Medicare Benefits Schedule - Note IN.0.15

Professional supervision  

CT services (items 56001 to 57362) are not eligible for a Medicare rebate unless the service is performed:

(a)     under the professional supervision of a specialist in the specialty of diagnostic radiology who is available:

·              to monitor and influence the conduct and diagnostic quality of the examination; and

·              if necessary, to personally attend on the patient; or

 (b)    if the above criterion cannot be complied with

·                 in an emergency, or

·                 because of medical necessity in a remote area - refer to IN.06 for definition of remote area. 

 Note:  Practitioners do not have to apply for a remote area exemption in these circumstances.  

 Items 57360 and 57364 apply only to a CT service that is:

(a)     performed under the professional supervision of a specialist or consultant physician recognised by the Conjoint Committee for the Recognition of Training in CT Coronary Angiography who is available:

·                  to monitor and influence the conduct and diagnostic quality of the examination; and

·                  if necessary, to attend on the patient personally; and

(b)    reported by a specialist or consultant physician recognised by the Conjoint Committee for the Recognition of Training in CT Coronary Angiography; or

        (c) if paragraphs a and b cannot be complied with

·                 in an emergency, or

·                 because of medical necessity in a remote area - refer to IN.06 for definition of remote area.

Use of PET/CT or SPECT/CT machines  

CT scans rendered on Positron Emission Tomography (PET)/CT Single Photon Emission Computed Tomography (SPECT)/CT units are eligible for a Medicare benefit provided: 

-          the CT scan is not solely used for the purposes of attenuation correction and anatomical correlation of any associated PET or SPECT scan; and

-          the CT scan is rendered under the same conditions as those applying to services rendered on stand-alone CT equipment.  For example, the service would need to be properly requested and performed under the professional supervision of a specialist radiologist, including specialist radiologists with dual nuclear medicine qualifications. 

Scan of more than one area/region

Where regions are scanned on the one occasion which are not covered by a combination item, for example, item 56219 (scan of the spine) with item 56620 (scan of lower limbs), both examinations would attract a separate benefit. 

Items covering individual contiguous regions must not be used when scans of multiple regions are performed. 

More than one attendance of the patient to complete a scan

Items 56220 to 56238 (CT of the spine) and 56620 to 56630 (CT of the extremities) apply once only for a service described in any of those items, regardless of the number of patient attendances required to complete the service.  For example, where a request relates to two or more regions of the spine and one region only is scanned on one occasion with the balance of regions being scanned on a subsequent occasion, benefits are payable for one combination service only upon completion. 

Pre-contrast scans

Pre-contrast scans are included in an item of service with contrast medium only when the pre-contrast scans are of the same region. 

Scan of Head

Exclusion of acoustic neuroma

If an axial scan is performed for the exclusion of acoustic neuroma, Medicare benefits are payable under item 56001 or 56007. 

Assessment of headache

If item 56007 is used for the assessment of headache of a patient, the fee mentioned in the item applies only if:

a.        a scan without intravenous contrast medium has been undertaken on the patient; and

b.       the service is required because the result of the scan is abnormal. 

This rule applies to a patient who:

·            is under 50 years; and

·            is (apart from the headache) otherwise well; and

·            has no localising symptoms or signs; and

·            has no history of malignancy or immunosuppression. 

Scan of Spine

Multiple regions

CT items exist which separate the examination of the spine into the cervical, thoracic and lumbosacral regions.

These items are 56220 to 56238 inclusive.  They include items for CT scans of two regions of the spine (56233 and 56234) and for all three regions of the spine (56237 and 56238).  Restrictions apply to the following items: 

-          item 56233 is used where two examinations of the kind referred to in items 56220, 56221 and 56223 are performed.  The item numbers of the examination which are performed must be shown on any accounts issued or patient assignment forms completed.

-          item 56234 is used where two examinations of the kind referred to in items 56224, 56225 and 56226 are performed.  The item numbers of the examination which are performed must be shown on any accounts issued or patient assignment forms completed.

Example: for a CT examination of the spine where the cervical and thoracic regions are to be studied (item 56233), item numbers 56220 and 56221 must be specified. 

With intrathecal contrast medium - item 56219

The item incorporates the cost of contrast medium for intrathecal injection and associated x-rays.  Benefits are not payable for this item when rendered in association with myelograms (items 59724 and 59725).  Where a myelogram is rendered under item 59724 and a CT is necessary, the relevant item would be scan of spine without intravenous contrast (items 56220, 56221 or 56223). 

Scan of the upper abdomen and pelvis

Items 56501 and 56507 are not eligible for benefits if performed for the purpose of performing a virtual colonoscopy (otherwise known as CT colonography and CT colography).  CT Colonography is covered by item 56553. 

Scan of the colon (Item 56553)

In item 56553, the terms 'high risk' and 'incomplete colonoscopy' are defined as follows: 

High Risk

Asymptomatic people fit into this category if they have:

-          three or more first-degree or a combination of first-degree and second-degree relatives on the same side of the family diagnosed with bowel cancer (suspected hereditary non-polyposis colorectal cancer or NPCC), or

-          two or more first-degree or second-degree relatives on the same side of the family diagnosed with bowel cancer, including any of the following high-risk features, or

-          multiple bowel cancers in the one person, or

-          bowel cancer before the age of 50 years, or

-          at least one relative with cancer of the endometrium, ovary, stomach, small bowel, ureter, biliary tract or brain, or

-          at least one first-degree relative with a large number of adenomas throughout the large bowel (suspected familial adenomatis polyposis or FAP), or

-          somebody in the family in whom the presence of a high-risk mutation in the adenomatis polyposis coli (APC) gene or one of the mismatch repair (MMR) genes has been identified. 

Source: NHMRC 2005 Clinical Practice Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer - Category 3 - those at potentially high risk. 

Incomplete Colonoscopy

For audit purposes, an incomplete colonoscopy is defined as one that is not completed for technical or medical reasons and must have been performed in the preceding 3 months.  

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