Medicare Benefits Schedule - Note TN.8.219

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Category 3 - THERAPEUTIC PROCEDURES

TN.8.219

Complex coronary artery disease definition

Complex Coronary Artery Disease

Complex coronary artery disease is defined as

  1. a stenosis >50% in the left main coronary artery; or
  2. >90% in the proximal left anterior coronary artery; or
  3. bifurcation lesions involving side branches with a diameter >2.75mm; or
  4. chronic vessel occlusions (>3 months); or
  5. severely angulated or severely calcified lesions; or
  6. SYNTAX score >23.

Such disease should only undergo PCI with a documented recommendation from a Heart Team Conference.

Related Items: 38314 38323


Related Items

Category 3 - THERAPEUTIC PROCEDURES

38314

38314 - Additional Information

Item Start Date:
01-Jul-2021
Description Updated:
01-Jul-2021
Schedule Fee Updated:
01-Jul-2022

Note: (stable multi-vessel disease - 3 coronary territory with selective angiography) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.4 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17C; 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, 38310, 38311, 38313, 38316, 38317, 38319, 38320, 38322 or 38323 applies

(Anaes.) (Assist.)

Fee: $2,438.30 Benefit: 75% = $1,828.75 85% = $2,345.10

(See para TN.8.218, TN.8.219, TN.8.226, TR.8.4, TR.8.5, TR.8.7 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

38323

38323 - Additional Information

Item Start Date:
01-Jul-2021
Description Updated:
01-Jul-2021
Schedule Fee Updated:
01-Jul-2022

Note: (stable multi-vessel disease - 3 coronary territories with selective angiography) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.4 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17C; 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, 38319, 38320 or 38322 applies 

(Anaes.) (Assist.)

Fee: $2,404.30 Benefit: 75% = $1,803.25 85% = $2,311.10

(See para TN.8.218, TN.8.219, TN.8.226, TR.8.4, TR.8.5, TR.8.7 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