Medicare Benefits Schedule - Item 32226

Endoscopic examination of the colon to the caecum by colonoscopy, for a patient who has a high risk of colorectal cancer due to:

(a) having either:

(i) a known or suspected familial condition, such as familial adenomatous polyposis, Lynch syndrome or serrated polyposis syndrome; or

(ii) a genetic mutation associated with hereditary colorectal cancer; or

(b) having had a previous colonoscopy that revealed:

(i) 5 or more sessile serrated lesions, each of which was less than 10 mm in diameter and had no dysplasia; or

(ii) 3 or more sessile serrated lesions, one or more of which was 10 mm or greater in diameter or had dysplasia; or

(iii) 3 or more traditional serrated adenomas, of any size;

other than a service associated with a service to which item 32230 applies

Applicable once in any 12 month period

Multiple Operation Rule

(Anaes.)

Fee: $380.90 Benefit: 75% = $285.70 85% = $323.80

(See para TN.8.2, TN.8.17, TN.8.152, TN.8.293 of explanatory notes to this Category)

• Previous - Item 32225
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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

The following are guidelines for appropriate minimum standards for the performance of GI endoscopy in relation to (a) cleaning, disinfection and sterilisation procedures, and (b) anaesthetic and resuscitation equipment.

These guidelines are based on the advice of the Gastroenterological Society of Australia, the Sections of HPB and Upper GI and of Colon and Rectal Surgery of the Royal Australasian College of Surgeons, and the Colorectal Surgical Society of Australia.

Cleaning, disinfection and sterilisation procedures
Endoscopic procedures should be performed in facilities where endoscope and accessory reprocessing protocols follow procedures outlined in:

1. Infection Control in Endoscopy, Gastroenterological Society of Australia and Gastroenterological Nurses College of Australia , 2011;
2. Australian Guidelines for the Prevention and Control of Infection in Healthcare (NHMRC, 2010);
3. Australian Standard AS 4187 2014 (and Amendments), Standards Association of Australia. 

Anaesthetic and resuscitation equipment
Where the patient is anaesthetised, anaesthetic equipment, administration and monitoring, and post-operative and resuscitation facilities should conform to the standards outlined in 'Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures' (PS09), Australian & New Zealand College of Anaesthetists, Gastroenterological Society of Australia and Royal Australasian College of Surgeons.

Single operator, single use peroral cholangiopancreatoscopy (POCPS) item 30665

For the purposes of item 30665 a treatment cycle, for a patient, means a series of treatments for the patient that:

(a)  begins on the day of the initial failed attempt at biliary stone removal via endoscopic retrograde cholangiopancreatography (ERCP) extraction techniques; and
(b)  ends at the conclusion of the aftercare period for the procedure, being either the lithotripsy procedure or a definitive surgical management procedure, that has resulted in removal of the biliary stones.

Conjoint Committee

For the purposes of Items 32023, 30664 and 30665 the procedure is to be performed by a surgeon or gastroenterologist with ERCP training recognised by the Conjoint Committee for the Recognition of Training in Gastrointestinal Endoscopy.

Related Items: 30473 30475 30478 30479 30481 30484 30485 30490 30491 30494 30680 30682 30684 30686 30687 30688 30690 30692 30694 32023 32084 32087 32094 32095 32106 32222 32223 32224 32225 32226 32227 32228 32229 32232

Colonoscopy items (items 32222-32229)

It is expected that clinicians using the MBS items for colonoscopy also refer to the updated National Health and Medical Research Council (NHMRC) approved Clinical practice guidelines for the prevention, early detection, and management of colorectal cancer: Risk and screening based on family history (the Guidelines, 2023); and the clinical practice guidelines for surveillance colonoscopy (2019).

The 2023 Guidelines recommend that age-appropriate patients with a near-average risk (no family history of colorectal cancer) or above average, but less than twice the average risk (only one first degree relative with colorectal cancer diagnosed at age 60 or older), are offered biennial screening using an immunochemical faecal occult blood test (iFOBT). The guidelines do not support the use of colonoscopy for patients who fall under the above risk categories who do not have symptoms or a positive iFOBT.

