Medicare Benefits Schedule - Note TN.8.226

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Category 3 - THERAPEUTIC PROCEDURES

TN.8.226

Staging Rules for Stable PCI

Staging of non-acute (stable) PCI

  • Staging of stable PCI is permissible when clinically appropriate. An example of appropriate stable staging could include intervention on the primary target lesion and a decision is made not to intervene on secondary lesions (in triple vessel disease) due to the patient’s deteriorating haemodynamic status (clinically unsafe to continue).

Requirements of subsequent stages of a staged stable PCI

  • The qualifying indication for the initial procedure is to be used as the qualifier for the relevant subsequent stages. Subsequent stages are expected to be completed within a reasonable time period following the initial intervention.
  • For subsequent stages of a stable PCI it is implied that diagnostic angiography has been completed in the previous 3 months and therefore it is only permissible to claim items 38320, 38322 or 38323 (standalone PCI items) for subsequent stages.
  • Note: For patients who meet the criteria in subclause (2)(b) of note TR.8.4 in 3 vascular territories (triple vessel disease), whether treated in an initial procedure (items 38314 or 38323) or in subsequent stages (items 38311, 38313, 38320 or 38322) it is expected that the patient must meet the criteria for (2)(b) of note TR.8.4 for each territory for each subsequent stage. This requirement ensures that the patient who has triple vessel disease must meet the criteria for (2)(b) for each territory when staged or completed in an initial procedure.

The Department will be closely monitoring claiming patterns for staged procedures, particularly where volumes for staged procedures at the same site are not consistent with the broader provider claiming base.

Multiple Providers of one episode of care (stable) PCI – Separate interventional sites or Same interventional site.

One of  the primary intentions of the changes to selective coronary angiography and PCI items, is to encourage the provision of the entire intervention in a single episode of care. Therefore, the provider should consider that there will be a reasonable need to intervene (revascularise), noting that in some cases intervention is not required (e.g. pressure testing – FFR result does not support the need for stenting).

It is recognised that some providers of interventional cardiology services only provide selective coronary angiography (diagnostic) and require a secondary provider to undertake angioplasty, stenting and/or atherectomy.

Non-interventional – selective angiography providers (clinical assessment suggests intervention required)

Stable patients

It is accepted clinical practice that the following patient pathways for stable PCI service provision (other than a complete service by an accredited PCI cardiologist) may occur when considering the role of the non-interventional cardiologist (non-PCI accredited) as follows:


Ad-hoc PCI:

  • Provider 1 completes the selective angiography and hands over to provider 2 to perform the PCI while the patient is still on the cardiac catheterisation table with the arterial access still in place.
  • Similar to the acute items, this scenario would likely be rare for e.g. dissection of a coronary artery caused by the angiography catheter that may convert the patient from stable to unstable.
  • It is current accepted practice that the selective coronary angiography component of the service can be performed by a non-interventional cardiologist and the PCI component (when required) completed by a PCI accredited provider.
  • Ideally ad-hoc stable PCI should be completed by a PCI accredited provider and therefore consideration should be given to current practice site arrangements going forward.


Delayed PCI:

  • Provider 1 completes ICA and refers the patient to provider 2, who performs the  PCI later on the same day.
  • In the stable patient this scenario presents the opportunity to pause and consider  whether optimal medical therapy, PCI or coronary artery bypass may be the preferred option in consultation with a PCI accredited cardiologist and/or cardiothoracic surgeon; and
  • It also allows for a further opportunity to obtain informed consent from the patient for the proposed intervention.
  • In most cases this would involve maintaining the arterial access with an indwelling arterial sheath to avoid repuncture.

Elective PCI:

  • Provider 1 completes ICA and refers the patient to provider 2, who performs the PCI on the next day, or any subsequent day.
  • Similar to delayed PCI, however the PCI accredited cardiologist may not be available on the same day as when the selective coronary angiography was completed; or
  • A  short trial of optimal medical therapy is recommended; or
  • Further non-invasive functional testing is recommended.

The Department will be closely monitoring claiming patterns, particularly at the same site where selective angiography is completed by a non-accredited cardiologist and the PCI component completed by a PCI accredited provider.

The following  provides guidance for when the  provider can only undertake the selective angiography component of a complete PCI service (PCI non-accredited provider):


Separate hospital/procedural sites (Stable)

The first provider undertakes the diagnostic angiography and either makes an independent decision or following discussion with the interventional cardiologist  refers to the secondary provider at another site for the purposes of revascularisation (e.g. referral from a rural or regional hospital to a metropolitan hospital). In this scenario there is a clear delineation between the angiography and revascularisation services due to the different geographical locations (separate episodes of care). Example claiming is as follows:

  • Stable - example
    Provider 1 – site 1 (diagnostic angiography) claims item 38248 stable – selective angiography). Provider 2 – site 2 (PCI) claims item 38320 (stable – PCI single territory)


Same hospital/procedural site (Stable)

  • The first provider undertakes the diagnostic angiography and either makes an independent decision or following discussion with the interventional cardiologist requesting that the secondary provider undertakes the revascularisation component.
  • Please note that the underlying intention of a complete PCI service is that the entire service, including diagnostic angiography is completed by a single provider where possible.

Abandoned T8 Surgical Procedures and Acute or Stable Percutaneous Coronary Intervention (PCI) – Excluding appropriate staging

The new acute PCI items have time restrictions applied whether claimed by the same or different providers. It is important for the patient that if a provider cannot complete (abandoned) the PCI and rescue PCI needs to be conducted by another provider, item 30001 is claimed. This will allow claiming by the provider who subsequently completes the rescue PCI, taking into consideration the time restrictions for each of the selective angiography items.

The new stable PCI items do not have time restrictions. However, it is important for the patient that if a provider cannot complete (abandoned) the PCI and rescue PCI needs to be conducted by another provider, item 30001 is claimed. This will allow claiming by the provider who subsequently completes the rescue PCI, taking into consideration the time restrictions for each of the selective angiography items.

 

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-Nov-2023

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: $1,951.25 Benefit: 75% = $1,463.45 85% = $1,852.55

(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-Nov-2023

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: $2,244.95 Benefit: 75% = $1,683.75 85% = $2,146.25

(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

38314

38314 - Additional Information

Item Start Date:
01-Jul-2021
Description Updated:
01-Jul-2021
Schedule Fee Updated:
01-Nov-2023

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: $2,538.75 Benefit: 75% = $1,904.10 85% = $2,440.05

(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-Nov-2023

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: $1,744.35 Benefit: 75% = $1,308.30 85% = $1,645.65

(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-Nov-2023

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: $2,209.60 Benefit: 75% = $1,657.20 85% = $2,110.90

(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-Nov-2023

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: $2,503.30 Benefit: 75% = $1,877.50 85% = $2,404.60

(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