Medicare Benefits Schedule - Note IN.0.18

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Category 5 - DIAGNOSTIC IMAGING SERVICES

IN.0.18

Group I5 - Magnetic Resonance Imaging

Itemisation

Items in Group I5 are divided into subgroups defined according to the area of the body to be scanned, (ie head, spine, musculoskeletal system, cardiovascular system or body) and the number of occasions in a defined period in which Medicare benefits may be claimed by a patient. Subgroups are divided into individual items, with each item being for a specific clinical indication.

Eligible services

Items in Subgroups 1 to 21 of Group I5 (other than items 63541 to 63544) apply to a MRI or MRA service performed:

a.       on request by a recognised specialist or consultant physician, where the request made in writing identifies the clinical indication for the service;

b.       under the professional supervision of an eligible provider; and

c.       with eligible equipment.

Items 63395 to 63397 and the items in Subgroups 19, 20 and 21 (other than items 63455 and 63461) of Group I5 apply to a MRI service performed:

a.       on request by a recognised specialist or consultant physician, where the request made in writing identifies the clinical indication for the service;

b.       under the professional supervision of an eligible provider; and

c.       with partial eligible equipment.

Items in Subgroup 22 of Group I5 apply to a MRI or MRA service performed:

a.       on request by a medical practitioner, where the request made in writing identifies the clinical indication for the service;

b.       under the professional supervision of an eligible provider; and

c.       with eligible equipment or partial eligible equipment.

Items in Subgroups 33 and 34 of Group I5 apply to a MRI service performed

a.       on request by a medical practitioner other than a specialist or consultant physician, where the request made in writing identifies the clinical indication for the service;

b.       under the professional supervision of an eligible provider; and

c.       with eligible equipment or partial eligible equipment.

Prostate Multiparametric MRI items 63541 to 63544 apply to a service performed:

a.        at the request of a specialist in the speciality of urology, radiation oncology, or medical oncology; and

b.       in a permissible circumstance; and

c.        using:

·         eligible equipment; or

·         partial eligible equipment.

Requests

A request must identify the clinical indications for the service.

MRI services can only be requested by a recognised specialist medical practitioner or consultant physician for the purposes of the Health Insurance Act 1973. However, there are exceptions to this provision for a limited number of MRI services:

-          all dental specialists, prosthodontists, oral and maxillofacial surgeons, oral medicine specialists and oral pathology specialists may request item 63334 - scan of musculoskeletal system for derangement of the temporomandibular joint (s); and

-          oral and maxillofacial surgeons and oral medicine and oral pathology specialists can also request item 63007 - scan of the head for skull base or orbital tumour; and

-          items in subgroup 33 and 34 may only be requested by a medical practitioner other than a specialist or a consultant physician.

For cardiac MRI items 63395 and 63397 (scan for diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC)), the request must specify that ARVC is suspected on the basis of diagnostic criteria endorsed by the Cardiac Society of Australia and New Zealand (CSANZ), in force at the time the service is requested.

Permissible circumstances for performance of service  

Benefits are only payable for MRI when performed as follows:

a.        both:

·         under the professional supervision of an eligible provider who is available to monitor and influence the conduct and diagnostic quality of the examination, including, if necessary, by personal attendance on the patient; and

·         reported by an eligible provider; or

b.       if paragraph (a) is not complied with:

·         in an emergency; or

·         because of medical necessity, in a remote location (refer to IN.0.7.)

Note: Practitioners do not have to apply for a remote area exemption in these circumstances.

Eligible providers

For items in Group I5 (excluding cardiac MRI items 63395 to 63397), an eligible provider is a specialist in diagnostic radiology who satisfies the Chief Executive Medicare (Services Australia) that he or she is a participant of the RANZCR Quality and Accreditation Program.

For cardiac MRI items 63395 to 63397, an eligible provider is a specialist in diagnostic radiology or a consultant physician, who is recognised by the Conjoint Committee for Certification in Cardiac MRI.  The conjoint committee is comprised of specialists from RANZCR and the Cardiac Society of Australia and New Zealand (CSANZ).

Eligible equipment is equipment which:

a.       is located at premises of a comprehensive practice; and

b.       is made available to the practice by a person: 

·         who is subject to a deed with the Commonwealth that relates to the equipment; and

·         for whom the deed has not been terminated; and

c.       is not identified as partial eligible equipment in the deed

Partial eligible equipment is equipment which:

a.       is located at premises of a comprehensive practice; and

b.       is made available to the practice by a person: 

·       who is subject to a deed with the Commonwealth that relates to the equipment; and

·       for whom the deed has not been terminated; and

c.       is identified as partial eligible equipment in the deed

The location of Medicare-eligible MRI machines is available at the Department of Health's website at http://www.health.gov.au.

Number of eligible services

Services in subgroups 1, 4, 6, 8, 11 and 18 have no frequency restriction.

Item MRI or MRA items Limitation Period Maximum number of services
1 63040 to 63073 12 months 3
2 63101 12 months 3
3 63125 to 63131 12 months 3
4 63161 to 63185 12 months 3
5 63219 to 63243 12 months 3
6 63271 to 63280 12 months 3
7 63322 to 63340 12 months  3
8 63361 12 months 2
9 63385 to 63391 12 months 2
10 63395  12 months 1
11 63397 36 months 1
12 63401 to 63404 12 months
13 63416 12 months
14 63425 to 63428 12 months 
15 63454 to 63467 12 months 
16 63547  patient's lifetime 
17 63482  12 months 
18 63507 to 63522 and 63551 to 63560 12 months

 
Items 63470 or 63473 in subgroup 20 may be claimed only once ever.

Items in subgroup 22 (modifying items) may only be ordered in conjunction with an eligible MRI/MRA service.

Example: Item 63271 in subgroup 10 can be claimed by a patient on three occasions in any 12 month period. If the patient had claimed Medicare benefits for the following:

Item Date of Service
63271 10/12/04
63271 18/04/05
63271 16/10/05
63271 11/12/05

The following table provides examples of further dates of service would, and would not, be eligible:

Date of Service Claimable Why?
12/03/05 No Between 10/12/04 and 9/12/05, the patient would have had 4 x 63271 in 12 months - 10/12/04, 12/03/05, 18/4/05 and 16/10/05
04/03/06 No Between 5/03/05 and 4/03/06, the patient would have had 4 x 63271 in 12 months - 18/04/05, 16/10/05, 11/12/05 and 4/03/06
20/04/06 Yes Between 21/04/05 and 20/04/06, the patient would have had 3 x 63271 in 12 months - 16/10/05, 11/12/05 and 20/04/06

The frequency restrictions are therefore considered to be rolling restrictions and not based on calendar or financial years.

In addition, restrictions on the number of services of the kind described in subgroup 12 apply to specific anatomical sites. Where an item description applies to more than one anatomical site the restriction on the number of services applies to each site.

Item 63328, MRI scan for derangement of the knee or its supporting structures, applies to two specific anatomical sites, ie, right knee and left knee. Each anatomical site may be scanned up to 3 times in any 12-month period.


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