Medicare Benefits Schedule - Note TN.8.98

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Category 3 - THERAPEUTIC PROCEDURES

TN.8.98

Breast Prosthesis, Removal and Replacement of - (Items 45553 and 45554)

It is generally expected that the replacement prosthesis will be the same size as the prosthesis that is removed. Medicare benefits are not payable for services under items 45553-45554 where the procedure is performed solely to increase breast size.

Where the original implant was not inserted in the context of breast cancer or developmental abnormality, intra-operative photographs of the patient in the supine position need to demonstrate unacceptable deformity in the form of a discrete concavity to justify use of 45553 or 45554.

In the context of eligibility for item 45553 and 45554, an unacceptable deformity would not include asymmetry caused as a result of removal of one implant out of a pair of implants.

Where a rupture has been established through imaging and reported, items 45553 and 45554 will still apply even if intra-operatively the implant is found to be structurally intact.

Full clinical details must be documented in patient notes, including pre-operative photographic and / or diagnostic imaging evidence demonstrating the clinical need for the service as this may be subject to audit.

Related Items: 45553 45554


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Category 3 - THERAPEUTIC PROCEDURES

45553

45553 - Additional Information

Item Start Date:
01-Nov-2006
Description Updated:
01-Nov-2018
Schedule Fee Updated:
01-Jul-2021

Breast prosthesis, removal of and replacement with another prosthesis, following medical complications (for rupture, migration of prosthetic material or symptomatic capsular contracture), if:

(a) either:

(i) it is demonstrated by intra-operative photographs post-removal that removal alone would cause unacceptable deformity; or

(ii) the original implant was inserted in the context of breast cancer or developmental abnormality; and

(b) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes

(Anaes.) (Assist.)

Fee: $594.75 Benefit: 75% = $446.10

(See para TN.8.98 of explanatory notes to this Category)

Category 3 - THERAPEUTIC PROCEDURES

45554

45554 - Additional Information

Item Start Date:
01-Dec-1991
Description Updated:
01-Nov-2018
Schedule Fee Updated:
01-Jul-2021

Breast prosthesis, removal and replacement with another prosthesis, following medical complications (for rupture, migration of prosthetic material or symptomatic capsular contracture), including excision of at least half of the fibrous capsule or formation of a new pocket, or both, if:

(a) either:

(i) it is demonstrated by intra-operative photographs post-removal that removal alone would cause unacceptable deformity; or

(ii) the original implant was inserted in the context of breast cancer or developmental abnormality; and

(b) the excised specimen is sent for histopathology and the volume removed is documented in the histopathology report; and

(c) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes

(Anaes.) (Assist.)

Fee: $727.80 Benefit: 75% = $545.85

(See para TN.8.98 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