Medicare Benefits Schedule - Note TR.8.5

Clause 5.10.17D Restriction on items 38244, 38247, 38248, 38249, 38251, 38252, 38307, 38308, 38310, 38311, 38313, 38314, 38320, 38322, 38323, 38316, 38317 and 38319—reports and clinical notes

Items 38244, 38247, 38248, 38249, 38251, 38252, 38307, 38308, 38310, 38311, 38313, 38314, 38320, 38322, 38323, 38316, 38317 and 38319 apply to a service provided to a patient only if a report or clinical note:

(a) is prepared for the service; and

(b) includes documentation that demonstrates how the item applies to the service, including how the patient is eligible for the service.

Related Items: 38244 38247 38248 38249 38251 38252 38307 38308 38310 38311 38313 38314 38316 38317 38319 38320 38322 38323

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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)

Multiple Operation Rule

Note: (stable coronary syndrome) the service only applies if the patient meets the requirements of the descriptor and the of Note: TR.8.3 and TR.8.5

Selective coronary angiography:

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

(b) as part of the management of the patient; and

(c) with placement of catheters and injection of opaque material into native coronary arteries; 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, 38247, 38249, 38251 or 38252 applies—applicable each 3 months

(Anaes.)

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

(See para TN.8.215, TR.8.3, TR.8.5, TR.8.6 of explanatory notes to this Category)

Multiple Operation Rule

Note: (stable coronary syndrome - graft) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.3 and TR.8.5

Selective coronary and graft angiography:

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

(b) as part of the management of the patient; and

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

(d) 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

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

(f) including all associated imaging;

other than a service associated with a service to which item 38200, 38203, 38206, 38244, 38247, 38248, 38251 or 38252 applies—applicable once each 3 months

(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.8.3, TR.8.5, TR.8.6 of explanatory notes to this Category)

Multiple Operation Rule

Note: (pre-operative assessment) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.5

Selective coronary angiography:

(a) for a symptomatic patient with valvular or other non-coronary structural heart disease; and

(b) as part of the management of the patient for:

(i) pre-operative assessment for planning non-coronary cardiac surgery, including by transcatheter approaches; or

(ii) evaluation of valvular heart disease or other non-coronary structural heart disease where clinical impression is discordant with non-invasive assessment; and

(c) with placement of catheters and injection of opaque material into native coronary arteries; 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, 38247, 38248, 38249 or 38252 applies—applicable once each 12 months

(Anaes.)

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

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

Multiple Operation Rule

Note: (pre-operative assessment - graft) the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: TR.8.5

Selective coronary and graft angiography:

(a) for a symptomatic patient with valvular or other non-coronary structural heart disease; and

(b) as part of the management of the patient for:

(i) pre-operative assessment for planning non-coronary cardiac surgery, including by transcatheter approaches; or

(ii) evaluation of valvular heart disease or other non-coronary structural heart disease where clinical impression is discordant with non-invasive assessment; and

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

(d) 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

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

(f) including all associated imaging;

other than a service associated with a service to which item 38200, 38203, 38206, 38244, 38247, 38248, 38249 or 38251 applies—applicable once each 12 months

(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.8.5 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: (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)

Multiple Operation Rule

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)

Multiple Operation Rule

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)

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)

Multiple Operation Rule

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)

Multiple Operation Rule

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)

Multiple Operation Rule

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)