Medicare Benefits Schedule - Note IN.0.13

Professional supervision for ultrasound services - R-type eligible services

Ultrasound services (items 55028 to 55895) marked with the symbol (R), except 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, and who is available to monitor and influence the conduct and diagnostic quality of the examination and, if necessary, to personally attend the patient, and meets either of the following requirements:

(i) 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.

(ii) 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.

The rules regarding items 55600 and 55603 are set out under the heading ‘Subgroup 4: Urological ultrasound – Items 55600 and 55603’.

Sonographer accreditation

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

Report requirements  

The sonographer's initial and surname are to be written on the report. They are not required on billing documents or on the copy of the report given to the patient.

Benefits payable

In most instances, a benefit is payable once only for ultrasonic examination at the one attendance, irrespective of the areas involved.

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 same 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 Items 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 to ensure an empty bladder has been reached.

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

General

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 based on 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 Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCR) 2015 Choosing Wisely recommendations or RANZCR Choosing Wisely recommendations that succeed it.

Examination of peripheral vessels

Vascular ultrasound services can be claimed in conjunction with item 11612 (Exercise study for the evaluation of lower extremity arterial disease).

Subgroup 4: Urological 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. Item 55600 applies where the service is rendered by a medical practitioner who did not assess the patient, whereas item 55603 applies where the service was rendered by a medical practitioner who did assess the patient.
   

Subgroup 5: Obstetric and Gynaecological ultrasound  

NR Services

Except for item 55758, 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.

Pre-requisite services

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, 55742, 55743, 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;
  
  
• "between 14 and 30 weeks of gestation” means from 14 weeks 0 days of pregnancy to 30 weeks plus 6 days of pregnancy (inclusive); and

• “before 28 weeks gestation” means up to 27 weeks plus 6 days of pregnancy (inclusive).

Singleton pregnancies

Obstetric ultrasound items 55700 to 55725 (except for items 55736 and 55739 which are performed pre-pregnancy) cover scanning of a patient who is experiencing a singleton pregnancy, with the items including requested and non-requested services. Item 55729 covers both single and multiple pregnancies.

Except for items 55700 (R) and 55703 (NR) all singleton items restrict the claiming of cervical length items 55757 and 55758 within 24 hours. Items 55700 and 55703 advise that the ultrasound service cannot be performed on the same patient within 24 hours of a service mentioned in item 55704, 55705, 55707, 55708, 55740, 55741, 55742 or 55743. This accords with clinical practice guidelines which do not recommend repeat scanning at intervals less than 24 hours.

For all other singleton items, the ultrasound cannot be performed on the same patient within 24 hours of a service mentioned in another item in Subgroup 5 of Group I1. The most appropriate item to be claimed should be chosen based on clinical need, with each ultrasound scan representing a completed medical service.

Nuchal Translucency Testing

A nuchal translucency measurement ultrasound is performed to assess the patient’s risk of fetal abnormality when the pregnancy is dated by a crown rump length of 45 to 84mm. If a nuchal translucency measurement is performed for a singleton pregnancy, items 55707 (R) or 55708 (NR) should be claimed. If a nuchal translucency measurement is performed for a multiple pregnancy, items 55742 (R) or 55743 (NR) should be claimed.

The nuchal translucency measurement ultrasound service should not be performed on the same patient within 24 hours of a service mentioned in another item in Subgroup 5 of Group I1. If nuchal translucency measurement for risk of foetal abnormality is performed (items 55707, 55708, 55742 or 55743) within 24 hours of any other additional items in Subgroup 5 of Group I1, only one fee is payable. It is the treating practitioner’s responsibility to consider the clinical circumstances of any services rendered and to determine the appropriate MBS item(s) to claim, if any.

The RANZCR provides a credentialling program for providers of nuchal translucency scans.

Cervical length items 55757 and 55758

Items 55757 (R) and 55758 (NR) are to assess the cervical length of the patient to determine risk of preterm labour and can be claimed for any pregnancy. These items cannot be co-claimed within 24 hours of another item in Subgroup 5 of Group I1. There are no clinical grounds for repeat scanning within 24 hours.

