Medicare Benefits Schedule - Note TR.8.2

Clause 5.10.17A Items 38244, 38247, 38307, 38308, 38310, 38316, 38317 and 38319—patient eligibility and timing

(1) A patient is eligible for a service to which item 38244, 38247, 38307, 38308, 38310, 38316, 38317 or 38319 applies if:

(a) subclause (2) applies to the patient; and

(b) a service to which the item applies has not been provided to the patient in the previous 3 months, unless:

(i) the patient experiences a new acute coronary syndrome or angina, as described in paragraph (2)(a), (b) or (c), in that period; or

(ii) for a service to which item 38316, 38317 or 38319 applies—the service was provided to the patient in that period as a subsequent stage following an initial primary percutaneous coronary intervention procedure.

(2) This subclause applies to a patient who has:

(a) an acute coronary syndrome evidenced by any of the following:

(i) ST segment elevation;

(ii) new left bundle branch block;

(iii) troponin elevation above the local upper reference limit;

(iv) new resting wall motion abnormality or perfusion defect;

(v) cardiogenic shock;

(vi) resuscitated cardiac arrest;

(vii) ventricular fibrillation;

(viii) sustained ventricular tachycardia; or

(b) unstable angina or angina equivalent with a crescendo pattern, rest pain or other high-risk clinical features, such as hypotension, dizziness, pallor, diaphoresis or syncope occurring at a low threshold; or

(c) either of the following, detected on computed tomography coronary angiography:

(i) significant left main coronary artery disease with greater than 50% stenosis or a cross-sectional area of less than 6 mm2;

(ii) severe proximal left anterior descending coronary artery disease (with stenosis of more than 70% or a cross-sectional area of less than 4 mm2 before the first major diagonal branch).

Related Items: 38244 38247 38307 38308 38310 38316 38317 38319 57364

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Multiple Operation Rule

Note: (acute coronary syndrome) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.2  and TR.8.5

Selective coronary angiography:

(a) for a patient who is eligible for the service under clause 5.10.17A; and

(b) with placement of one or more catheters and injection of opaque material into native coronary arteries; and

(c) with or without left heart catheterisation, left ventriculography or aortography; and

(d) including all associated imaging;

other than a service associated with a service to which 38200, 38203, 38206, 38247, 38248, 38249, 38251 or 38252 applies

(Anaes.)

Fee: $973.20 Benefit: 75% = $729.90 85% = $874.50

(See para TN.8.215, TR.8.2, TR.8.5 of explanatory notes to this Category)

Multiple Operation Rule

Note: (acute coronary syndrome - graft) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.2 and TR.8.5

Selective coronary and graft angiography:

(a) for a patient who is eligible for the service under clause 5.10.17A; and

(b) with placement of one or more catheters and injection of opaque material into the native coronary arteries; and

(c) if free coronary grafts attached to the aorta or direct internal mammary artery grafts are present—with placement of one or more catheters and injection of opaque material into those grafts (irrespective of the number of grafts); and

(d) with or without left heart catheterisation, left ventriculography or aortography; and

(e) including all associated imaging;

other than a service associated with a service to which item 38200, 38203, 38206, 38244, 38248, 38249, 38251 or 38252 applies

(Anaes.)

Fee: $1,559.20 Benefit: 75% = $1,169.40 85% = $1,460.50

(See para IN.2.1, TN.8.215, TN.8.216, TR.8.2, TR.8.5 of explanatory notes to this Category)

Bulk bill incentive

Note: the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.3 (item 38247), TR.8.2 (item 38249) or item 38252 if subclause (iv) applies.

Computed tomography of the coronary arteries performed on a minimum of a 64 slice (or equivalent) scanner, if:

(a) the service is requested by a specialist or consultant physician; and

(b) at least one of the following apply to the patient:

(i) the patient has stable symptoms and newly recognised left ventricular systolic dysfunction of unknown aetiology;

(ii) the patient requires exclusion of coronary artery anomaly or fistula;

(iii) the patient will be undergoing non-coronary cardiac surgery;

(iv) the patient meets the criteria to be eligible for a service to which item 38247, 38249 or 38252 applies, but as an alternative to selective coronary angiography will require an assessment of the patency of one or more bypass grafts

(R) 

(Anaes.)

Fee: $758.30 Benefit: 75% = $568.75 85% = $659.60

(See para IN.0.19, IN.2.1, TR.8.2, TR.8.3, TR.8.6 of explanatory notes to this Category)

Multiple Operation Rule

Note: (acute coronary syndrome - 1 coronary territory with selective coronary angiography)  the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.2 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17A; 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;

(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, 38308, 38310, 38311, 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.8.217, TN.8.225, TR.8.2, TR.8.5 of explanatory notes to this Category)

Multiple Operation Rule

Note: (acute coronary syndrome - 2 coronary territories with selective coronary angiography) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.2 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17A; 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, 38310, 38311, 38313, 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.8.217, TN.8.225, TR.8.2, TR.8.5 of explanatory notes to this Category)

Multiple Operation Rule

Note: (acute coronary syndrome - 3 coronary territories with selective coronary angiography) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.2 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17A; 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, 38311, 38313, 38314, 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.8.217, TN.8.225, TR.8.2, TR.8.5 of explanatory notes to this Category)

Multiple Operation Rule

Note: (acute coronary syndrome - 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.8.2 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17A; 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, 38317, 38319, 38320, 38322 or 38323 applies 

(Anaes.) (Assist.)

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

(See para TN.8.217, TN.8.225, TR.8.2, TR.8.5 of explanatory notes to this Category)

Multiple Operation Rule

Note: (acute coronary syndrome - 2 coronary territories without selective angiography) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.2 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17A; 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, 3808, 38310, 38311, 38313, 38314, 38316, 38319, 38320, 38322 or 38323 applies 

(Anaes.) (Assist.)

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

(See para TN.8.217, TN.8.225, TR.8.2, TR.8.5 of explanatory notes to this Category)

Multiple Operation Rule

Note: (acute coronary syndrome - 3 coronary territories without selective angiography) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.2 and TR.8.5

Percutaneous coronary intervention:

(a) for a patient:

(i) eligible for the service under clause 5.10.17A; 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, 38320, 38322 or 38323 applies 

(Anaes.) (Assist.)

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

(See para TN.8.217, TN.8.225, TR.8.2, TR.8.5 of explanatory notes to this Category)