Medicare Benefits Schedule - Note PN.1.3

Services Rendered by Disqualified Practitioner

Medicare benefits are not payable for pathology services if at the time the service is rendered, the person, by or on whose behalf the service is rendered, is a person in relation to whom a determination is in force in relation to that class of services.  That is, where an Approved Pathology Practitioner has breached an undertaking, and a determination has been made that Medicare benefits should not be paid during a specified period (of up to five years) in respect of specified pathology services rendered by the practitioner. 

Note: An Approved Pathology Practitioner may be disqualified for reasons other than a breach of undertaking.  

Certain Pathology Tests Do Not Attract Medicare Benefits

Certain tests of public health significance do not qualify for payment of Medicare benefits.  Examples of services in this category are:

-                  examination by animal inoculation;

-                  Guthrie test for phenylketonuria;

-                  neonatal screening for hypothyroidism (T4/TSH estimation);

-                  neonatal screening for Cystic Fibrosis;

-                  neonatal screening for Galactosemia;

-                  pathology services used with the intention of monitoring the performance enhancing effects of any substance;

-                  pathology tests carried out on specimens collected from persons occupationally exposed to sexual transmission of disease where the purpose of the collection of specimens is for testing in accordance with conditions determined by the health authority of the State or Territory in which the service is performed. 

In addition to the above, certain other tests do not qualify for payment of Medicare benefits.  These include:

-                  cytotoxic food testing;

-                  pathology services performed for the purposes of control estimation, repeat tests (eg. for confirmation of earlier tests on the same specimen, etc);

-                  preparation of autogenous vaccines;

-                  tissue banking and preparation procedures;

-                  pathology services performed on stillborn babies or cadavers;

-                  pathology services which are performed routinely in association with the termination of pregnancy without there being any indication for the necessity of the services. 

However, benefits will be paid for the following pathology tests:           

-     item 65060  ‑  haemoglobin estimation;

-     item 65090  ‑  blood grouping ABO and Rh (D antigen);

-     item 65096  ‑  examination of serum for Rh and other blood group antibodies.

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