Medicare Benefits Schedule - Note TN.8.97

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Category 3 - THERAPEUTIC PROCEDURES

TN.8.97

Breast Reconstruction - Large Muscle or Myocutaneous Flap - (Items 45530 and 45531)

When a prosthesis or prostheses are inserted in conjunction with this operation, benefit would be attracted under Item 45527 or 45529. Benefits would also be payable for nipple reconstruction (Item 45545) when performed.

When claiming item 45530 for a pedicled rectus abdominis flap; item 45571 should be claimed for closure of the abdomen and reconstruction of the umbilicus, including repair of the musculoaponeurotic layer of abdomen. When claiming item 45530 for a latissimus dorsi flap, no item for the closure of the musculoaponeurotic layer should be claimed as it is expected that repair will be by direct suture.

Lipectomy items 30166, 30169, 30177 and 30179 and radical abdominoplasty items 30175 and 30176 should not be claimed in association with post-mastectomy breast reconstruction items 45530 and 45531.

 

Related Items: 30166 30169 30175 30176 30177 30179 45527 45529 45530 45531 45571


Related Items

Category 3 - THERAPEUTIC PROCEDURES

45527

45527 - Additional Information

Item Start Date:
01-Dec-1991
Description Updated:
01-Jul-2023
Schedule Fee Updated:
01-Nov-2023

Breast reconstruction (unilateral), following mastectomy, using a permanent prosthesis, other than a service associated with a service to which item 45006 or 45012 applies (H)

(Anaes.) (Assist.)

Fee: $1,179.10 Benefit: 75% = $884.35

(See para TN.8.97 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

45530

45530 - Additional Information

Item Start Date:
01-Dec-1991
Description Updated:
01-Jul-2023
Schedule Fee Updated:
01-Nov-2023

Post-mastectomy breast reconstruction, autologous (unilateral), using a large muscle or myocutaneous flap, isolated on its vascular pedicle, excluding repair of muscular aponeurotic layer, other than a service associated with a service to which item 30166, 30169, 30175, 30176, 30177, 30179, 45006 or 45012 applies (H)

(Anaes.) (Assist.)

Fee: $1,210.10 Benefit: 75% = $907.60

(See para TN.8.8, TN.8.97 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

45529

45529 - Additional Information

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

Breast reconstruction (bilateral), following mastectomy, using permanent prostheses, other than a service associated with a service to which item 45006 or 45012 applies (H)

(Anaes.) (Assist.)

Fee: $2,063.35 Benefit: 75% = $1,547.55

(See para TN.8.97 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

45531

45531 - Additional Information

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

Post-mastectomy breast reconstruction, autologous (bilateral), using a large muscle or myocutaneous flap, isolated on its vascular pedicle, excluding repair of muscular aponeurotic layer, other than a service associated with a service to which item 30166, 30169, 30175, 30176, 30177, 30179, 45006 or 45012 applies (H)

(Anaes.) (Assist.)

Fee: $2,117.70 Benefit: 75% = $1,588.30

(See para TN.8.8, TN.8.97 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

45571

45571 - Additional Information

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

Closure of abdomen with reconstruction of umbilicus, with or without lipectomy, to be used following the harvest of an autologous flap, being a service associated with a service to which item 45530, 45531, 45562, 45564, 45565, 45567, 46080, 46082, 46084, 46086, 46088 or 46090 applies, including repair of the musculoaponeurotic layer of the abdomen (including insertion of prosthetic mesh if used) (H)

(Anaes.) (Assist.)

Fee: $1,139.20 Benefit: 75% = $854.40

(See para TN.8.8, TN.8.97 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

30166

30166 - Additional Information

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

Removal of redundant abdominal skin and lipectomy, as a wedge excision, for functional problems following significant weight loss equivalent to at least 5 body mass index points and if there has been a stable weight for a period of at least 6 months prior to surgery, other than a service associated with a service to which item 30175, 30176, 30177, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070, 46072, 46080, 46082, 46084, 46086, 46088 or 46090 applies (H)

(Anaes.) (Assist.)

Fee: $825.55 Benefit: 75% = $619.20

(See para TN.8.8, TN.8.97 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

30169

30169 - Additional Information

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

Removal of redundant non-abdominal skin and lipectomy for functional problems following significant weight loss equivalent to at least 5 body mass index points and if there has been a stable weight for a period of at least 6 months prior to surgery, one or 2 non-abdominal areas, other than a service associated with a service to which item 30175, 30176, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070, 46072, 46080, 46082, 46084, 46086, 46088 or 46090 applies (H)

(Anaes.) (Assist.)