Multiple pregnancies

Obstetric ultrasound items 55740 to 55774 (except for items 55757 and 55758) cover scanning of a patient who is experiencing a multiple pregnancy. 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. Due to the ongoing risks and complications associated with multiple pregnancies regardless of pregnancy outcomes, any pregnancy identified as multiple at the commencement of the second trimester (13+0 weeks) should continue to utilise the multiple pregnancy items for the duration of that pregnancy.

With the exception of items 55740 (R) and 55741 (NR), the multiple pregnancy items cannot be co-claimed within 24 hours of cervical length items 55757 (R) or 55758 (NR). Items 55740 and 55741 cannot be co-claimed within 24 hours of another item in Subgroup 5 of Group I1. There are no clinical grounds for repeat scanning within 24 hours.

Obstetric and gynaecological services—Requests and clinical notes

For R-type obstetric and gynaecological ultrasound services, the request form must state the relevant condition or clinical indication for the service.

For NR type obstetric and gynaecological ultrasound services, the clinical notes of the services must state the relevant condition or clinical indication for the service.

Obstetric ultrasound and non-metropolitan providers (items 55712, 55721, 55764 and 55772)

In addition to the requirement that the request form and clinical notes must state the relevant condition or clinical indication for the service, where a practitioner has obstetric privileges at a non-metropolitan hospital and requests items 55712, 55721, 55764 and 55772, the practitioner must confirm his/her eligibility by stating 'non-metropolitan obstetric privileges' on the request 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.

Subgroup 6:  Musculoskeletal (MSK)

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.

Related Items: 55700 55703 55704 55705 55740 55741 55742 55743 55757 55758

• Previous - Note IN.0.12
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Bulk bill incentive

Pelvis or abdomen, pregnancy‑related or pregnancy complication, ultrasound (the current ultrasound) scan of, by any or all approaches, for determining the gestation, location, viability or number of fetuses, if:

(a) the dating of the pregnancy (as confirmed by the current ultrasound) is less than 12 weeks of gestation; and

(b) the current ultrasound is not performed on the same patient within 24 hours of a service mentioned in item 55704, 55705, 55707, 55708, 55740, 55741, 55742 or 55743 (R) 

 

 

 

 

Fee: $65.00 Benefit: 75% = $48.75 85% = $55.25

(See para IN.0.13, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Pelvis or abdomen, pregnancy‑related or pregnancy complication, ultrasound (the current ultrasound) scan of, by any or all approaches, for determining the gestation, location, viability or number of fetuses, if:

(a) the dating of the pregnancy (as confirmed by the current ultrasound) is less than 12 weeks of gestation; and

(b) the current ultrasound is not performed on the same patient within 24 hours of a service mentioned in item 55704, 55705, 55707, 55708, 55740, 55741, 55742 or 55743 (NR)

Fee: $37.85 Benefit: 75% = $28.40 85% = $32.20

(See para IN.0.13, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Pelvis or abdomen, pregnancy‑related or pregnancy complication, fetal development and anatomy, ultrasound (the current ultrasound) scan of, by any or all approaches, for determining the structure, gestation, location, viability or number of fetuses, if:

(a) the dating of the pregnancy (as confirmed by the current ultrasound) is 12 to 16 weeks of gestation; and

(b) the current ultrasound is not performed on the same patient within 24 hours of a service mentioned in another item in this Subgroup (R)

Fee: $75.85 Benefit: 75% = $56.90 85% = $64.50

(See para IN.0.13, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Pelvis or abdomen, pregnancy‑related or pregnancy complication, fetal development and anatomy, ultrasound (the current ultrasound) scan of, by any or all approaches, for determining the structure, gestation, location, viability or number of fetuses, if:

(a) the dating of the pregnancy (as confirmed by the current ultrasound) is 12 to 16 weeks of gestation; and

(b) the current ultrasound is not performed on the same patient within 24 hours of a service mentioned in another item in this Subgroup (NR)

Fee: $37.85 Benefit: 75% = $28.40 85% = $32.20

(See para IN.0.13, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Pelvis or abdomen, pregnancy‑related or pregnancy complication, fetal development and anatomy, ultrasound (the current ultrasound) scan of, by any or all approaches, for determining the structure, gestation, location, viability or number of fetuses, if:

