Medicare Benefits Schedule - Item 38522

Search Results for Item 38522

View Associated Notes

Category 3 - THERAPEUTIC PROCEDURES

38522

38522 - Additional Information

Item Start Date:
01-Jul-2022
Description Updated:
01-Jan-2024
Schedule Fee Updated:
01-Jul-2024

Group
T8 - Surgical Operations
Subgroup
6 - Cardio-Thoracic
Subheading
7 - Valvular Procedures

TAVI, for the treatment of symptomatic severe native calcific aortic stenosis, performed via transfemoral delivery, unless transfemoral delivery is contraindicated or not feasible, if:

(a) the TAVI Patient is at low risk for surgery; and

(b) the service:

      (i) is performed by a TAVI Practitioner in a TAVI Hospital; and

      (ii) includes all intraoperative diagnostic imaging that the TAVI Practitioner performs upon the TAVI Patient; and

      (iii) includes valvuloplasty, if required;

not being a service which has been rendered within 5 years of a service to which this item or item 38495 or 38514 applies (H)

Multiple Operation Rule

(Anaes.) (Assist.)

Fee: $1,631.65 Benefit: 75% = $1,223.75

(See para AN.33.1, TN.8.135, TN.8.278 of explanatory notes to this Category)


Associated Notes

Category 1 - PROFESSIONAL ATTENDANCES

AN.33.1

TAVI CASE CONFERENCE - (ITEMS 6080 AND 6081)

Items 6080 and 6081 apply to a TAVI Case Conference organised to discuss a patient’s suitability to receive the service described in items 38495 or 38514 for Transcatheter Aortic Valve Implantation (TAVI). 

For items 6080 and 6081 a TAVI Case Conference is a process by which:

(a)    there is a team of 3 or more participants, where:

        (i)     the first participant is a cardiothoracic surgeon; and

        (ii)    the second participant is an interventional cardiologist; and

        (iii)   the third participant is a specialist or consultant physician who does not perform a service described in items 38495 or 38514 for the patient being assessed; and

        (iv)   either the first or the second participant is also a TAVI Practitioner; and

(b)    the team assesses a patient’s risk and technical suitability to receive the service described in items 38495 or 38514, taking into account matters such as:

        (i)      the patient’s risk and technical suitability for a surgical aortic valve replacement; and

        (ii)     the patient’s cognitive function and frailty; and

(c)    the result of the assessment is that the team makes a recommendation about whether or not the patient is suitable to receive the service described in item 38495 or item 38514; and

(d)    the particulars of the assessment and recommendation are recorded in writing.  

TAVI Practitioner

For items 6080 and 6081 a TAVI Practitioner is either a cardiothoracic surgeon or interventional cardiologist who is accredited by Cardiac Accreditation Services Limited.  

Accreditation by Cardiac Accreditation Services Limited must be valid prior to the service being undertaken in order for benefits to be payable under items 38495 or 38514.  

The process for accreditation and re-accreditation is outlined in the Transcatheter Aortic Valve Implantation - Rules for the Accreditation of TAVI Practitioners, issued by Cardiac Accreditation Services Limited, and is available on the Cardiac Accreditation Services Limited website, www.tavi.org.au. 

Cardiac Accreditation Services Limited is a national body comprising representatives from the Australian & New Zealand Society of Cardiac & Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). 

Coordination of a TAVI Case Conference

For item 6080, coordination means undertaking all of the following activities in relation to a TAVI Case Conference:

  1. ensuring that the patient is aware of the purpose and nature of the patient’s TAVI Case Conference and has consented to their TAVI Case Conference;
  2. recording the day the conference was held, and the times the conference started and ended;
  3. recording the names of the participants of the conference;
  4. provision of expertise to inform the recommendation resulting from the case conference;
  5. recording minutes of the TAVI Case Conference including the recommendation resulting from the conference;
  6. ensuring that the patient is aware of  the recommendation. 

Attendance at a TAVI Case Conference

For item 6081, attendance means undertaking all of the following activities in relation to a TAVI Case Conference:

  1. retaining a record of the day the conference was held, and the times the conference started and ended;
  2. retaining a record of the names of the participants;
  3. provision of expertise to inform the recommendation resulting from the case conference;
  4. retaining a record of the recommendation resulting from  the conference.

General requirements

The TAVI Case Conference must be arranged in advance, within a time frame that allows for all the participants to attend.  A TAVI Case Conference is to last at least 10 minutes and a minimum of three suitable participants (as defined under the item requirements), must be present for the whole of the case conference. All participants must be in communication with each other throughout the conference, either face to face, by telephone or by video link, or a combination of these. 

A record of the TAVI Case Conference which contains: a list of the participants; the times the conference commenced and concluded; a description of the assessment of suitability; and a summary of the outcomes must be kept in the patient's record. The notes and summary of outcomes must be provided to all participants. 

Prior informed consent must be obtained from the patient, or the patient's agent. In obtaining informed consent the TAVI Practitioner coordinating the TAVI Case Conference should ensure the patient has been:

  • Informed that their medical history, diagnosis and care preferences will be discussed with other case conference participants;
  • Informed that they may incur a charge for the service for which a Medicare rebate will be payable.

Medicare benefits are only payable in respect of the service provided by the coordinating TAVI Practitioner or the attending interventional cardiologist, cardiothoracic surgeon or independent specialist or consultant physician. Benefits are not payable for another medical practitioner organising a case conference or for attendance by other medical practitioners at a TAVI Case Conference.

