Medicare Benefits Schedule - Note IN.0.18

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Category 5 - DIAGNOSTIC IMAGING SERVICES

IN.0.18

Group I5 - Magnetic Resonance Imaging

Meaning of the term ‘scan’ in MRI items

In items 63001 to 63563 and 63740 to 63743, scan means a minimum of 3 sequences.

Eligible services

Items in Subgroups 1 to 21 (other than items 63541 and 63543) apply to an MRI or MRA service performed:

(a)   on request by a recognised specialist or consultant physician, where the request made in writing identifies the clinical indication for the service;

(b)   under the professional supervision of an eligible provider; and

(c)   with fully eligible equipment.

For information on what constitutes fully eligible equipment, please refer to ‘MRI equipment eligibility’ below.

Items 63395 to 63397 and the items in Subgroups 19, 20 and 21 (other than item 63461) apply to an MRI service performed:

(a)   on request by a recognised specialist or consultant physician, where the request made in writing identifies the clinical indication for the service;

(b)   under the professional supervision of an eligible provider; and

(c)   with partially eligible equipment.

For information on what constitutes partially eligible equipment, please refer to ‘MRI equipment eligibility’ below.

Items in Subgroup 22 apply to an MRI or MRA service performed:

(a)   on request by a medical practitioner, where the request made in writing identifies the clinical indication for the service;

(b)   under the professional supervision of an eligible provider; and

(c)   with fully eligible equipment or partially eligible equipment.

Items in Subgroups 33 and 34 of Group I5 apply to an MRI service performed:

(a)   on request by a medical practitioner other than a specialist or consultant physician, where the request made in writing identifies the clinical indication for the service;

(b)   under the professional supervision of an eligible provider; and

(c)   with fully eligible equipment or partially eligible equipment.

Prostate Multiparametric MRI items 63541 and 63543 apply to a service performed:

(a)   at the request of a specialist in the speciality of urology, radiation oncology, or medical oncology; and

(b)   in a permissible circumstance which includes being rendered under the professional supervision of an eligible provider unless it is performed in an emergency or in a remote location because of medical necessity (please refer to ‘Permissible circumstances for performance of service’ below); and

(c)   using fully eligible equipment or partially eligible equipment.

See also note IN.5.2 for specific conditions relating to items 63541 and 63543.

Requests

A request must identify the clinical indications for the service.

MRI services can only be requested by a recognised specialist medical practitioner or consultant physician for the purposes of the Health Insurance Act 1973. However, there are exceptions to this provision for a limited number of MRI services:

  • all dental specialists, prosthodontists, oral and maxillofacial surgeons, oral medicine specialists and oral pathology specialists may request item 63334 - scan of musculoskeletal system for derangement of the temporomandibular joint(s); and
  • oral and maxillofacial surgeons and oral medicine and oral pathology specialists can also request item 63007 - scan of the head for skull base or orbital tumour; and
  • items in subgroup 33 and 34 may only be requested by a medical practitioner other than a specialist or a consultant physician.

For cardiac MRI items 63395 and 63397 (scan for diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC)), the request must specify that ARVC is suspected on the basis of diagnostic criteria endorsed by the Cardiac Society of Australia and New Zealand (CSANZ), in force at the time the service is requested.

Permissible circumstances for performance of service

Benefits are only payable for MRI when performed as follows:

(a)   both

- under the professional supervision of an eligible provider who is available to monitor and influence the conduct and diagnostic quality of the examination, including, if necessary, by personal attendance on the patient; and

- reported by an eligible provider; or

(b)    if paragraph (a) is not complied with

- in an emergency; or

- because of medical necessity, in a remote location (refer to IN.0.6).

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

Eligible providers

For items in Group I5 (excluding cardiac MRI items 63395 to 63397), an eligible provider is a specialist in diagnostic radiology who satisfies the Chief Executive Medicare (Services Australia) that he or she is a participant of the RANZCR Quality and Accreditation Program.

For cardiac MRI items 63395 to 63397, an eligible provider is a specialist in diagnostic radiology or a consultant physician, who is recognised by the Conjoint Committee for Certification in Cardiac MRI. The conjoint committee is comprised of specialists from RANZCR and the Cardiac Society of Australia and New Zealand (CSANZ).

