Medicare Benefits Schedule - Note TN.8.152

Colonoscopy items (items 32222-32229)
It is expected that clinicians using the MBS items for colonoscopy also refer to national guidelines such as the National Health and Medical Research Council (NHMRC) Clinical Practice Guidelines for Surveillance Colonoscopy (NHMRC guidelines). For more information on clinical practice guidelines for surveillance colonoscopy see the colorectal cancer pages on the Cancer Council Australia website.

Surveillance colonoscopy should be planned based on high-quality endoscopy in a well-prepared colon using most recent and previous procedure information when histology is known. Clinicians should use their best clinical judgement to determine the interval between testing and the item that best suits the condition of the patient.

The NHMRC guidelines do not support the use of colonoscopy for patients at average or slightly above average risk of colorectal cancer who do not have symptoms or a positive faecal occult blood test (FOBT).

Items 32222-32228 specify that there is endoscopic examination to the caecum. The ‘to the caecum’ requirements for colonoscopy examinations do not apply to patients who have no caecum following right hemi colectomy. For these patients the examination should be to the anastomosis. Item 32084 should be billed if preparation is inadequate to allow visualisation to the caecum.

General practitioners should ensure colonoscopy referral practices align with applicable national guidelines, including the Royal Australian College of General Practitioners’ guidelines for preventive activities in general practice (the red book). In addition, general practitioners are urged to recommend biennial FOBT screening to age-appropriate patients.

Colonoscopy where a polyp/polyps are removed
Items 32222-32226 and 32228 provide for diagnostic colonoscopy when claimed alone. Where a polyp or polyps are removed during the colonoscopy, item 32229 should also be claimed in association with the appropriate colonoscopy item.

Definition of previous history (items 32222-32225)
For items 32223-32225 the most appropriate item to be billed is determined by the previous history of the patient. The previous history for the purpose of these items is defined by number, size and type of adenomas removed during any previous colonoscopy.

Although a patient with a previous history of 1-2 low risk adenomas (<10mm with no high-risk histological features) is eligible for a colonoscopy every five years under item 32223, clinical guidelines indicate that colonoscopy every 10 years is sufficient.

Definition of moderate risk of colorectal cancer due to family history (item 32223)
For item 32223 a patient is considered at moderate risk of colorectal cancer if there is moderate risk family history of colorectal cancer – defined as:
   - 1 first degree relative less than 55 years of age at diagnosis; OR
   - 2 first degree relatives with a history of colorectal cancer; OR
   - 1 first degree relative and 2 second degree relatives with a history of colorectal cancer.
The national clinical practice guidelines support the use of FOBT as a first line test for patients with a low risk family history of colorectal cancer. 

Exception item (item 32228)
Timing of colonoscopy following polypectomy should conform to the recommended surveillance intervals set out in clinical guidelines, taking into account individualised risk assessment. In the absence of reliable clinical history, clinicians should use their best clinical judgement to determine the interval between testing and the item that best suits the condition of the patient. Where the clinician is unable to access sufficient patient information to enable a colonoscopy to be performed under items 32222-32226, but in their opinion there is a clinical need for a colonoscopy, then item 32228 should be used. This item is available once per patient per lifetime.

Time intervals
Items 32223, 32224, 32225 and 32226 have time intervals for repeat colonoscopy which are consistent with guidelines. These services are payable under Medicare only when provided in accordance with the approved intervals.

Patients may fit several categories and the most appropriate fit is a matter for clinician judgement with the highest risk indicating what subsequent colonoscopy intervals are appropriate. The examples provided below show that the result of the histopathology will not lengthen the surveillance intervals (in the case of patient with familial adenomatous polyposis (FAP) or Lynch syndrome) and may actually shorten the surveillance intervals.

Example 1
A patient at high risk of colorectal cancer with FAP or Lynch syndrome has a number of polyps removed at a surveillance colonoscopy. Item 32226 and 32229 are the appropriate items to bill. If the histology result returns 1-2 adenomas for patients at low to moderate risk then the next surveillance colonoscopy is recommended in 5 years. However, the patient’s familial condition means that a shorter interval (12 months) is recommended and payable.

