Medicare Benefits Schedule - Item 31537

Insertion of a marker clip into a breast, including axilla, following a breast biopsy and using imaging (but not including the associated imaging), if additional surgery, neoadjuvant systemic therapy, follow up imaging or radiation may be required and the insertion is for any of the following reasons:

(a) to mark the site of a lesion that has been totally or almost completely removed;

(b) to confirm biopsy site if multiple lesions are present;

(c) to confirm biopsy site of an ill-defined lesion;

(d) future surgery or preoperative localisation is considered to be potentially difficult due to lesion conspicuity;

(e) preoperative localisation is likely to be carried out using a modality different from the biopsy modality;

(f) for correlation across modalities for diagnostic reasons

Multiple Operation Rule

(Anaes.)

Fee: $215.80 Benefit: 75% = $161.85 85% = $183.45

(See para TN.8.2, TN.8.280 of explanatory notes to this Category)

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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

MBS item 31536 is for the preoperative insertion of a hookwire (or a similar device) into the breast or axilla to mark the site of a lesion, when the insertion is not associated with a breast biopsy. The hookwire (or similar device) is to be inserted under imaging which is billed under a separate MBS item.

MBS item 31537 is for the insertion of a marker clip (or tissue marker) into the breast and/or axilla, to mark the site of lesion that has been totally or almost removed at biopsy and requires localisation. It is intended that the schedule fee for this item is inclusive of all components in delivering the service.

In accordance with accepted clinical practice guidelines, marker clips (or tissue markers) are not required for every biopsy and the particular occasions where they should be inserted are listed in MBS item 31537 (a) – (f). Please note the requirement at d) includes where neoadjuvant therapy may occur prior to future interventions on the breast and there is potential lack of lesion conspicuity following completion of neoadjuvant therapy.

Providers are required to use imaging when inserting the marker clip(s), however, the appropriate imaging modality can be determined by the practitioner and the imaging component is to be claimed under the relevant diagnostic imaging item.

When it is clinically relevant to insert more than one marker clip, the Multiple Operation Rule (MOR) will apply. The MOR will apply to all clips that are inserted at breast biopsy, regardless of site. This means the MOR will apply to all clips that are inserted as part of the same patient episode.

For further information practitioners could refer to the accepted clinical guidance for the use of marker clips that is provided by BreastScreen Australia and Assessment Services.

Related Items: 31500 31503 31506 31509 31515 31536 31537