Medicare Benefits Schedule - Note TN.8.4

Definition

Section 3(5) of the Health Insurance Act 1973 states that services included in the Schedule (other than attendances) include all professional attendances necessary for the purposes of post-operative treatment of the patient.  For the purposes of this book, post-operative treatment is generally referred to as "aftercare".

Aftercare is deemed to include all post-operative treatment rendered by medical specialists and consultant physicians, and includes all attendances until recovery from the operation, the final check or examination, regardless of whether the attendances are at the hospital, private rooms, or the patient's home.  Aftercare need not necessarily be limited to treatment given by the surgeon or to treatment given by any one medical practitioner.

If the initial procedure is performed by a general practitioner, normal aftercare rules apply to any post-operative service provided by the same practitioner.

The medical practitioner determines each individual aftercare period depending on the needs of the patient as the amount and duration of aftercare following an operation may vary between patients for the same operation, as well as between different operations.

Private Patients

Medicare will not normally pay for any consultations during an aftercare period as the Schedule fee for most operations, procedures, fractures and dislocations listed in the MBS item includes a component of aftercare.

There are some instances where the aftercare component has been excluded from the MBS item and this is clearly indicated in the item description.

There are also some minor operations that are merely stages in the treatment of a particular condition.  As such, attendances subsequent to these services should not be regarded as aftercare but rather as a continuation of the treatment of the original condition and attract benefits.  Likewise, there are a number of services which may be performed during the aftercare period for pain relief which would also attract benefits.  This includes all items in Groups T6 and T7, and items 39013, 39100, 39110, 39014, 39111, 39116, 39117, 39118, 39119, 39121, 39127, 39130, 39133, 39136, 39324 and 39327.

Where there may be doubt as to whether an item actually does include the aftercare, the item description includes the words "including aftercare".

If a service is provided during the aftercare phase for a condition not related to the operation, then this can be claimed, provided the account identifies the service as 'Not normal aftercare', with a brief explanation of the reason for the additional services.

If a patient was admitted as a private patient in a public hospital, then unless the MBS item does not include aftercare, no Medicare benefits are payable for aftercare.

Medicare benefits are not payable for surgical procedures performed primarily for cosmetic reasons.  However, benefits are payable for certain procedures when performed for specific medical reasons, such as breast reconstruction following mastectomy.  Surgical procedures not listed on the MBS do not attract a Medicare benefit.

Where an initial or subsequent consultation relates to the assessment and discussion of options for treatment and, a cosmetic or other non-rebatable service are discussed, this would be considered a rebatable service under Medicare.  Where a consultation relates entirely to a cosmetic or other non-Medicare rebatable service (either before or after that service has taken place), then that consultation is not rebatable under Medicare.  Any aftercare associated with a cosmetic or non-Medicare rebatable service is also not rebatable under Medicare.

Public Patients

All care directly related to a public in-patient's care should be provided free of charge.  Where a patient has received in-patient treatment in a hospital as a public patient (as defined in Section 3(1) of the Health Insurance Act 1973), routine and non-routine aftercare directly related to that episode of admitted care will be provided free of charge as part of the public hospital service, regardless of where it is provided, on behalf of the state or territory as required by the National Healthcare Agreement.  In this case no Medicare benefit is payable.

Notwithstanding this, where a public patient independently chooses to consult a private medical practitioner for aftercare, then the clinically relevant service provided during this professional attendance will attract Medicare benefits.

Where a public patient independently chooses to consult a private medical practitioner for aftercare following treatment from a public hospital emergency department, then the clinically relevant service provided during this professional attendance will attract Medicare benefits.

Fractures

Where the aftercare for fractures is delegated to a doctor at a place other than where the initial reduction was carried out, then Medicare benefits may be apportioned on a 50:50 basis rather than on the 75:25 basis for surgical operations.

Where the reduction of a fracture is carried out by hospital staff in the out-patient or emergency department of a public hospital, and the patient is then referred to a private practitioner for aftercare, Medicare benefits are payable for the aftercare on an attendance basis.

The following table shows the period which has been adopted as reasonable for the after‑care of fractures:‑

Note: This list is a guide only and each case should be judged on individual merits.

Related Items: 30219 30223 32500 34521 34524 39013 39014 39015 39100 39110 39111 39116 39117 39118 39119 39121 39127 39130 39133 39136 39324 39327 41626 41656 42614 42644 42650

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Multiple Operation Rule

NASOLACRIMAL TUBE (unilateral), removal or replacement of, or LACRIMAL PASSAGES, probing to establish patency of the lacrimal passage and/or site of obstruction, unilateral, including lavage, not being a service associated with a service to which item 42610 applies (excluding aftercare)

Fee: $51.05 Benefit: 75% = $38.30 85% = $43.40

(See para TN.8.4 of explanatory notes to this Category)

Multiple Operation Rule

CORNEA OR SCLERA, complete removal of embedded foreign body from - not more than once on the same day by the same practitioner (excluding aftercare)

(Anaes.)