Example 2
A patient at moderate risk of colorectal cancer because of family history has a number of polyps removed at a surveillance colonoscopy. Item 32223 and 32229 are the appropriate items to bill based on the patient’s family history. If the histology testing returns showing an adenoma with high‑risk histological features then the next surveillance colonoscopy is recommended in 3 years instead of 5 years.

How to use the items with new patients who have undergone previous colonoscopy

Patients whose care continues within one practice should have the relevant history readily available to guide decision making. For new patients, practitioners should make reasonable efforts to establish a patient’s previous colonoscopy history. This includes seeking information from My Health Record, the records department of the hospital where the previous procedure occurred, the GP or the patient. The patients’ MBS claims history for colonoscopy services will also assist with this.

For audit purposes it is important to record the most appropriate item. In accordance with good practice, clinicians are required to maintain records that include pathology results which must be made available to the patient or other practitioners as required.

The Australian Commission on Safety and Quality in Health Care’s Colonoscopy Clinical Care Standard states all facilities and clinicians delivering colonoscopy services must provide a timely copy of the colonoscopy report and histology result to the patient and their GPs. Compliance with the Colonoscopy Clinical Care Standard is mandatory under the Australian Health Service Safety and Quality Accreditation Scheme.

Patient eligibility for colonoscopy services
Services Australia will be able to confirm whether a colonoscopy service has been claimed by an individual patient and the date of service. It will also be able to confirm any restriction on the frequency of the item claimed which would prevent a rebate from being paid if the service was provided again within the restricted period. Patients can seek clarification from Services Australia by calling 132 011.

Patients can also access their own claiming history with a My Health Record or by establishing a Medicare online account through myGov or the Express Plus Medicare mobile app.

Further information about these services can be found on the Services Australia website.

Practitioners providing colonoscopy services can call Medicare on 132 150 to check the patient’s claiming history. The patient’s Medicare card number will be required together with the range of item numbers to be checked. For example, the new item numbers for colonoscopy services are in the range 32222-32229. The operator will interrogate the patient’s claiming history and provide advice on any claims paid for a colonoscopy service within the range of items specified and the date of the service.

Providers can also check a patient's eligibility via Health Professional Online Services (HPOS). HPOS will be able to return advice on whether a service is payable or not payable.

All patients who require a colonoscopy will be eligible for a service. However, MBS rebates will not be payable for services which do not meet the clinical indications and the item requirements for a colonoscopy or a repeat colonoscopy where the interval is specified in the item. Practitioners should ensure that their practice conforms to the approved clinical guidelines.

The Services Australia enquiry lines for providers and for patients is available 24 hours a day, seven days a week. Further information about these services can be found on the Services Australia website.

Related Items: 32222 32223 32224 32225 32226 32227 32228 32229

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Multiple Operation Rule

Endoscopic examination of the colon to the caecum by colonoscopy, for a patient:

(a) following a positive faecal occult blood test; or

(b) who has symptoms consistent with pathology of the colonic mucosa; or

(c) with anaemia or iron deficiency; or

(d) for whom diagnostic imaging has shown an abnormality of the colon; or

(e) who is undergoing the first examination following surgery for colorectal cancer; or

(f) who is undergoing pre‑operative evaluation; or

(g) for whom a repeat colonoscopy is required due to inadequate bowel preparation for the patient’s previous colonoscopy; or

(h) for the management of inflammatory bowel disease

Applicable only once on a day under a single episode of anaesthesia or other sedation

(Anaes.)

Fee: $368.00 Benefit: 75% = $276.00 85% = $312.80

(See para TN.8.2, TN.8.17, TN.8.152 of explanatory notes to this Category)

Multiple Operation Rule

Endoscopic examination of the colon to the caecum by colonoscopy, for a patient:

(a) who has had a colonoscopy that revealed:

(i) 1 to 4 adenomas, each of which was less than 10 mm in diameter, had no villous features and had no high grade dysplasia; or

(ii) 1 or 2 sessile serrated lesions, each of which was less than 10 mm in diameter, and without dysplasia; or

(b) with a moderate risk of colorectal cancer due to family history; or

(c) with a history of colorectal cancer, who has had an initial post‑operative colonoscopy that did not reveal any adenomas or colorectal cancer

Applicable only once in any 5 year period

(Anaes.)

