Medicare Benefits Schedule - Item 35631

Operative laparoscopy, including any of the following:
(a) unilateral or bilateral ovarian cystectomy;
(b) salpingo-oophorectomy;
(c) salpingectomy for tubal pathology (including ectopic pregnancy by tubal removal or salpingostomy, but excluding sterilisation);
(d) excision of mild endometriosis;
not being a service associated with a service to which any other intraperitoneal or retroperitoneal procedure item (other than item 30724 or 30725) applies (H)

Multiple Operation Rule

(Anaes.) (Assist.)

Fee: $810.60 Benefit: 75% = $607.95

(See para TN.1.4, TN.8.2, TN.8.229, TN.8.248 of explanatory notes to this Category)

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Medicare benefits are not payable in respect of ANY other item in the Medicare Benefits Schedule, including Diagnostic Imaging and Pathology (with the exception of items 73384, 73385, 73386 and 73387) in lieu of or in connection with items 13200 - 13221.  Specifically, Medicare benefits are not payable for these items in association with items 104, 105, 14203, 14206, 35631, 35632, 35637, 35641, pathology tests (not including pathology items 73384, 73385, 73386 and 73387) or diagnostic imaging. 

A treatment cycle that is a series of treatments for the purposes of ART services is defined as beginning either on the day on which treatment by superovulatory drugs is commenced or on the first day of the patient's menstrual cycle, and ending either; not more than 30 days later, or if a service mentioned in item 13212, 13215 or 13221 is provided in connection with the series of treatments-on the day after the day on which the last of those services is provided. 

The date of service in respect of treatment covered by Items 13200, 13201, 13203, 13209 and 13218 is DEEMED to be the FIRST DAY of the treatment cycle. 

Items 13200, 13201, 13202 and 13203 are linked to the supply of hormones under the Section 100 (National Health Act) arrangements. Providers must notify Services Australia of Medicare card numbers of patients using hormones under this program, and hormones are only supplied for patients claiming one of these four items. 

Medicare benefits are not payable for assisted reproductive services rendered in conjunction with surrogacy arrangements where surrogacy is defined as 'an arrangement whereby a woman agrees to become pregnant and to bear a child for another person or persons to whom she will transfer guardianship and custodial rights at or shortly after birth'. 

NOTE: Items 14203 and 14206 are not payable for artificial insemination.

Related Items: 104 105 13200 13201 13202 13203 13209 13212 13215 13218 13221 14203 14206 35631 35632 35637 35641 66695 66698 66701 66704 66707 73384 73385 73386 73387 73521 73525

The fees for two or more operations, listed in Group T8 (other than Subgroup 12 of that Group), performed on a patient on the one occasion  are calculated by the following rule:‑

-               100% for the item with the greatest Schedule fee

plus 50% for the item with the next greatest Schedule fee

plus 25% for each other item.

Note:

(a)           Fees so calculated which result in a sum which is not a multiple of 5 cents are to be taken to the next higher multiple of 5 cents.

(b)           Where two or more operations performed on the one occasion have Schedule fees which are equal, one of these amounts shall be treated as being greater than the other or others of those amounts.

(c)           The Schedule fee for benefits purposes is the aggregate of the fees calculated in accordance with the above formula.

(d)           For these purposes the term "operation" only refers to all items in Group T8 (other than Subgroup 12 of that Group). 

This rule does not apply to an operation which is one of two or more operations performed under the one anaesthetic on the same patient if the medical practitioner who performed the operation did not also perform or assist at the other operation or any of the other operations, or administer the anaesthetic.  In such cases the fees specified in the Schedule apply. 

Where two medical practitioners operate independently and either performs more than one operation, the method of assessment outlined above would apply in respect of the services performed by each medical practitioner. 

If the operation comprises a combination of procedures which are commonly performed together and for which a specific combined item is provided in the Schedule, it is regarded as the one item and service in applying the multiple operation rule. 

There are a number of items in the Schedule where the description indicates that the item applies only when rendered in association with another procedure. The Schedule fees for such items have therefore been determined on the basis that they would always be subject to the "multiple operation rule". 

Where the need arises for the patient to be returned to the operating theatre on the same day as the original procedure for further surgery due to post-operative complications, which would not be considered as normal aftercare - see note TN.8.4, such procedures would generally not be subject to the "multiple operation rule".  Accounts should be endorsed to the effect that they are separate procedures so that a separate benefit may be paid. 

Extended Medicare Safety Net Cap 

The Extended Medicare Safety Net (EMSN) benefit cap for items subject to the multiple operations rule, where all items in that claim are subject to a cap are calculated from the abated (reduced) schedule fee. 

For example, if an item has a Schedule fee of $100 and an EMSN benefit cap equal to 80 per cent of the schedule fee, the calculated EMSN benefit cap would be $80.  However, if the schedule fee for the item is reduced by 50 per cent in accordance with the multiple operations rule provisions, and all items in that claim carry a cap, the calculated EMSN benefit cap for the item is $40 (50% of $100*80%). 

Related Items: 13241 31537 32222 32223 32224 32225 32226 32227 32228 32229 35591 35592 35609 35610 35631 35632 35668 35669 35671 35721 35724 35751 36504 36505 36507 36508 36836 37226

Appropriate documentation, ideally with photographic and/or histological evidence, is to be collected and retained to demonstrate the complexity of the procedure performed. Where photographic evidence is not retained, the reasons for this should be clearly documented.

Related Items: 35631 35632 35637 35641 35658 35750 35751 35753 35754 35756

For the purposes of any item in which an endometriosis grading is referenced the equivalent grade under the American Fertility Society (rAFS) endometriosis classification system is as follows:
Minimal endometriosis is the equivalent of stage I.
Mild endometriosis is the equivalent stage II.
Moderate endometriosis is the equivalent to stage III.
Servere endometriosis is the equivalent stage IV or higher.

Related Items: 35631 35632 35637 35641