services (items 55028 to 55895) marked with the symbol (R) with the exception of items 55600 and 55603 are not eligible for a Medicare rebate unless the diagnostic imaging procedure is performed under the professional supervision of a:
(a) specialist or a consultant physician in the practice of his or her specialty who is available to monitor and influence the conduct and diagnostic quality of the examination, and if necessary to personally attend the patient; or
(b) practitioner who is not a specialist or consultant physician who meets the requirements of A or B hereunder, and who is available to monitor and influence the conduct and diagnostic quality of the examination and, if necessary, to personally attend the patient.
A. Between 1 September 1997 and 31 August 1999, at least 50 services were rendered by or on behalf of the practitioner at the location where the service was rendered and the rendering of those services entitled the payment of Medicare benefits.
B. Between 1 September 1997 and 31 August 1999, at least 50 services were rendered by or on behalf of the practitioner in nursing homes or patients' residences and the rendering of those services entitled payment of Medicare benefits.
If paragraph (a) or (b) cannot be complied with, ultrasound services are eligible for a Medicare rebate:
- in an emergency; or
- in a location that is not less than 30 kilometres by the most direct road route from another practice where services that comply with paragraph (a) or (b) are available.
Note: Practitioners do not have to apply for a remote area exemption in these circumstances.
Sonographers performing medical ultrasound examinations (either R or NR type items) on behalf of a medical practitioner must be suitably qualified, involved in a relevant and appropriate Continuing Professional Development program and be Registered on the Register of Accredited Sonographers held by Services Australia.
Eligibility for registration
To be eligible for registration on the Register of Accredited Sonographers held by Services Australia, the person must be accredited with the Australian Sonographer Accreditation Registry. For accreditation with the Australian Sonographer Accreditation Registry the person must hold an accredited postgraduate qualification in medical ultrasound or be studying ultrasound.
For further information, please contact Services Australia, Provider Liaison Section, on 132 150 for the cost of a local call or the Australian Sonographer Accreditation Registry through its website at www.asar.com.au.
The sonographer's initial and surname is to be written on the report. It is not required on billing documents. The name of the sonographer is not required to be included on the copy of the report given to the patient. For the purpose of this rule, the "name" means the sonographer's initial and surname.
As a rule, benefit is payable once only for ultrasonic examination at the one attendance, irrespective of the areas involved.
Except as indicated in the succeeding paragraphs, attendance means that there is a clear separation between one service and the next. For example, where there is a short time between one ultrasound and the next, benefits will be payable for one service only. As a guide, Services Australia will look to a separation of three hours between services and this must be stated on accounts issued for more than one service on the one day.
Where more than one ultrasound service is rendered on the one occasion and the service relates to a non-contiguous body area, and they are "clinically relevant", (i.e. the service is generally accepted in the medical profession as being necessary for the appropriate treatment or management of the patient to whom it is rendered), benefits greater than the single rate may be payable. Accounts should be marked "non-contiguous body areas".
Benefits for two contiguous areas may be payable where it is generally accepted that there are different preparation requirements for the patient and a clear difference in set-up time and scanning. Accounts should be endorsed "contiguous body area with different set-up requirements".
Subgroup 1 - General Ultrasound
Abdominal Ultrasound Items 55036 and 55037
Medicare benefits are not payable for ultrasound items 55036 and 55037 unless a morphological assessment of the abdomen has been performed. That is, the items should be used for imaging purposes, not for non-imaging procedures such as transient elastography.
Urinary ultrasound item 55084 and 55085
When a post-void residual is the only service clinically indicated and/or rendered, it is inappropriate to report a pelvic, urinary or abdominal ultrasound, instead of or in addition to this service (55084 or 55085). Similarly, if a complete pelvic, urinary or abdominal ultrasound is billed, it is inappropriate to bill separately for a post-void residual determination, since payment of this has already been included in the payment for the complete scans.
The report must contain an entry denoting the post-void residual amount and/or bladder capacity as calculated/estimated from the ultrasound device. In addition, the medical record must contain documentation of the indication for the service and the number of times performed.
Subgroup 2 - Transoesophageal echocardiography
This subgroup now only contains transoesophageal echocardiography - items 55118, 55130 and 55135. Transthoracic and stress echocardiography are now in subgroup 7, the notes for which are covered in notes IN.1.3 to IN.1.10. and IR.0.1 to IR.1.3.
Subgroup 3 – Vascular Ultrasound
Medicare benefits are only payable for:
- a maximum of two vascular ultrasound studies in a seven-day period. A vascular ultrasound study may include one or more items. Additionally where a patient is referred for a bilateral study of both arms or both legs, the account should indicate 'bilateral' or 'left' and 'right' to enable a benefit to be paid.
- clinically relevant services, that is, the service is generally accepted in the medical profession as being necessary for the appropriate treatment or management of the patient to whom it is rendered. Any decision to have a patient return on a different day to complete a multi-area diagnostic imaging service should only be made on the basis of clinical necessity.
Deep vein thrombosis (DVT) – items 55244 and 55246
Medical practitioners referring patients for duplex ultrasound for suspected lower limb DVT (items 55244 and 55246) should read and consider the RANZCR 2015 Choosing Wisely recommendations, or such RANZCR Choosing Wisely recommendations that succeed it.
Examination of peripheral vessels
Vascular ultrasound services can be claimed in conjunction with item 11612 (Exercises study for the evaluation of lower extremity arterial disease).