It is expected that a patient would not normally require more than one TAVI Case Conference in determining suitability for the services described in items 38495 or 38514.  As such, item 6080 is only payable once per patient in a five year period.  Item 6081 is payable only twice per patient in a five year period.

Items 6080 and 6081 do not preclude the claiming of a consultation on the same day if other clinically relevant services are provided. 

Related Items: 6080 6081 38495 38514 38522

Category 3 - THERAPEUTIC PROCEDURES

TN.8.135

Transcatheter Aortic Valve Implantation (Item 38495)

Items 38495 (high-risk), 38514 (intermediate-risk) and 38522 (low-risk with native calcific aortic stenosis) apply only to a service for Transcatheter Aortic Valve Implantation (TAVI) for the treatment of symptomatic severe aortic stenosis (items 38495 & 38514) and Transcatheter Aortic Valve Implantation (TAVI) for the treatment of symptomatic severe native calcific aortic stenosis, that is to be provided in a TAVI Hospital by a TAVI Practitioner on a TAVI patient.

TAVI Hospital

For items 38495, 38514 and 38522 a TAVI Hospital means a hospital, as defined by subsection 121-5(5) of the Private Health Insurance Act 2007, that is clinically accepted as being a suitable hospital in which the service described in items 38495, 38514 or 38522 may be performed.

The Transcatheter Aortic Valve Implantation - Rules for the Accreditation of TAVI Practitioners developed by Cardiac Accreditation Services Limited provides guidance on what are considered by the sector as minimum requirements that must be met in order to be a clinically acceptable facility that is suitable for TAVI procedures to be performed at. 

Transcatheter Aortic Valve Implantation - Rules for the Accreditation of TAVI Practitioners can be accessed via www.tavi.org.au. 

TAVI Practitioner

For items 38495, 38514 and 38522 a TAVI Practitioner is either a cardiothoracic surgeon or interventional cardiologist who is accredited by Cardiac Accreditation Services Limited. 

Accreditation by Cardiac Accreditation Services Limited must be valid prior to the service being undertaken in order for benefits to be payable under items 38495, 38514 and 38522.  

The process for accreditation and re-accreditation is outlined in the Transcatheter Aortic Valve Implantation - Rules for the Accreditation of TAVI Practitioners, issued by Cardiac Accreditation Services Limited, and is available on the Cardiac Accreditation Services Limited website, www.tavi.org.au. 

Cardiac Accreditation Services Limited is a national body comprising representatives from the Australian & New Zealand Society of Cardiac & Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). 

TAVI Patient

A TAVI Patient means a patient who, as a result of a TAVI Case Conference, has been assessed as having one of the following:

  1. an unacceptably high risk for surgical aortic valve replacement and is recommended as being suitable to receive the service described in item 38495; or
  2. has been assessed as having an intermediate risk for surgical aortic valve replacement and is recommended as being suitable to receive the service described in item 38514; or
  3. has been assessed as having a low risk for surgical aortic valve replacement (with native calcific aortic stenosis) and is recommended as being suitable to receive the service described in item 38522

A TAVI Case Conference is a process by which:

(a)    there is a team of 3 or more participants, where:

        (i)     the first participant is a cardiothoracic surgeon; and

        (ii)    the second participant is an interventional cardiologist; and

        (iii)   the third participant is a specialist or consultant physician who does not perform a service described in items 38495, 38514 or 38522 for the patient being assessed; and

        (iv)   either the first or the second participant is also a TAVI Practitioner; and

(b)    the team assesses a patient’s risk and technical suitability to receive the service described in item 38495, item 38514 or item 38522, taking into account matters such as:

        (i)      the patient’s risk and technical suitability for a surgical aortic valve replacement; and

        (ii)     the patient’s cognitive function and frailty; and

(c)    the result of the assessment is that the team makes a recommendation about whether or not the patient is suitable to receive the service described in item 38495, 38514 or 38522; and

(d)    the particulars of the assessment and recommendation are recorded in writing.

While benefits are payable for an eligible TAVI Case Conference under Items 6080 and 6081, a claim for these services does not have to be made in order for a benefit to be paid under items 38495, 38514 or 38522.  Item 38495, item 38514 or item 38522 are only payable once per patient in a five year period. E.g. if a patient has received a rebate for item 38495 then they cannot receive a rebate for items 38495, 38514 or 38522 for 5 years. 

Related Items: 6080 6081 38495 38514 38522

Category 3 - THERAPEUTIC PROCEDURES

TN.8.278

Balloon valvuloplasty co-claiming restriction with Transcatheter Aortic Valve Implantation (TAVI) items

The services performed under TAVI items (38495, 38514 and 38522) are complete medical services and include balloon valvuloplasty as part of the TAVI procedural service. MBS item 38270 for balloon valvuloplasty cannot be co-claimed with the TAVI items for the same occasion of service.

Accompanying text is required for claims where a TAVI item and item 38270 are performed on the same day at separate occasions. Suitable texts could include "separate attendances" or "10 AM and 3PM".

Providers are legally responsible for services billed under their provider number or their own name. This includes any incorrect billing of services that result in overpayment of Medicare benefits, regardless of who does the billing or receives the benefit.

Related Items: 38270 38495 38514 38522


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