MRI equipment eligibility

Fully eligible equipment is equipment which:

(a)   is located at premises of a comprehensive practice in Modified Monash Areas 2 to 7; OR

(b)   is located at premises:
         (i) of a comprehensive practice in Modified Monash Areas 1; and

                (ii) is made available to the practice by a person:
                   - who is subject to a deed with the Commonwealth that relates to the equipment

                (iii) is not identified as partial eligible equipment in the deed

 Partially eligible equipment is equipment which:

(a)   is located at premises of a comprehensive practice; and

(i)   is made available to the practice by a person:

- who is subject to a deed with the Commonwealth that relates to the equipment; and

(ii)   is identified as partial eligible equipment in the deed

A comprehensive practice for MRI services

The Health Insurance (Diagnostic Imaging Services Table) Regulations defines a comprehensive practice as a medical practice, or a radiology department of a hospital, that provides X‑ray, ultrasound and computed tomography services (whether or not it provides other services).

The location of Medicare-eligible MRI machines is available at the Department of Health's website at www.health.gov.au by searching for “MRI Unit Locations”.

 Limitation period for certain Medicare eligible MRI services

Item MRI or MRA items Limitation Period Maximum number of services
1 63040 to 63073 12 months 3
2 63101 12 months 3
3 63125 to 63131 12 months 3
4 63161 to 63185 12 months 3
5 63219 to 63243 12 months 3
6 63271 to 63280 12 months 3
7 63322 to 63340 12 months  3
8 63361 12 months 2
9 63385 to 63391 12 months 2
10 63395  12 months 1
11 63397 36 months 1
12 63401 to 63404 12 months
13 63416 12 months
14 63425 to 63428 12 months 
15 63461 to 63467 12 months 
15A 63541 12 months 1
* 63545 12 months 1
16 63547  patient's lifetime 
17 63482  12 months 
18 63507 to 63522 and 63551 to 63560 12 months
19 63563 24 months 1

Please note the # indicates restriction is included in the item descriptor.

The frequency restrictions are considered to be rolling restrictions and not based on calendar or financial years.

MRI items for the staging of histologically diagnosed cervical cancer at FIGO stage 1B or greater (63470 or 63473)

Items 63470 or 63473 in subgroup 20 may be claimed only once ever. After either 63470 or 63473 is claimed the patient is no longer eligible for Medicare benefits under either item.

MRI items for Crohn’s disease (63740 to 63743)

Medicare benefits are only payable once in a 12 month period for item 63740, where it is provided for assessment of change to therapy in a patient with small bowel Crohn’s disease. The 12 month limitation does not apply to this item otherwise.

Medicare benefits are only payable once in a 12 month period for item 63743, where it is provided for assessment of change to therapy of pelvis sepsis and fistulas from Crohn’s disease. The 12 month limitation does not apply to this item otherwise.

MRI Subgroup 22 Modifying Items and eligible MRI and MRA service

Items in subgroup 22 (modifying items) may only be claimed in conjunction with an eligible MRI/MRA service.

Restrictions when applied to bilateral anatomical sites

Restrictions on the number of services of the kind described in subgroup 12 apply to specific anatomical sites. Where an item description applies to more than one anatomical site the restriction on the number of services applies to each site.

For example, item 63328 provides for an MRI scan for derangement of the knee or its supporting structures and applies to two specific anatomical sites, ie, right knee and left knee. Each anatomical site may be scanned up to 3 times in any 12-month period as clinically required.

Co-claiming head and spine MRI scans – items 63001-63131 and 63151 to 63280

Benefits are payable for only one head MRI scan at the same attendance. The items that will restrict with each other are in the range 63001 to 63131.

Benefits are payable for only one spine MRI scan at the same attendance. The items that will restrict with each other are in the range 63151 to 63280.

The head or spine item with the highest schedule fee can be claimed where indications spanning two or more service have been requested.

More than one item can be claimed where the clinical need for the additional service is:

  • stated in the request for the service; and
  • appropriately documented in the record of the service.

These rules clarify the policy intent for the items, that is, only one item should be claimable for a scan irrespective of the:

  • number of clinical conditions being investigated; and
  • the number of sequences required to complete the scan.