Fee: $660.45 Benefit: 75% = $495.35

(See para TN.8.8, TN.8.97 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

30175

30175 - Additional Information

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

Radical abdominoplasty, with repair of rectus diastasis, excision of skin and subcutaneous tissue, and transposition of umbilicus, not being a laparoscopic procedure, if:
(a) the patient has an abdominal wall defect as a consequence of pregnancy; and
(b) the patient:

(i) has a diastasis of at least 3cm measured by diagnostic imaging prior to this service; and
(ii) has either or both of the following:

(A) at least moderately severe pain or discomfort at the site of the diastasis in the abdominal wall during functional use and the pain or discomfort has been documented in the patient’s records by the practitioner providing the service;
(B) low back pain or urinary symptoms likely due to rectus diastasis and the pain or symptoms have been documented in the patient’s records by the practitioner providing the service; and

(iii) has failed to respond to non-surgical conservative treatment, that must have included physiotherapy; and
(iv) has not been pregnant in the last 12 months; and

(c) the service is not a service associated with a service to which item 30166, 30169, 30176, 30177, 30179, 30651, 30655, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070, 46072, 46080, 46082, 46084, 46086, 46088 or 46090 applies
Applicable once per lifetime (H)

(Anaes.) (Assist.)

Fee: $1,067.80 Benefit: 75% = $800.85

(See para TN.8.8, TN.8.97, TN.8.276 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

30176

30176 - Additional Information

Item Start Date:
01-Jan-2016
Description Updated:
01-Jul-2023
Schedule Fee Updated:
01-Nov-2023

Radical abdominoplasty, with excision of skin and subcutaneous tissue, repair of musculoaponeurotic layer and transposition of umbilicus, not being a service associated with a service to which item 30166, 30169, 30175, 30177, 30179, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070 or 46072 applies, if the patient has previously had a massive intra-abdominal or pelvic tumour surgically removed (H)

(Anaes.) (Assist.)

Fee: $1,084.90 Benefit: 75% = $813.70

(See para TN.8.97 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

30177

30177 - Additional Information

Item Start Date:
01-Dec-1991
Description Updated:
01-Jul-2023
Schedule Fee Updated:
01-Nov-2023

Lipectomy, excision of skin and subcutaneous tissue associated with redundant abdominal skin and fat that is a direct consequence of significant weight loss, in conjunction with a radical abdominoplasty, with or without repair of musculoaponeurotic layer and transposition of umbilicus, not being a service associated with a service to which item 30166, 30175, 30176, 30179, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070, 46072, 46080, 46082, 46084, 46086, 46088 or 46090 applies, if:

(a) there is intertrigo or another skin condition that risks loss of skin integrity and has failed 3 months of conventional (or non-surgical) treatment; and

(b) the redundant skin and fat interferes with the activities of daily living; and

(c) the weight has been stable for at least 6 months following significant weight loss prior to the lipectomy

(H)

(Anaes.) (Assist.)

Fee: $1,084.90 Benefit: 75% = $813.70

(See para TN.8.8, TN.8.97 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

30179

30179 - Additional Information

Item Start Date:
01-Jan-2016
Description Updated:
01-Jul-2023
Schedule Fee Updated:
01-Nov-2023

Circumferential lipectomy, as an independent procedure, to correct circumferential excess of redundant skin and fat that is a direct consequence of significant weight loss, with or without a radical abdominoplasty, not being a service associated with a service to which item 30175, 30176, 30177, 45530, 45531, 45564, 45565, 45567, 46060, 46062, 46064, 46066, 46068, 46070, 46072, 46080, 46082, 46084, 46086, 46088 or 46090 applies, if:

(a) the circumferential excess of redundant skin and fat is complicated by intertrigo or another skin condition that risks loss of skin integrity and has failed 3 months of conventional (or non-surgical) treatment; and

(b) the circumferential excess of redundant skin and fat interferes with the activities of daily living; and

(c) the weight has been stable for at least 6 months following significant weight loss prior to the lipectomy

(H)

(Anaes.) (Assist.)

Fee: $1,335.30 Benefit: 75% = $1,001.50

(See para TN.8.8, TN.8.97 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