Medicare Benefits Schedule - Item 12250

Search Results for Item 12250

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Category 2 - DIAGNOSTIC PROCEDURES AND INVESTIGATIONS

12250

12250 - Additional Information

Item Start Date:
01-Oct-2008
Description Updated:
01-Mar-2021
Schedule Fee Updated:
01-Jul-2024

Group
D1 - Miscellaneous Diagnostic Procedures And Investigations
Subgroup
10 - Other Diagnostic Procedures And Investigations

Overnight investigation of sleep for at least 8 hours of a patient aged 18 years or more to confirm diagnosis of obstructive sleep apnoea, if:

(a) either:

(i) the patient has been referred by a medical practitioner to a qualified adult sleep medicine practitioner or a consultant respiratory physician who has determined that the patient has a high probability for symptomatic, moderate to severe obstructive sleep apnoea based on a STOP‑Bang score of 3 or more, an OSA50 score of 5 or more or a high risk score on the Berlin Questionnaire, and an Epworth Sleepiness Scale score of 8 or more; or

(ii) following professional attendance on the patient (either face‑to‑face or by video conference) by a qualified adult sleep medicine practitioner or a consultant respiratory physician, the qualified adult sleep medicine practitioner or consultant respiratory physician determines that investigation is necessary to confirm the diagnosis of obstructive sleep apnoea; and

(b) during a period of sleep, there is continuous monitoring and recording, performed in accordance with current professional guidelines, of the following measures:

(i) airflow;

(ii) continuous EMG;

(iii) continuous ECG;

(iv) continuous EEG;

(v) EOG;

(vi) oxygen saturation;

(vii) respiratory effort; and

(c) the investigation is performed under the supervision of a qualified adult sleep medicine practitioner; and

(d) either:

(i) the equipment is applied to the patient by a sleep technician; or

(ii) if this is not possible—the reason it is not possible for the sleep technician to apply the equipment to the patient is documented and the patient is given instructions on how to apply the equipment by a sleep technician supported by written instructions; and

(e) polygraphic records are:

(i) analysed (for assessment of sleep stage, arousals, respiratory events and cardiac abnormalities) with manual scoring, or manual correction of computerised scoring in epochs of not more than 1 minute; and

(ii) stored for interpretation and preparation of a report; and

(f) interpretation and preparation of a permanent report is provided by a qualified adult sleep medicine practitioner with personal direct review of raw data from the original recording of polygraphic data from the patient; and

(g) the investigation is not provided to the patient on the same occasion that a service mentioned in any of items 11000, 11003, 11004, 11005, 11503, 11704, 11705, 11707, 11714, 11716, 11717, 11723, 11735 and 12203 is provided to the patient

Applicable only once in any 12 month period

Fee: $381.95 Benefit: 75% = $286.50 85% = $324.70

(See para DN.1.17 of explanatory notes to this Category)


Associated Notes

Category 2 - DIAGNOSTIC PROCEDURES AND INVESTIGATIONS

DN.1.17

Investigations for sleep disorders (Items 12203 to 12250)

 

 

MBS Item Service Type Study Level Applicable Guidelines
12203 Adult sleep study in Laboratory 1

Guidelines for the performance of sleep studies in adults – a position statement of the Australasian Sleep Association

The American Academy of Sleep Medicine (AASM) Manual for the Scoring of Sleep and Associated Events: rules, terminology and technical specifications relating to the provision of polysomnography (PSG)

An Australian Commentary on the AASM Manual for the Scoring of Sleep and Associated Events relating to the provision of polysomnography (PSG)

12204 1
12205 1
12207 1
12208 1
12210 Paediatric sleep study in laboratory 1
12213 1
12215 1
12217 1
12250 Adult sleep study - unattended 2

NB. Currently there are no MBS items available for levels 3 and 4 sleep studies.

Current Professional Guidelines:

Items 12203 to 12250 require the continuous monitoring and recording of all listed parameters that are measured and performed in accordance with the current professional guidelines.