Where a request form seeks an investigation of more than one clinical condition, the item to claim is the item with the highest schedule fee. If the items have the same schedule fee, the item to be claimed is the item applicable to the first mentioned indication on the request form.

More than one item can be claimed where the request for the scan states that there is a clinical need for the additional service, and this is appropriately documented in the diagnostic imaging record for the patient. This does not mean different clinical indications listed in a request, rather it means that the requester is seeking separate and distinct scans.

Providers will need to indicate on the claim that separate and distinct scans have been requested.

MRI scan of the pelvis for pregnancy - 18 weeks gestation – suspected fetal abnormality (MBS item 63454) 

Clinical Notes and Diagnostic Imaging Request

For item 63454 the requesting specialist practising in the specialty of obstetrics is to record in their clinical notes and the imaging request:

·         the pregnancy is at, or after, 18 weeks gestation; and

·         fetal abnormality is suspected; and

·         an ultrasound has been previously performed and the diagnosis of fetal abnormality is indeterminate or requires further examination of the patient.

Providers

The service can only be requested by a specialist practising in the specialty of obstetrics.

Gestation period

For item 63454, “at or after 18 weeks gestation” means from 18 weeks 0 days of pregnancy onwards as confirmed by an ultrasound.

MRI scan of both breast for detection of cancer – younger than 60 years (MBS Item 63464)[HL2] 

Clinical Notes and Diagnostic Imaging Request

For item 63464 the requesting specialist or consultant physician is to record in their clinical notes and the imaging request:

  • the patient is asymptomatic; and
  • the patient is younger than 60 years of age; and
  • the patient is at a high risk of developing breast cancer due to one or more of the clinical indicators contained in the item descriptor. Reference the relevant clinical indicator/s in the clinical notes and request.

Clinically Relevant Evaluation Algorithm

A clinically relevant evaluation algorithm referenced in item 63464(c)(v) is considered to be the Tyrer‑Cuzick (IBIS Risk Evaluator) algorithm version 8 (or later version). The lifetime risk estimation is one of a number of clinical indicators contained in the item descriptor which can support a patient being eligible to claim item 63464. 

Restrictions

For item 63464, the service is not to be performed with items 55076 or 55079.

The service can only be claimed once in any 12-month period.

Age requirements

The age references in item 63464 are as follows:

  • younger than 60 years of age refers to a patient who has not yet turned 60 years of age.
  • before the age of 50 years refers to the patient being up to and including 49 years of age.
  • at age 45 years or younger refers to the patient being up to and including 45 years of age.

MRI scan of the pelvis for multiple pregnancy - 18 weeks gestation – suspected fetal abnormality (MBS Item 63549) 

Clinical Notes and Diagnostic Imaging Request

For item 63549 the requesting specialist practising in the specialty of obstetrics is to record in their clinical notes and the imaging request:

  • the patient has a multiple pregnancy; and
  • the pregnancy is at, or after, 18 weeks gestation; and
  • fetal abnormality is suspected; and
  • an ultrasound has been previously performed and diagnosis of fetal abnormality is indeterminate or requires further examination of the patient.

Providers

The service can only be requested by a specialist practising in the specialty of obstetrics.

Gestation period

For item 63549, “at or after 18 weeks gestation” means from 18 weeks 0 days of pregnancy onwards as confirmed by an ultrasound.

MRI scan of the liver (MBS Item 63545) 

Clinical Notes and Diagnostic Imaging Request

For item 63545 the requesting specialist or consultant physician is to record in their clinical notes and the imaging request:

  • the patient has a confirmed extra-hepatic primary malignancy (other than hepatocellular carcinoma), with no persistent extra-hepatic disease and
  • computed tomography of the patient’s liver is negative or inconclusive for metastatic disease; and
  • the identification of liver metastases would change the patient’s treatment planning.

Restrictions

The service can only be claimed once in any 12 month period.

MRI scan of the pelvis for sub-fertility and deep endometriosis (MBS Item 63563)

Clinical Notes and Diagnostic Imaging Request

For item 63563 the requesting specialist or consultant physician is to record in their clinical notes and the imaging request that the scan is for the investigation of

  • sub-fertility requiring one or more of the following:

o    an investigation of suspected Mullerian duct anomaly seen in pelvic ultrasound or hysterosalpingogram;

o    an assessment of uterine mass identified on pelvic ultrasound before consideration of surgery;

o    an investigation of recurrent implantation failure in IVF (2 or more embryo transfer cycles without viable pregnancy); or

  • surgical planning of a patient with known or suspected deep endometriosis involving either the bowel, bladder or ureter, where the results of pelvic ultrasound are inconclusive.

