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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
Category 3 - THERAPEUTIC PROCEDURES
38311 - Additional Information
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: $2,019.55 Benefit: 75% = $1,514.70 85% = $1,920.85
(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 - Additional Information
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: $2,323.50 Benefit: 75% = $1,742.65 85% = $2,224.80
(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 - Additional Information
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: $2,627.60 Benefit: 75% = $1,970.70 85% = $2,528.90
(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 - Additional Information
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: $1,805.40 Benefit: 75% = $1,354.05 85% = $1,706.70
(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 - Additional Information
Note: (stable multi-vessel disease - 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.8.4 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: $2,286.95 Benefit: 75% = $1,715.25 85% = $2,188.25
(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 - Additional Information
Note: (stable multi-vessel disease - 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.8.4 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: $2,590.90 Benefit: 75% = $1,943.20 85% = $2,492.20
(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