Medicare Benefits Schedule - Note TN.8.217

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Category 3 - THERAPEUTIC PROCEDURES

TN.8.217

Staging rules for PCI for acute

Staging

  • If a staged procedure is appropriately performed over multiple days, items 38316, 38317 or 38319 must be used for subsequent stages.
  • For subsequent stages of an acute percutaneous coronary intervention completed up to 3 months after the initial procedure, it is expected that the patient would receive the subsequent stage/s of the intervention based on the qualifying indication for the initial procedure

Vascular Territories

  • The item number claimed should reflect the number of coronary vascular territories (Left Anterior Descending, Circumflex or Right Coronary Artery distribution) that are treated during the procedure, not the total number of treated territories the patient has received to date.
  • For isolated Left Main (no involvement of the bifurcation), a single territory should be claimed but if the treated segment involves the bifurcation then 2 territories should be claimed.
  • The Intermediate Artery when treated in isolation is single territory, when treated with the Left Anterior Descending or Circumflex or both, should be claimed as two territories.
  • A single lesion in a bypass graft should be claimed as single territory regardless of how many vascular territories are supplied by that graft. If the graft has multiple lesions and those lesions are in separate skip portions to a different territory, then an additional territory may be claimed.

Related Items: 38307 38308 38310 38316 38317 38319


Related Items

Category 3 - THERAPEUTIC PROCEDURES

38307

38307 - Additional Information

Item Start Date:
01-Jul-2021
Description Updated:
09-Jul-2021
Schedule Fee Updated:
01-Nov-2023

Note: (acute coronary syndrome - 1 coronary territory with selective coronary angiography)  the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.2 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17A; and

(ii) for whom selective coronary angiography has not been completed in the previous 3 months; and

(b) including selective coronary angiography and all associated imaging, catheter and contrast; and

(c) including either or both:

(i) percutaneous angioplasty;

(ii) transluminal insertion of one or more stents; and

(d) performed on one coronary vascular territory; and

(e) excluding aftercare;

other than a service associated with a service to which item 38200, 38203, 38206, 38244, 38247, 38248, 38249, 38251, 38252, 38308, 38310, 38311, 38313, 38314, 38316, 38317, 38319, 38320, 38322 or 38323 applies 

(Anaes.) (Assist.)

Fee: $1,951.25 Benefit: 75% = $1,463.45 85% = $1,852.55

(See para TN.8.217, TN.8.225, TR.8.2, TR.8.5 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

38308

38308 - Additional Information

Item Start Date:
01-Jul-2021
Description Updated:
09-Jul-2021
Schedule Fee Updated:
01-Nov-2023

Note: (acute coronary syndrome - 2 coronary territories with selective coronary angiography) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.2 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17A; and

(ii) for whom selective coronary angiography has not been completed in the previous 3 months; and

(b) including selective coronary angiography and all associated imaging, catheter and contrast; and

(c) including either or both:

(i) percutaneous angioplasty; and

(ii) transluminal insertion of one or more stents; and

(d) performed on 2 coronary vascular territories; and

(e) excluding aftercare;

other than a service associated with a service to which item 38200, 38203, 38206, 38244, 38247, 38248, 38249, 38251, 38252, 38307, 38310, 38311, 38313, 38314, 38316, 38317, 38319, 38320, 38322 or 38323 applies

(Anaes.) (Assist.)

Fee: $2,244.95 Benefit: 75% = $1,683.75 85% = $2,146.25

(See para TN.8.217, TN.8.225, TR.8.2, TR.8.5 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

38310

38310 - Additional Information

Item Start Date:
01-Jul-2021
Description Updated:
09-Jul-2021
Schedule Fee Updated:
01-Nov-2023

Note: (acute coronary syndrome - 3 coronary territories with selective coronary angiography) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.2 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17A; and

(ii) for whom selective coronary angiography has not been completed in the previous 3 months; and

(b) including selective coronary angiography and all associated imaging, catheter and contrast; and

(c) including either or both:

(i) percutaneous angioplasty; and

(ii) transluminal insertion of one or more stents; and

(d) performed on 3 coronary vascular territories; and

(e) excluding aftercare;

other than a service associated with a service to which item 38200, 38203, 38206, 38244, 38247, 38248, 38249, 38251, 38252, 38307, 38308, 38311, 38313, 38314, 38316, 38317, 38319, 38320, 38322 or 38323 applies 

(Anaes.) (Assist.)

Fee: $2,538.75 Benefit: 75% = $1,904.10 85% = $2,440.05

(See para TN.8.217, TN.8.225, TR.8.2, TR.8.5 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

38316

38316 - Additional Information

Item Start Date:
01-Jul-2021
Description Updated:
09-Jul-2021
Schedule Fee Updated:
01-Nov-2023

Note: (acute coronary syndrome - 1 coronary territory without selective angiography) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.2 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17A; and

(ii) for whom selective coronary angiography has been completed in the previous 3 months; and

(b) including any associated coronary angiography; and

(c) including either or both:

(i) percutaneous angioplasty; and

(ii) transluminal insertion of one or more stents; and

(d) performed on one coronary vascular territory; and

(e) excluding aftercare;

other than a service associated with a service to which item 38200, 38203, 38206, 38244, 38247, 38248, 38249, 38251, 38252, 38307, 38308, 38310, 38311, 38313, 38314, 38317, 38319, 38320, 38322 or 38323 applies 

(Anaes.) (Assist.)

Fee: $1,744.35 Benefit: 75% = $1,308.30 85% = $1,645.65

(See para TN.8.217, TN.8.225, TR.8.2, TR.8.5 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

38317

38317 - Additional Information

Item Start Date:
01-Jul-2021
Description Updated:
09-Jul-2021
Schedule Fee Updated:
01-Nov-2023

Note: (acute coronary syndrome - 2 coronary territories without selective angiography) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.2 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17A; and

(ii) for whom selective coronary angiography has been completed in the previous 3 months; and

(b) including any associated coronary angiography; and

(c) including either or both:

(i) percutaneous angioplasty; and

(ii) transluminal insertion of one or more stents; and

(d) performed on 2 coronary vascular territories; and

(e) excluding aftercare;

other than a service associated with a service to which item 38200, 38203, 38206, 38244, 38247, 38248, 38249, 38251, 38252, 38307, 3808, 38310, 38311, 38313, 38314, 38316, 38319, 38320, 38322 or 38323 applies 

(Anaes.) (Assist.)

Fee: $2,209.60 Benefit: 75% = $1,657.20 85% = $2,110.90

(See para TN.8.217, TN.8.225, TR.8.2, TR.8.5 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

38319

38319 - Additional Information

Item Start Date:
01-Jul-2021
Description Updated:
09-Jul-2021
Schedule Fee Updated:
01-Nov-2023

Note: (acute coronary syndrome - 3 coronary territories without selective angiography) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.2 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17A; and

(ii) for whom selective coronary angiography has been completed in the previous 3 months; and

(b) including any associated coronary angiography; and

(c) including either or both:

(i) percutaneous angioplasty; and

(ii) transluminal insertion of one or more stents; and

(d) performed on 3 coronary vascular territories; and

(e) excluding aftercare;

other than a service associated with a service to which item 38200, 38203, 38206, 38244, 38247, 38248, 38249, 38251, 38252, 38307, 38308, 38310, 38311, 38313, 38314, 38316, 38317, 38320, 38322 or 38323 applies 

(Anaes.) (Assist.)

Fee: $2,503.30 Benefit: 75% = $1,877.50 85% = $2,404.60

(See para TN.8.217, TN.8.225, TR.8.2, TR.8.5 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