(a) an ultrasound of the same pregnancy confirms a multiple pregnancy; and

(b) the dating of the pregnancy (as confirmed by the current ultrasound) is 12 to 16 weeks of gestation; and

(c) the current ultrasound is not performed on the same patient within 24 hours of a service mentioned in another item in this Subgroup (R)

Fee: $112.75 Benefit: 75% = $84.60 85% = $95.85

(See para IN.0.13, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Pelvis or abdomen, pregnancy‑related or pregnancy complication, fetal development and anatomy, ultrasound (the current ultrasound) scan of, by any or all approaches, for determining the structure, gestation, location, viability or number of fetuses, if:

(a) an ultrasound of the same pregnancy confirms a multiple pregnancy; and

(b) the dating of the pregnancy (as confirmed by the current ultrasound) is 12 to 16 weeks of gestation; and

(c) the current ultrasound is not performed on the same patient within 24 hours of a service mentioned in another item in this Subgroup (NR)

Fee: $56.35 Benefit: 75% = $42.30 85% = $47.90

(See para IN.0.13, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Pelvis or abdomen, pregnancy‑related or pregnancy complication, fetal development and anatomy, ultrasound (the current ultrasound) scan of, by any or all approaches, if:

(a) an ultrasound of the same pregnancy confirms a multiple pregnancy; and

(b) the pregnancy (as confirmed by the current ultrasound) is dated by a fetal crown rump length of 45 to 84 mm; and

(c) nuchal translucency measurement is performed to assess the risk of fetal abnormality; and

(d) the current ultrasound is not performed on the same patient within 24 hours of a service mentioned in another item in this Subgroup (R)

Fee: $112.75 Benefit: 75% = $84.60 85% = $95.85

(See para IN.0.13, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Pelvis or abdomen, pregnancy‑related or pregnancy complication, fetal development and anatomy, ultrasound (the current ultrasound) scan of, by any or all approaches, if:

(a) an ultrasound of the same pregnancy confirms a multiple pregnancy; and

(b) the pregnancy (as confirmed by the current ultrasound) is dated by a fetal crown rump length of 45 to 84 mm; and

(c) nuchal translucency measurement is performed to assess the risk of fetal abnormality; and

(d) the current ultrasound is not performed on the same patient within 24 hours of a service mentioned in another item in this Subgroup (NR)

Fee: $56.35 Benefit: 75% = $42.30 85% = $47.90

(See para IN.0.13, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Pelvis or abdomen, ultrasound (the current ultrasound) scan of, for cervical length assessment for risk of preterm labour, by any or all approaches, if:

(a) the dating of the pregnancy (as confirmed by the current ultrasound) is between 14 and 30 weeks of gestation; and

(b) any of the following apply:

(i) the patient has a history indicating high risk of preterm labour or birth or second trimester fetal loss;

(ii) the patient has symptoms suggestive of threatened preterm labour or second trimester fetal loss;

(iii) the patient’s cervical length is less than 25 mm on an ultrasound before 28 weeks gestation; and

(c) the current ultrasound is not performed on the same patient within 24 hours of a service mentioned in another item in this Subgroup (R)

 

Fee: $53.65 Benefit: 75% = $40.25 85% = $45.65

(See para IN.0.13, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Pelvis or abdomen, ultrasound (the current ultrasound) scan of, for cervical length assessment for risk of preterm labour, by any or all approaches, if:

(a) the dating of the pregnancy (as confirmed by the current ultrasound) is between 14 and 30 weeks of gestation; and

(b) any of the following apply:

(i) the patient has a history indicating high risk of preterm labour or birth or second trimester fetal loss;

(ii) the patient has symptoms suggestive of threatened preterm labour or second trimester fetal loss;

(iii) the patient’s cervical length is less than 25 mm on an ultrasound before 28 weeks gestation; and

(c) the current ultrasound is not performed on the same patient within 24 hours of a service mentioned in another item in this Subgroup (NR)

Fee: $20.40 Benefit: 75% = $15.30 85% = $17.35

(See para IN.0.13, IN.0.19 of explanatory notes to this Category)