This means practitioners are required to ensure they are able to meet the polysomnography (PSG) requirements including technical specifications and electrode placements in the following documents:

·       Guidelines for the performance of sleep studies in adults – a position statement of the Australasian Sleep Association. Refer to the document under the heading Sleep Studies in Adults - Position statements (sleep.org.au)

·       The American Academy of Sleep Medicine (AASM) Manual for the Scoring of Sleep and Associated Events: rules, terminology and technical specifications (you will require an account to access this resource). Refer to the section Sleep Staging Rules in the AASM Scoring Manual - American Academy of Sleep Medicine

·       An Australian Commentary on the AASM Manual for the Scoring of Sleep and Associated Events. Refer to the document under the heading Scoring of Sleep and Associated Events - Position statements (sleep.org.au)

Please note that for MBS purposes Home Sleep Apnoea Test (HSAT) requirements in the above documents apply to levels 3 and 4 sleep studies and are therefore not applicable for MBS items 12203 to 12250.

Referral Criteria in items 12203 and 12250

Items 12203 and 12250 are applicable for patients who require a diagnostic sleep study. They enable direct GP referral to a diagnostic sleep study without personal assessment by a sleep or respiratory physician, when validated screening questionnaires suggest a high pre-test probability for diagnosis of symptomatic, moderate to severe obstructive sleep apnoea (OSA). The screening questionnaires should be administered by the referring practitioner. Alternatively, the need for testing can be determined by a sleep or respiratory physician following direct clinical assessment (either face-to-face or by video conference).

Screening Questionnaires 

For the purpose of items 12203 or 12250, a high probability for symptomatic, moderate to severe OSA would be indicated by one of the following clinical screening tool outcomes:

  • STOP-Bang score of 3 or more AND an Epworth Sleepiness Scale score of 8 or more;

OR

  • OSA50 score of 5 or more AND an Epworth Sleepiness Scale score of 8 or more;

OR

  • high risk score on the Berlin Questionnaire AND an Epworth Sleepiness Scale score of 8 or more.

The STOP-Bang, OSA50, Berlin questionnaires and Epworth Sleepiness Scale can be accessed on the American Thoracic Society website (www.thoracic.org/members/assemblies/assemblies/srn/questionaires/), and the Australasian Sleep Association’s position statements can be found on their website (https://sleep.org.au/Public/Public/Resource-Centre/Position-statements.aspx).

Evidence of the screening tests being administered to the patient in full, including screening test scores must be recorded in the patient’s clinical record as this may be subject to audit.

Please note that the presence of a high probability for symptomatic, moderate to severe obstructive sleep apnoea in a patient does not mean a study can be provided under either 12203 or 12250 utilising the HSAT guidelines. The service being delivered must meet all the requirements contained in the MBS item number being claimed regardless of patient risk for obstructive sleep apnoea (which would be in accordance with the PSG guidelines).

Referrals for attended (Level 1) or unattended (level 2) diagnostic studies

Where a patient with suspected OSA has been directly referred for a Level 1 sleep study under item 12203, but there is insufficient information to indicate if there are any contraindications for a Level 2 study, the following options are available:

The patient can be assessed by a qualified sleep medicine practitioner or consultant respiratory physician to determine the most suitable study (i.e. Level 1 or Level 2); or
The validated screening questionnaires can be administered to the patient by the sleep medicine practitioner, sleep technician or practice staff. If the screening questionnaires indicate a high pre-test probability for the diagnosis of symptomatic, moderate to severe OSA, the sleep provider can either – arrange for the patient to have a Level 2 study (notifying the referring practitioner of this decision); or seek additional information from the referring practitioner on why a Level 1 study is required (e.g. whether the patient has any contraindications for a Level 2 study). If there remains any uncertainty about the type of study which the patient should receive, a qualified sleep medicine practitioner or consultant respiratory physician should assess the patient.   

Referrals made without (or incomplete) screening questionnaires (Items 12203 and 12250)

If a patient has been directly referred to a qualified sleep medicine practitioner or consultant respiratory physician without the use of the screening questionnaires, the screening questionnaires can be administered to the patient by the sleep provider (e.g. by a sleep technician or other practice staff). Where the screening questionnaires have been provided with the referral, but they are incomplete, the sleep provider may wish to contact the patient to determine what their responses were to the relevant questions. 