When colonoscopy is considered clinically appropriate, general practitioners should ensure colonoscopy referral practices align with applicable national guidelines, including the Royal Australian College of General Practitioners’ guidelines for preventive activities in general practice (the Red Book). Additionally, surveillance colonoscopy protocols should be determined based on high-quality endoscopy in a well-prepared colon using most recent and previous procedure information when histology is known.

Colonoscopy to the caecum

Items 32222-32228 specify endoscopic examination to the caecum. If preparation is inadequate to allow visualisation to the caecum, item 32084 should be billed. The ‘to the caecum’ requirements for colonoscopy examinations do not apply to patients who have no caecum following right hemi colectomy. For these patients the examination should be to the anastomosis.

Colonoscopy where a polyp/polyps are removed
Items 32222-32226 and 32228 provide for diagnostic colonoscopy when claimed alone. Where a polyp or polyps are removed during the colonoscopy, item 32229 should also be claimed in association with the appropriate colonoscopy item.

Where polyps >= 25 mm are removed via endoscopic mucosal resection (EMR), item 32230 should be billed and is inclusive of the service described in colonoscopy items 32222-32226 and 32228.

Colonoscopy where a patient has a moderate or high risk of colorectal cancer due to family history
Item 32223 should be used for patients considered at moderate or high risk of colorectal cancer due to family history.

Moderate risk is defined by the risk of developing colorectal cancer being at least two times higher than average, but could be up to four times higher than average if they have any of the following:
   - one first degree relative less than 60 years of age at diagnosis; OR
   - two first degree relatives with a history of colorectal cancer; OR
   - one first degree relative and one or more second degree relatives with a history of colorectal cancer.

Colonoscopy should be offered every five years starting at 10 years earlier than the earliest age of diagnosis of colorectal cancer in a first-degree relative or age 50, whichever is earlier, to 74.

High Risk is defined by the risk of developing colorectal cancer being at least four times higher than average, but could be up to 20 times higher than average, if they have any of the following:

-  two first-degree relatives AND one second-degree relative with colorectal cancer, with at least one diagnosed before the age of 50; OR

-  two first-degree relatives AND two or more second-degree relatives with colorectal cancer diagnosed at any age; OR

-  three or more first degree relatives with colorectal cancer diagnosed at any age.

Colonoscopy should be offered every five years starting at 10 years younger than the earliest age of diagnosis of colorectal cancer in a first-degree relative or age 40, whichever is earlier, to age 74.

Definition of previous history (items 32223-32225)
For items 32223-32225 the most appropriate item to be billed is determined by the previous history of the patient. Previous history for the purpose of these items is defined by number, size, and type of adenomas removed during any previous colonoscopy.

Although a patient is eligible for a colonoscopy every five years under item 32223, clinical guidelines indicate that colonoscopy every 10 years is sufficient if they have a previous history of 1-2 low risk adenomas.

Exception item (item 32228)
Where the clinician is unable to access sufficient patient information to enable a colonoscopy to be performed under items 32222-32226, but in their opinion, there is a clinical need for a colonoscopy, then item 32228 should be used. This item is available once per patient per lifetime.

Timing of colonoscopy following polypectomy should conform to the recommended surveillance intervals set out in clinical guidelines, taking into account individualised risk assessment. In the absence of reliable clinical history, clinicians should use their best clinical judgement to determine the interval between testing and the item that best suits the condition of the patient.

Time intervals
Items 32223, 32224, 32225 and 32226 have time intervals for repeat colonoscopy which are consistent with guidelines. These services are payable under Medicare only when provided in accordance with the approved intervals.

Patients may fit several categories and the most appropriate fit is a matter for clinician judgement with the highest risk indicating what subsequent colonoscopy intervals are appropriate. The examples provided below show that the result of the histopathology will not lengthen the surveillance intervals (in the case of patient with familial adenomatous polyposis (FAP) or Lynch syndrome) and may actually shorten the surveillance intervals.