Fee: $76.25 Benefit: 75% = $57.20 85% = $64.85

(See para TN.8.4, TN.8.78 of explanatory notes to this Category)

Multiple Operation Rule

CORNEA, epithelial debridement for corneal ulcer or corneal erosion (excluding aftercare)

(Anaes.)

Fee: $76.25 Benefit: 75% = $57.20 85% = $64.85

(See para TN.8.4 of explanatory notes to this Category)

Multiple Operation Rule

Injection of primary branch of trigeminal nerve (ophthalmic, maxillary or mandibular branches) with alcohol, cortisone, phenol, or similar neurolytic substance, under image guidance

(Anaes.)

Fee: $251.15 Benefit: 75% = $188.40 85% = $213.50

(See para TN.7.6, TN.8.4 of explanatory notes to this Category)

Multiple Operation Rule

Left cervical percutaneous zygapophyseal joint denervation by radio-frequency probe, or cryoprobe, using radiological imaging control

Applicable to one or more services provided in a single attendance, for not more than 3 attendances in a 12 month period

(Anaes.)

Fee: $346.35 Benefit: 75% = $259.80 85% = $294.40

(See para TN.8.4, TN.8.245 of explanatory notes to this Category)

Multiple Operation Rule

PERCUTANEOUS CORDOTOMY

(Anaes.) (Assist.)

Fee: $667.85 Benefit: 75% = $500.90 85% = $574.65

(See para TN.8.4 of explanatory notes to this Category)

Multiple Operation Rule

Subcutaneous reservoir and spinal catheter, insertion of, for the management of chronic pain, including cancer pain (H)

(Anaes.)

Fee: $500.75 Benefit: 75% = $375.60

(See para TN.8.4, TN.8.244 of explanatory notes to this Category)

Multiple Operation Rule

Epidural lead or leads, percutaneous placement of, including intraoperative test stimulation, for the management of chronic neuropathic pain or pain from refractory angina pectoris (H)

(Anaes.) (Assist.)

Fee: $712.65 Benefit: 75% = $534.50

(See para TN.8.4, TN.8.244 of explanatory notes to this Category)

Multiple Operation Rule

Either:
(a) subcutaneously implanted infusion pump, removal of; or
(b) spinal catheter, removal or repositioning of;
for the management of chronic pain, including cancer pain (H) 

(Anaes.)

Fee: $168.55 Benefit: 75% = $126.45

(See para TN.8.4, TN.8.244 of explanatory notes to this Category)

Multiple Operation Rule

Epidural or peripheral nerve lead that was implanted for the management of chronic neuropathic pain or pain from refractory angina pectoris, open surgical removal of, performed in the operating theatre of a hospital (H) 

(Anaes.) (Assist.)

Fee: $168.55 Benefit: 75% = $126.45

(See para TN.8.4, TN.8.244 of explanatory notes to this Category)

Multiple Operation Rule

Incision of tympanic membrane, or installation of therapeutic agent, to the middle ear through an intact drum:

(a) not including local anaesthetic; and

(b) excluding aftercare; and

(c) other than a service associated with a service to which item 41632 applies

(Anaes.)

Fee: $152.25 Benefit: 75% = $114.20 85% = $129.45

(See para TN.8.4 of explanatory notes to this Category)

Multiple Operation Rule

NASAL HAEMORRHAGE, POSTERIOR, ARREST OF, with posterior nasal packing with or without cauterisation and with or without anterior pack (excluding aftercare)

(Anaes.)

Fee: $129.85 Benefit: 75% = $97.40 85% = $110.40

(See para TN.8.4 of explanatory notes to this Category)

Multiple Operation Rule

Injection of one or more zygo-apophyseal or costo-transverse joints with one or more of contrast media, local anaesthetic or corticosteroid under image guidance

(Anaes.)

Fee: $115.35 Benefit: 75% = $86.55 85% = $98.05

(See para TN.7.5, TN.7.6, TN.8.4, TN.8.240 of explanatory notes to this Category)

Multiple Operation Rule

Intracranial parenchymal pressure monitoring device, insertion of—including burr hole (excluding after care)

(Anaes.)

Fee: $397.50 Benefit: 75% = $298.15

(See para TN.8.4, TN.8.166 of explanatory notes to this Category)

Multiple Operation Rule

Medial branch block of one or more primary posterior rami, injection of an anaesthetic agent under image guidance 

(Anaes.)

Fee: $132.00 Benefit: 75% = $99.00 85% = $112.20

(See para TN.7.6, TN.8.4 of explanatory notes to this Category)

Multiple Operation Rule

Left lumbar percutaneous zygapophyseal joint denervation by radio-frequency probe, or cryoprobe, using radiological imaging control

Applicable to one or more services provided in a single attendance, for not more than 3 attendances in a 12 month period

(Anaes.)