Attended (Level 1 study) versus unattended (Level 2 study) sleep studies

Determination of the need for a sleep study should conform with Australasian Sleep Association guidelines.

Unattended sleep studies are suitable for many patients with suspected OSA but patients with other sleep disorders should undergo an attended study. Assessment for potential contraindications to an unattended sleep study can be undertaken by either the referring practitioner, qualified adult sleep medicine practitioner or consultant respiratory physician. Standardised referrals should request sufficient information to enable such assessment.

In accordance with the Australasian Sleep Association’s Guidelines for Sleep Studies in Adults, relative contraindications for an unattended sleep study to investigate suspected OSA include but are not limited to:

(a) intellectual disability or cognitive impairment;

(b) physical disability with inadequate carer attendance;

(c) significant co-morbid conditions including neuromuscular disease, heart failure or advanced respiratory disease where more complex disorders are likely;

(d) suspected respiratory failure where attended measurements are required, including measurement of carbon dioxide partial pressures;

(e) suspected parasomnia or seizure disorder;

(f) suspected condition where recording of body position is considered to be essential and would not be recorded as part of an unattended sleep study;

(g) previously failed or inconclusive unattended sleep study;

(h) unsuitable home environment including unsafe environments or where patients are homeless; and

(i) consumer preference based on a high level of anxiety about location of study or where there is unreasonable cost or disruption based on distance to be travelled, or home circumstances.

Patients who have these features may be suitable for either attended (Level 1) or unattended (Level 2) studies.

Treatment options following diagnostic sleep study

The results and treatment options following any diagnostic sleep study should be discussed during a professional attendance with a medical practitioner before the initiation of any therapy. If there is uncertainty about the significance of diagnostic sleep study results or the appropriate management for that individual then referral to a sleep or respiratory medicine specialist is recommended.

Any professional attendance by a qualified sleep medicine practitioner or consultant respiratory physician associated with this service may be undertaken face-to-face or by video conference.

Meaning of ‘at least 8 hours’

The requirement ‘for at least 8 hours’ means the overnight investigation (including patient set-up time and actual period of recording) must be of at least 8 hours duration. Providers must keep evidence of the duration of the overnight investigation (including set-up time and period of recording) as part of their administrative records for MBS sleep studies. 

Polygraphic data

Item 11503 is not for the purpose of investigation of sleep disorders. Polygraphic data obtained as part of a sleep study item in the range 12203 to 12250 cannot be used for the purpose of claiming item 11503.

Billing requirements for level 1 and 2 sleep studies

All items are subject to MBS compliance processes and activities, including random and targeted audits which may require a provider to submit evidence about the services claimed. For sleep studies this would include a full copy of the PSG record that includes the raw data. The written report issued at the completion of the sleep study should include all of the requirements listed in the relevant clinical guidelines for types 1 and 2 sleep studies.

Items 12203 to 12250 do not support a figurehead billing arrangement. Figurehead or ‘headline’ billing is where one practitioner’s provider number is used to bill patients for the services provided by other practitioners.

While individual components of the sleep study service (e.g. supervision of the investigation and interpretation and preparation of a permanent report) do not need to be performed by the same qualified sleep medicine practitioner, it is an MBS requirement that the qualified sleep medicine practitioner who prepared the report on the results of the investigation bill the relevant item.

Benefits are not payable for items 12203 to 12250 where the interpretation and preparation of a permanent report is provided by a technician or supervised staff rather than by a qualified sleep medicine practitioner.

Where the date of service for a sleep study item is the same as the date of service of any items 11000 to 11005, 11503, 11713 and 12203/12250, for a benefit to be payable, there must be written notification on the account identifying that the service under any of those items was not provided on the same occasion as the sleep study item.

The date of service for the purposes of items 12203 to 12250 is deemed to be the day of the morning the overnight investigation is completed. Billing for the service must only occur once all of the requirements of the item have been fulfilled. 

Related Items: 12203 12204 12205 12207 12208 12210 12213 12215 12217 12250


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