Medicare Benefits Schedule - Note PN.6.2

Items in Groups P10 of the Pathology Services Table are only applicable to services performed:

(i)         by or on behalf of an Approved Pathology Practitioner who is a recognised specialist pathologist; and

(ii)        in private practice. 

Accordingly, these fees are not payable for pathology services rendered by an Approved Pathology Practitioner, being a specialist pathologist when requested for a privately referred out-patient of a recognised hospital. 

The patient episode initiation fees (PEIs) will be applicable on an episodic basis i.e. a claim may be made for the provision of pathology services requested by a practitioner in respect of one individual on the same day.  For example, if a practitioner orders three pathology tests for a person on the one day, Medicare benefits will be payable for each of those tests but only one PEI will be applicable. 

This Rule applies even when the treating practitioner has requested pathology tests from two or more Approved Pathology Practitioners. Thus a PEI will only be paid for the first account submitted unless an exemption listed in Rule 4 or 14.(7) applies or an exemption has been granted under "S4B(3)". 

Under Rule 14.(7) two PEIs are payable in relation to the same patient episode where a referring practitioner refers two different specimens to two different Approved Pathology Authorities in the following circumstances:

-           a tissue pathology specimen and any other non-tissue pathology specimen; or

-           a cytopathology specimen and any other non-cytopathology specimen. 

Rule 14.(8) also provides that only one PEI will be paid for the collection of specimens from a patient on one day in or by a single Approved Pathology Authority. 

The patient episode initiation benefits are two-tiered.  Higher benefits are paid for the collection of specimens from patients  who are not private inpatients or private outpatients of a recognised hospital where the specimens are tested in a private laboratory. 

A lower and uniform PEI benefit is paid where patients are private patients associated with a recognised hospital and the specimens are tested in a private laboratory or where the testing is performed by a prescribed laboratory on specimen collected from a patient eligible to claim Medicare benefits.

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