Fee: $283.35 Benefit: 75% = $212.55 85% = $240.85

(See para TN.8.4, TN.8.245 of explanatory notes to this Category)

Multiple Operation Rule

Right lumbar percutaneous zygapophyseal joint denervation by radio-frequency probe, or cryoprobe, using radiological imaging control

Applicable to one or more services provided in a single attendance, for not more than 3 attendances in a 12 month period

(Anaes.)

Fee: $283.35 Benefit: 75% = $212.55 85% = $240.85

(See para TN.8.4, TN.8.245 of explanatory notes to this Category)

Multiple Operation Rule

Left thoracic percutaneous zygapophyseal joint denervation by radio-frequency probe or cryoprobe using radiological imaging control

Applicable to one or more services provided in a single attendance, for not more than 3 attendances in a 12 month period

(Anaes.)

Fee: $314.85 Benefit: 75% = $236.15 85% = $267.65

(See para TN.8.4, TN.8.245 of explanatory notes to this Category)

Multiple Operation Rule

Right thoracic percutaneous zygapophyseal joint denervation by radio-frequency probe, or cryoprobe, using radiological imaging control

Applicable to one or more services provided in a single attendance, for not more than 3 attendances in a 12 month period

(Anaes.)

Fee: $314.85 Benefit: 75% = $236.15 85% = $267.65

(See para TN.8.4, TN.8.245 of explanatory notes to this Category)

Multiple Operation Rule

Right cervical percutaneous zygapophyseal joint denervation by radio-frequency probe, or cryoprobe, using radiological imaging control

Applicable to one or more services provided in a single attendance, for not more than 3 attendances in a 12 month period

(Anaes.)

Fee: $346.35 Benefit: 75% = $259.80 85% = $294.40

(See para TN.8.4, TN.8.245 of explanatory notes to this Category)

Multiple Operation Rule

Varicose veins, multiple injections of sclerosant using continuous compression techniques, including associated consultation, one or both legs, if:

(a) proximal reflux of 0.5 seconds or longer has been demonstrated; and

(b) the service is not for cosmetic purposes; and

(c) the service is not associated with:

(i) any other varicose vein operation on the same leg (excluding aftercare); or

(ii) a service on the same leg (excluding aftercare) to which any of the following items apply:

(A) 35200;

(B) 59970 to 60078;

(C) 60500 to 60509;

(D) 61109

Applicable to a maximum of 6 treatments in a 12 month period

(Anaes.)

Fee: $116.05 Benefit: 75% = $87.05 85% = $98.65

(See para TN.8.4, TN.8.32, TN.8.33, TN.8.228 of explanatory notes to this Category)

Multiple Operation Rule

INTRA-ABDOMINAL ARTERY OR VEIN, cannulation of, for infusion chemotherapy, by open operation (excluding aftercare)

(Anaes.) (Assist.)

Fee: $835.15 Benefit: 75% = $626.40

(See para TN.8.4 of explanatory notes to this Category)

Multiple Operation Rule

ARTERIAL CANNULATION for infusion chemotherapy by open operation, not being a service to which item 34521 applies (excluding after-care)

(Anaes.) (Assist.)

Fee: $437.20 Benefit: 75% = $327.90

(See para TN.8.4 of explanatory notes to this Category)

Multiple Operation Rule

HAEMATOMA, FURUNCLE, SMALL ABSCESS OR SIMILAR LESION not requiring admission to a hospital - INCISION WITH DRAINAGE OF (excluding aftercare)

Fee: $28.90 Benefit: 75% = $21.70 85% = $24.60

(See para TN.8.4 of explanatory notes to this Category)

Multiple Operation Rule

LARGE HAEMATOMA, LARGE ABSCESS, CARBUNCLE, CELLULITIS or similar lesion, requiring admission to a hospital, INCISION WITH DRAINAGE OF (excluding aftercare)

(Anaes.)

Fee: $172.25 Benefit: 75% = $129.20

(See para TN.8.4 of explanatory notes to this Category)

Multiple Operation Rule

Neurectomy or removal of tumour or neuroma from superficial peripheral nerve

(Anaes.) (Assist.)

Fee: $292.60 Benefit: 75% = $219.45 85% = $248.75

(See para TN.8.4, TN.8.254 of explanatory notes to this Category)

Multiple Operation Rule

NEURECTOMY, NEUROTOMY or removal of tumour from deep peripheral or cranial nerve, by open operation, not being a service to which item 41575, 41576, 41578 or 41579 applies

(Anaes.) (Assist.)

Fee: $500.85 Benefit: 75% = $375.65

(See para TN.8.4, TN.8.254 of explanatory notes to this Category)