Subgroup 4: Urological ultrasound Prostate ultrasound - Items 55600 and 55603
Benefits for these items are payable where the service is rendered in the following circumstances:
- a digital rectal examination of the prostate was personally performed by the medical practitioner who also personally rendered the ultrasound service; and
- the transducer probe or probes used can obtain both axial and sagittal scans in 2 planes at right angles; and
- the patient was assessed prior to the service by a medical practitioner recognised in one or more of the specialties specified, not more than 60 days prior to the ultrasound service.
Items 55600 applies where the service is rendered by a medical practitioner who did not assess the patient, whereas items 55603 applies where the service was rendered by a medical practitioner who did assess the patient.
Subgroup 5: Obstetric and Gynaecological ultrasound
Medicare benefits are not payable for more than three NR-type ultrasound services in Subgroup 5 of Group I1 (ultrasound) that are performed on the same patient in any one pregnancy.
A patient must have previously had either a 55706 or 55709 ultrasound in the same pregnancy to be eligible to claim for either a 55712 or 55715 obstetric service. To be eligible to claim for either a 55721 or 55725 obstetric service, a patient must have previously had either a 55718 or 55723 ultrasound in the same pregnancy.
Frequency of services
Medicare benefits are only payable once per item per pregnancy for items 55706, 55707, 55708, 55709, 55718, 55723, 55759, 55762, 55768 and 55770.
Dating of pregnancy
When dating a pregnancy for the purpose of items 55700 to 55774, a patient is:
- "less than 12 weeks of gestation" means up to 11 weeks and 6 days of pregnancy;
- "12 to 16 weeks of gestation" means from 12 weeks 0 days of pregnancy up to 16 weeks plus 6 days of pregnancy (inclusive);
- "17 to 22 weeks of gestation" means from 17 weeks 0 days of pregnancy up to 22 weeks plus 6 days of pregnancy (inclusive);
- "after 22 weeks of gestation" means from 23 weeks 0 days of pregnancy onwards;
- "after 24 weeks of gestation" means from 25 weeks 0 days of pregnancy onwards.
Nuchal Translucency Testing
Where a nuchal translucency measurement is performed when the pregnancy is dated by a crown rump length of 45-84mm in conjunction with items 55700 (R) or 55703 (NR) or 55704 (R) or 55705 (NR), then items 55707 (R) or 55708 (NR) should be claimed. If nuchal translucency measurement for risk of foetal abnormality is performed in conjunction with any additional condition in items 55700, 55703, 55704 or 55705, only one fee is payable.
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists provides a credentialling program for providers of nuchal translucency scans.
Obstetric ultrasound items 55759 to 55774 cover scanning of a patient who is experiencing a multiple pregnancy. The items incorporate a fee adjustment in recognition of the added complexity and costs associated with scanning multiple pregnancies. Based on the recommendations of the profession, the items apply only to patients where a multiple pregnancy has been confirmed by ultrasound. The items include identical restrictions and provisions as the second and third trimester items (55706-55725), and include items for requested and non-requested services.
Obstetric ultrasound and non-metropolitan providers (items 55712, 55721, 55764 and 55772)
Where a practitioner has obstetric privileges at a non-metropolitan hospital and refers for items 55712, 55721 and 55764 and 55772, the practitioner must confirm his/her eligibility by stating 'non-metropolitan obstetric privileges' on the referral form.
In relation to items 55712, 55721, 55764 and 55772,a non-metropolitan area includes any location outside of the Sydney, Melbourne, Brisbane, Adelaide, Perth, Greater Hobart, Darwin or Canberra major statistical divisions, as defined in the Australian Standard Geographical Classification 2010 published by the Australian Bureau of Statistics (publication number 1216.0 of 2010).
Subgroup 6: Musculoskeletal (MSK)
Medicare benefits are only payable for a musculoskeletal ultrasound service (items 55812 to 55895) if the medical practitioner responsible for the conduct and report of the examination personally attends during the performance of the scan and personally examines the patient. Services that are performed because of medical necessity in a remote location are exempt from this requirement - see IN.0.6 for definition of remote area. Note: Practitioners do not have to apply for a remote area exemption in these circumstances.
Multiple Musculoskeletal Ultrasound Scans
Generally Medicare benefits are payable for more than one musculoskeletal ultrasound scan performed on the same day, however the scans are subject to Rule A of the general diagnostic imaging multiple services rules.
It is not permitted to split a bilateral scan. Where bilateral ultrasound scans are performed, the relevant item should be itemised once only on accounts and receipts or Medicare bulk billing forms. For example if both shoulders are scanned, item 55866 or 55867, as the case may be, should be claimed once only. This is because the item descriptor for these items covers both sides. A patient should not be asked to make a second appointment in order to attract a benefit for multiple scans.
Shoulder and knee (items 55864 to 55867 and 55880 to 55883)
Benefits for shoulder and knee ultrasound items are only payable when the request is based on the clinical indicators outlined in the item descriptions. Benefits are not payable when referred for non-specific shoulder or knee pain alone or other specific conditions such as meniscal and cruciate ligament tears and assessment of chondral surfaces.
Items in association with a surgical procedure (55848 and 55850)
Item 55848 is a musculoskeletal (MSK) ultrasound service for use in association with a surgical procedure, such as a joint injection.
Item 55850 is a musculoskeletal ultrasound service for use in association with a surgical procedure, such as a joint injection, which is inclusive of a diagnostic ultrasound. This item cannot be claimed if diagnostic ultrasound was not conducted during the examination.
Subgroup 7 - Transthoracic and stress echocardiography
The notes for these items are shown in notes IN.1.3 to IN.1.10. and IR.0.1 to IR.1.3.
- 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