Example 1
A patient at high risk of colorectal cancer with FAP or Lynch syndrome has a number of polyps removed at a surveillance colonoscopy. Item 32226 and 32229 are the appropriate items to bill. If the histology result returns 1-2 adenomas for patients at low to moderate risk then the next surveillance colonoscopy is recommended in 5 years. However, the patient’s familial condition means that a shorter interval (12 months) is recommended and payable.

Example 2
A patient at moderate risk of colorectal cancer because of family history has a number of polyps removed at a surveillance colonoscopy. Item 32223 and 32229 are the appropriate items to bill based on the patient’s family history. If the histology testing returns showing an adenoma with high‑risk histological features then the next surveillance colonoscopy is recommended in 3 years instead of 5 years.

How to use the items with new patients who have undergone previous colonoscopy

For new patients, practitioners should make reasonable efforts to establish a patient’s previous colonoscopy history. Patients whose care continues within one practice should have the relevant history readily available to guide decision making. Information can be sourced from My Health Record, the records department of the hospital where the previous procedure occurred, the GP, or the patient. The patient’s MBS claims history for colonoscopy services will also assist with this.

For audit purposes it is important to record the most appropriate item. In accordance with good practice, clinicians are required to maintain records that include pathology results which must be made available to the patient or other practitioners as required.

The Australian Commission on Safety and Quality in Health Care’s Colonoscopy Clinical Care Standard states all facilities and clinicians delivering colonoscopy services must provide a timely copy of the colonoscopy report and histology result to the patient and their GP. For National Bowel Cancer Screening Program patients, outcome reporting should be provided to the National Cancer Screening Register. Compliance with the Colonoscopy Clinical Care Standard is mandatory under the Australian Health Service Safety and Quality Accreditation Scheme.

Patient eligibility for colonoscopy services
All patients who require a colonoscopy will be eligible for a service. However, MBS benefits will not be claimable for services which do not meet the clinical indications and the item requirements for a colonoscopy or a repeat colonoscopy where the interval is specified in the item. Practitioners should ensure that their practice conforms to the approved clinical guidelines.

Practitioners providing colonoscopy services can call Services Australia on 132 150 to check a patient’s claiming history. The patient’s Medicare card number will be required together with the range of item numbers to be checked. For example, the new item numbers for colonoscopy services are in the range 32222-32229. The operator will interrogate the patient’s claiming history and provide advice on any claims paid for a colonoscopy service within the range of items specified and the date of the service. They will also be able to confirm any restriction on the frequency of the item claimed which would prevent a benefit from being paid if the service was provided again within the restricted period. Providers can also check a patient's eligibility via Health Professional Online Services (HPOS). HPOS will be able to return advice on whether a service is payable or not payable.

Patients can also seek clarification from Services Australia by calling 132 011 or access their own claiming history through My Health Record or by establishing a Medicare online account through myGov or the Express Plus Medicare mobile app.

The Services Australia enquiry lines for providers and for patients is available 24 hours a day, seven days a week. Further information can be found on the Services Australia website.

Related Items: 32222 32223 32224 32225 32226 32227 32228 32229

Endoscopic mucosal resection (EMR) item 32230 is inclusive of the colonoscopy service described in items 32222, 32223, 32224, 32225, 32226 and 32228.

There is a same day, same provider, same patient restriction with claiming any of the colonoscopy items 32222, 32223, 32224, 32225, 32226 and 32228 with item 32230.

Scenario 1

Should identification of a polyp >= 25 mm occur at time of colonoscopy and the provider is sufficiently skilled and the location of the procedure (facility) appropriately resourced, the polyp may be removed (resected) in situ at time of initial colonoscopy provided adequate consent was obtained by the endoscopist before the procedure.

Where this is the case, the provider will no longer bill a colonoscopy item 32222, 32223, 32224, 32225, 32226 or 32228, rather they will bill item 32230.

Scenario 2

Where the provider is unable to remove the polyp/s >=25 mm, and the patient is required to return to have the polyp removed, then the initial procedure identifying the polyp and thus the need for EMR would be billed to either 32222, 32223, 32224, 32225, 32226 or 32228 and the subsequent resection procedure to 32230.

Related Items: 32222 32223 32224 32225 32226 32228 32229 32230