Medicare Benefits Schedule - Note TN.1.9

TN.1.9 Intensive Care Units - (Items 13870 to 13888)

'Intensive Care Unit' means a separate hospital area that:

(a)     is equipped and staffed so as to be capable of providing to a patient:

(i)      mechanical ventilation for respiratory failure for at least 24 hours; and

(ii)     invasive cardiovascular monitoring; and

(b)      is supported by:

(i)      at least one specialist in the specialty of intensive care who is immediately available and exclusively rostered to the ICU during normal working hours; and

(ii)     a registered medical practitioner who is present in the hospital and immediately available to the unit at all times; and

(iii)    a registered nurse for at least 18 hours in each day; and

(c)     has defined admission and discharge policies. 

"immediately available" means that the intensivist must be predominantly present in the ICU during normal working hours. Reasonable absences from the ICU would be acceptable to attend conferences, meetings and other commitments, which might involve absences of up to 2 hours during the working day, provided suitable cover is available. Outside normal working hours the specialist must be immediately contactable and, if required, available to return to the ICU within a reasonable time.

"exclusively rostered" means that the specialist's sole clinical commitment is to intensive care. 

For Neonatal Intensive Care Units an 'Intensive Care Unit' means a separate hospital area that:

(a)    is equipped and staffed so as to be capable of providing to a patient, being a newly-born child:

(i)   mechanical ventilation for a period of several days; and

(ii)  invasive cardiovascular monitoring; and

(b)   is supported by:

 (i)     at least one consultant physician in the specialty of paediatric medicine, appointed to manage the unit, and who is immediately available and exclusively rostered to the ICU during normal working hours; and

(ii)     a registered medical practitioner who is present in the hospital and immediately available to the unit at all times; and

(iii)    a registered nurse for at least 18 hours in each day; and

(c)     has defined admission and discharge policies. 

Medicare benefits are payable under the 'management' items only once per day irrespective of the number of intensivists involved with the patient on that day. However, benefits are also payable for an attendance by another specialist/consultant physician who is not managing the patient but who has been asked to attend the patient. Where appropriate, accounts should be endorsed to the effect that the consultation was not part of the patient's intensive care management in order to identify which consultations should attract benefits in addition to the intensive care items. 

In respect of Neonatal Intensive Care Units, as defined above, benefits are payable for admissions of babies who meet the following criteria:-

(i)               all babies weighing less than 1000gms;

(ii)              all babies with an endotracheal tube, and for the 24 hours following endotracheal tube removal;

(iii)             all babies requiring Constant Positive Airway Pressure (CPAP) for acute respiratory instability;

(iv)             all babies requiring more than 40% oxygen for more than 4 hours;

(v)              all babies requiring an arterial line for blood gas or pressure monitoring; or

(vi)             all babies having frequent seizures. 

Cases may arise where babies admitted to a Neonatal Intensive Care Unit under the above criteria who, because they no longer satisfy the criteria are ready for discharge, in accordance with accepted discharge policies, but who are physically retained in the Neonatal Intensive Care Unit for other reasons. For benefit purposes such babies must be deemed as being discharged from the Neonatal Intensive Care Unit and not eligible for benefits under items 13870, 13873, 13876, 13881, 13882, 13885 and 13888. 

Likewise, Medicare benefits are not payable under items 13870, 13873, 13876,  13881 13882, 13885 and 13888 in respect of babies not meeting the above criteria, but who, for whatever other reasons, are physically located in a Neonatal Intensive Care Unit. 

Medicare benefits are payable for admissions to an Intensive Care Unit following surgery only where clear clinical justification for post-operative intensive care exists. 

Related Items: 13870 13873 13876 13881 13882 13885 13888

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(Note: See para T1.8 of Explanatory Notes to this

Category for definition of an Intensive Care Unit)

MANAGEMENT of a patient in an Intensive Care Unit by a specialist or consultant physician who is immediately available and exclusively rostered for intensive care - including initial and subsequent attendances, electrocardiographic monitoring, arterial sampling and bladder catheterisation - management on the first day (H)

Fee: $412.55 Benefit: 75% = $309.45

(See para TN.1.9, TN.1.10, TN.1.11 of explanatory notes to this Category)

MANAGEMENT of a patient in an Intensive Care Unit by a specialist or consultant physician who is immediately available and exclusively rostered for intensive care - including all attendances, electrocardiographic monitoring, arterial sampling and bladder catheterisation - management on each day subsequent to the first day (H)

Fee: $305.95 Benefit: 75% = $229.50

(See para TN.1.9, TN.1.11 of explanatory notes to this Category)

CENTRAL VENOUS PRESSURE, pulmonary arterial pressure, systemic arterial pressure or cardiac intracavity pressure, continuous monitoring by indwelling catheter in an intensive care unit and managed by a specialist or consultant physician who is immediately available and exclusively rostered for intensive care - once only for each type of pressure on any calendar day (up to a maximum of 4 pressures) (H)

Fee: $87.60 Benefit: 75% = $65.70

(See para TN.1.9, TN.1.10, TN.1.11 of explanatory notes to this Category)

AIRWAY ACCESS, ESTABLISHMENT OF AND INITIATION OF MECHANICAL VENTILATION, in an Intensive Care Unit, not in association with any anaesthetic service, by a specialist or consultant physician for the purpose of subsequent ventilatory support (H)

Fee: $166.80 Benefit: 75% = $125.10

(See para TN.1.9 of explanatory notes to this Category)

VENTILATORY SUPPORT in an Intensive Care Unit, management of, by invasive means, or by non-invasive means where the only alternative to non-invasive ventilatory support would be invasive ventilatory support, by a specialist or consultant physician who is immediately available and exclusively rostered for intensive care, each day (H)

Fee: $131.30 Benefit: 75% = $98.50

(See para TN.1.9, TN.1.11 of explanatory notes to this Category)

CONTINUOUS ARTERIO VENOUS OR VENO VENOUS HAEMOFILTRATION, in an intensive care unit, management by a specialist or consultant physician who is immediately available and exclusively rostered for intensive care - on the first day (H)

Fee: $175.05 Benefit: 75% = $131.30

(See para TN.1.9, TN.1.11 of explanatory notes to this Category)

CONTINUOUS ARTERIO VENOUS OR VENO VENOUS HAEMOFILTRATION, in an intensive care unit, management by a specialist or consultant physician who is immediately available and exclusively rostered for intensive care - on each day subsequent to the first day  (H)

Fee: $87.60 Benefit: 75% = $65.70

(See para TN.1.9, TN.1.11 of explanatory notes to this Category)