Fee: $368.00 Benefit: 75% = $276.00 85% = $312.80

(See para TN.8.2, TN.8.17, TN.8.152 of explanatory notes to this Category)

Multiple Operation Rule

Endoscopic examination of the colon to the caecum by colonoscopy, for a patient with a moderate risk of colorectal cancer due to:

(a) a history of adenomas, including an adenoma that:

(i) was 10 mm or greater in diameter; or

(ii) had villous features; or

(iii) had high grade dysplasia; or

(b) having had a previous colonoscopy that revealed:

(i) 5 to 9 adenomas, each of which was less than 10 mm in diameter, had no villous features and had no high grade dysplasia; or

(ii) 1 or 2 sessile serrated lesions, each of which was 10 mm or greater in diameter or had dysplasia; or

(iii) a hyperplastic polyp that was 10 mm or greater in diameter; or

(iv) 3 or more sessile serrated lesions, each of which was less than 10 mm in diameter and had no dysplasia; or

(v) 1 or 2 traditional serrated adenomas, of any size

Applicable only once in any 3 year period (Anaes.)

Fee: $368.00 Benefit: 75% = $276.00 85% = $312.80

(See para TN.8.2, TN.8.17, TN.8.152 of explanatory notes to this Category)

Multiple Operation Rule

Endoscopic examination of the colon to the caecum by colonoscopy, for a patient with a high risk of colorectal cancer due to having had a previous colonoscopy that:

(a) revealed 10 or more adenomas; or

(b) included a piecemeal, or possibly incomplete, excision of a large, sessile polyp

Applicable not more than 4 times in any 12 month period

(Anaes.)

Fee: $368.00 Benefit: 75% = $276.00 85% = $312.80

(See para TN.8.2, TN.8.17, TN.8.152 of explanatory notes to this Category)

Multiple Operation Rule

 Endoscopic examination of the colon to the caecum by colonoscopy, for a patient who has a high risk of colorectal cancer due to:

(a) having either:

(i) a known or suspected familial condition, such as familial adenomatous polyposis, Lynch syndrome or serrated polyposis syndrome; or

(ii) a genetic mutation associated with hereditary colorectal cancer; or

(b) having had a previous colonoscopy that revealed:

(i) 5 or more sessile serrated lesions, each of which was less than 10 mm in diameter and had no dysplasia; or

(ii) 3 or more sessile serrated lesions, 1 or more of which was 10 mm or greater in diameter or had dysplasia; or

(iii) 3 or more traditional serrated adenomas, of any size

Applicable only once in any 12 month period (Anaes.)

Fee: $368.00 Benefit: 75% = $276.00 85% = $312.80

(See para TN.8.2, TN.8.17, TN.8.152 of explanatory notes to this Category)

Multiple Operation Rule

Endoscopic examination of the colon to the caecum by colonoscopy:

(a) for the treatment of bleeding, including one or more of the following:

    (i) radiation proctitis;

    (ii) angioectasia;

    (iii) post‑polypectomy bleeding; or

(b) for the treatment of colonic strictures with balloon dilatation

Applicable only once on a day under a single episode of anaesthesia or other sedation

(Anaes.)

Fee: $516.40 Benefit: 75% = $387.30 85% = $438.95

(See para TN.8.2, TN.8.17, TN.8.152 of explanatory notes to this Category)

Multiple Operation Rule

Endoscopic examination of the colon to the caecum by colonoscopy, other that a service to which item 32222, 32223, 32224, 32225, or 32226 applies. Applicable only once

(Anaes.)

Fee: $368.00 Benefit: 75% = $276.00 85% = $312.80

(See para TN.8.2, TN.8.17, TN.8.152 of explanatory notes to this Category)

Multiple Operation Rule

Removal of one or more polyps during colonoscopy, in association with a service to which item 32222, 32223, 32224, 32225, 32226, or 32228 applies

(Anaes.)

Fee: $296.85 Benefit: 75% = $222.65 85% = $252.35

(See para TN.8.2, TN.8.17, TN.8.152 of explanatory notes to this Category)