Medicare Benefits Schedule - Note TR.8.4

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Category 3 - THERAPEUTIC PROCEDURES

TR.8.4

Stable - Percutaneous Coronary Intervention Indications

Clause 5.10.17C Items 38311, 38313, 38314, 38320, 38322 and 38323—patient eligibility

(1) A patient is eligible for a service to which item 38311, 38313, 38314, 38320, 38322 or 38323 applies if:

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

(b) the patient is recommended for the service as a result of a heart team conference that meets the requirements of subclause (4).

(2) This subclause applies to a patient if:

(a) the patient has any of the following:

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

(ii) myocardial ischaemia demonstrated on functional imaging;

(iii) high risk features such as ST segment elevation, sustained ST depression, hypotension or a Duke treadmill score of minus 11 or less, demonstrated by stress electrocardiogram testing; and

(b) the patient has either of the following in a vascular territory treated:

(i) a stenosis of 70% or more;

(ii) a fractional flow reserve of 0.80 or less, or non-hyperaemic pressure ratios distal to the lesions of 0.89 or less; and

(c) for items 38314 and 38323—either:

(i) the patient does not have diabetes mellitus and the multi-vessel coronary artery disease of the patient meets the criterion in subclause (3); or

(ii) despite a recommendation that surgery is preferable, the patient has expressed a preference for catheter-based intervention.

(3) For the purposes of subparagraph (2)(c)(i), the criterion for the multi-vessel coronary artery disease is that the disease does not involve any of the following:

(a) stenosis of more than 50% in the left main coronary artery;

(b) bifurcation lesions involving side branches with a diameter of more than 2.75 mm; 

(c) chronic vessel occlusions for more than 3 months;

(d) severely angulated or calcified lesions;

(e) a SYNTAX score of more than 23.

(4) 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 specialist or consultant physician;

(iii) for items 38314 and 38323—a cardiothoracic surgeon;

(iv) for items 38311, 38313, 38320 and 38322—a cardiothoracic surgeon or a non-interventional cardiologist; 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 percutaneous coronary intervention; 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: 38311 38313 38314 38320 38322 38323


Related Items

Category 3 - THERAPEUTIC PROCEDURES

38311

38311 - Additional Information

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

Note: (stable multi-vessel disease - 1 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 under clause 5.10.17C for the service and a service to which item 38314 applies; 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 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, 38313, 38314, 38316, 38317, 38319, 38320, 38322 or 38323 applies 

(Anaes.) (Assist.)

Fee: $1,874.10 Benefit: 75% = $1,405.60 85% = $1,786.20

(See para TN.8.218, TN.8.226, TR.8.4, TR.8.5, TR.8.6 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

38313

38313 - Additional Information

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

Note: (stable multi-vessel disease - 2 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 under clause 5.10.17C for the service and a service to which item 38314 applies; 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, 38308, 38310, 38311, 38314, 38316, 38317, 38319, 38320, 38322 or 38323 applies 

(Anaes.) (Assist.)

Fee: $2,156.20 Benefit: 75% = $1,617.15 85% = $2,068.30

(See para TN.8.218, TN.8.226, TR.8.4, TR.8.5, TR.8.6 of explanatory notes to this Category)

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% = $2,350.40

(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

38320

38320 - Additional Information

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

Note: (stable multi-vessel disease - 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.8.4 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible under clause 5.10.17C for the service and a service to which item 38323 applies; 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, 38316, 38317, 38319, 38322 or 38323 applies 

(Anaes.) (Assist.)

Fee: $1,675.35 Benefit: 75% = $1,256.55 85% = $1,587.45

(See para TN.8.218, TN.8.226, TR.8.4, TR.8.5, TR.8.6 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

38322

38322 - Additional Information

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

Note: (stable multi-vessel disease - 2 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 under clause 5.10.17C for the service and a service to which item 38323 applies; 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, 38308, 38310, 38311, 38313, 38314, 38316, 38317, 38319, 38320 or 38323 applies 

(Anaes.) (Assist.)

Fee: $2,122.20 Benefit: 75% = $1,591.65 85% = $2,034.30

(See para TN.8.218, TN.8.226, TR.8.4, TR.8.5, TR.8.6 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% = $2,316.40

(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