Medicare Benefits Schedule - Note TR.8.3

Clause 5.10.17B Items 38248 and 38249—patient eligibility

(1) A patient is eligible for a service to which item 38248 or 38249 applies if:

(a) subclause (2) applies to the patient; or

(b) the patient is recommended for coronary angiography as a result of a heart team conference that meets the requirements of subclause (3).

(2) This subclause applies to a patient who has:

(a) limiting angina or angina equivalent, despite an adequate trial of optimal medical therapy; or

(b) high risk features, including at least one of the following:

(i) myocardial ischaemia demonstrated on functional imaging;

(ii) ST segment elevation, sustained ST depression, hypotension or a Duke treadmill score of minus 11 or less, demonstrated by stress electrocardiogram testing;

(iii) computed tomography coronary angiography evidence of one or more coronary arteries with stenosis of 70% or more; or

(iv) left ventricular dysfunction with an ejection fraction of less than 40% or segmental wall motion abnormality at rest

(3) For the purposes of paragraph (1)(b), the requirements for a heart team conference are as follows:

(a) the conference must be conducted by a team of specialists or consultant physicians practising in the speciality of cardiology or cardiothoracic surgery, including each of the following:

(i) an interventional cardiologist;

(ii) a non-interventional cardiologist;

(iii) a specialist or consultant physician; and

(b) the team must:

(i) assess the patient’s risk and technical suitability to receive the service; and

(ii) make a recommendation about whether or not the patient is suitable for invasive coronary angiography; and

(c) a record of the conference must be created, and must include the following:

(i) the particulars of the assessment of the patient during the conference;

(ii) the recommendations made as a result of the conference;

(iii) the names of the members of the team making the recommendations.

Related Items: 38248 38249 57364

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Multiple Operation Rule

Note: (stable coronary syndrome) the service only applies if the patient meets the requirements of the descriptor and the of Note: TR.8.3 and TR.8.5

Selective coronary angiography:

(a) for a patient who is eligible for the service under clause 5.10.17B; and

(b) as part of the management of the patient; and

(c) with placement of catheters and injection of opaque material into native coronary arteries; and

(d) with or without left heart catheterisation, left ventriculography or aortography; and

(e) including all associated imaging;

other than a service associated with a service to which item 38200, 38203, 38206, 38244, 38247, 38249, 38251 or 38252 applies—applicable each 3 months

(Anaes.)

Fee: $973.20 Benefit: 75% = $729.90 85% = $874.50

(See para TN.8.215, TR.8.3, TR.8.5, TR.8.6 of explanatory notes to this Category)

Multiple Operation Rule

Note: (stable coronary syndrome - graft) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.3 and TR.8.5

Selective coronary and graft angiography:

(a) for a patient who is eligible for the service under clause 5.10.17B; and

(b) as part of the management of the patient; and

(c) with placement of one or more catheters and injection of opaque material into native coronary arteries; and

(d) if free coronary grafts attached to the aorta or direct internal mammary artery grafts are present—with placement of one or more catheters and injection of opaque material into those grafts (irrespective of the number of grafts); and

(e) with or without left heart catheterisation, left ventriculography or aortography; and

(f) including all associated imaging;

other than a service associated with a service to which item 38200, 38203, 38206, 38244, 38247, 38248, 38251 or 38252 applies—applicable once each 3 months

(Anaes.)

Fee: $1,559.20 Benefit: 75% = $1,169.40 85% = $1,460.50

(See para IN.2.1, TN.8.215, TN.8.216, TR.8.3, TR.8.5, TR.8.6 of explanatory notes to this Category)

Bulk bill incentive

Note: the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.3 (item 38247), TR.8.2 (item 38249) or item 38252 if subclause (iv) applies.

Computed tomography of the coronary arteries performed on a minimum of a 64 slice (or equivalent) scanner, if:

(a) the service is requested by a specialist or consultant physician; and

(b) at least one of the following apply to the patient:

(i) the patient has stable symptoms and newly recognised left ventricular systolic dysfunction of unknown aetiology;

(ii) the patient requires exclusion of coronary artery anomaly or fistula;

(iii) the patient will be undergoing non-coronary cardiac surgery;

(iv) the patient meets the criteria to be eligible for a service to which item 38247, 38249 or 38252 applies, but as an alternative to selective coronary angiography will require an assessment of the patency of one or more bypass grafts

(R) 

(Anaes.)

Fee: $758.30 Benefit: 75% = $568.75 85% = $659.60

(See para IN.0.19, IN.2.1, TR.8.2, TR.8.3, TR.8.6 of explanatory notes to this Category)