Restrictions

The service can only be claimed once in any 2 year period.

Definitions

“Recurrent implantation failure” is defined as failure to establish clinical pregnancy following two or more embryo transfer cycles. The number of embryos per cycle can be one or more.

 “Viable pregnancy” is defined as any pregnancy that results in a live birth.

 

 

Related Items: 63464 63549 63563


Related Items

Category 5 - DIAGNOSTIC IMAGING SERVICES

63464

63464 - Additional Information

Item Start Date:
01-Feb-2009
Description Updated:
01-Nov-2022
Schedule Fee Updated:
01-Jul-2022

MRI scan of both breasts for the detection of cancer in a patient, if:

(a) a dedicated breast coil is used; and

(b) the request for the scan identifies that the patient is asymptomatic and is younger than 60 years of age; and

(c) the request for the scan identifies that the patient is at high risk of developing breast cancer due to one or more of the following:

(i) genetic testing has identified the presence of a high risk breast cancer gene mutation in the patient or in a first degree relative of the patient;

(ii) both:

(A) one of the patient’s first or second degree relatives was diagnosed with breast cancer at age 45 years or younger; and

(B) another first or second degree relative on the same side of the patient’s family was diagnosed with bone or soft tissue sarcoma at age 45 years or younger;

(iii) the patient has a personal history of breast cancer before the age of 50 years;

(iv) the patient has a personal history of mantle radiation therapy;

(v) the patient has a lifetime risk estimation greater than 30% or a 10 year absolute risk estimation greater than 5% using a clinically relevant risk evaluation algorithm; and

(d) the service is not performed in conjunction with item 55076 or 55079

Applicable not more than once in a 12 month period (R) (Contrast)

(Anaes.)

Fee: $701.05 Benefit: 75% = $525.80 85% = $607.85

(See para IN.0.18, IN.0.19 of explanatory notes to this Category)

Category 5 - DIAGNOSTIC IMAGING SERVICES

63549

63549 - Additional Information

Item Start Date:
01-Nov-2022
Description Updated:
01-Nov-2022
Schedule Fee Updated:
01-Nov-2022

MRI scan of the pelvis or abdomen, for a patient with a multiple pregnancy, if:

(a) the multiple pregnancy is at, or after, 18 weeks gestation; and

(b) fetal abnormality is suspected; and

(c) an ultrasound has been performed and is provided by, or on behalf of, or at the request of, a specialist who is practising in the specialty of obstetrics; and

(d) the diagnosis of fetal abnormality as a result of the ultrasound is indeterminate or requires further examination; and

(e) the MRI service is requested by a specialist practising in the specialty of obstetrics (R) (Contrast)

(Anaes.)

Fee: $1,828.80 Benefit: 75% = $1,371.60 85% = $1,735.60

(See para IN.0.18 of explanatory notes to this Category)

Category 5 - DIAGNOSTIC IMAGING SERVICES

63563

63563 - Additional Information

Item Start Date:
01-Nov-2022
Description Updated:
01-Nov-2022
Schedule Fee Updated:
01-Nov-2022

MRI scan of the pelvis or abdomen, if the request for the scan identifies that the investigation is for:

(a) sub‑fertility that requires one or more of the following:

(i) an investigation of suspected Mullerian duct anomaly seen in pelvic ultrasound or hysterosalpingogram;

(ii) an assessment of uterine mass identified on pelvic ultrasound before consideration of surgery;

(iii) an investigation of recurrent implantation failure in IVF (2 or more embryo transfer cycles without viable pregnancy); or

(b) surgical planning of a patient with known or suspected deep endometriosis involving the bowel, bladder or ureter (or any combination of the bowel, bladder or ureter), where the results of pelvic ultrasound are inconclusive

Applicable not more than once in a 2 year period (R) (Contrast)

(Anaes.)

Fee: $409.65 Benefit: 75% = $307.25 85% = $348.25

(See para IN.0.18, IN.0.19 of explanatory notes to this Category)


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