Medicare Benefits Schedule - Note TN.8.152

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

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Multiple Operation Rule

Endoscopic examination of the colon to the caecum by colonoscopy, for a patient:

(a) following a positive faecal occult blood test; or

(b) who has symptoms consistent with pathology of the colonic mucosa; or

(c) who has anaemia or iron deficiency; or

(d) for whom diagnostic imaging has shown an abnormality of the colon; or

(e) who is undergoing the first examination following surgery for colorectal cancer; or

(f) who is undergoing pre‑operative evaluation; or

(g) for whom a repeat colonoscopy is required due to inadequate bowel preparation for the patient’s previous colonoscopy; or

(h) for the management of inflammatory bowel disease;

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

Applicable once on a day under a single episode of anaesthesia or other sedation

(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)

Multiple Operation Rule

Endoscopic examination of the colon to the caecum by colonoscopy, for a patient:

(a) who has had a colonoscopy that revealed:

(i) one to 4 adenomas, each of which was less than 10 mm in diameter, had no villous features and had no high grade dysplasia; or

(ii) one or 2 sessile serrated lesions, each of which was less than 10 mm in diameter, and without dysplasia; or

(b) who has a moderate risk of colorectal cancer due to family history; or

(c) who has a history of colorectal cancer and has had an initial post‑operative colonoscopy that did not reveal any adenomas or colorectal cancer;

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

Applicable once in any 5 year period

(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)

Multiple Operation Rule

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

(a) a history of adenomas, including an adenoma that:

(i) was 10 mm or greater in diameter; or

(ii) had villous features; or

(iii) had high grade dysplasia; or

(b) having had a previous colonoscopy that revealed:

(i) 5 to 9 adenomas, each of which was less than 10 mm in diameter, had no villous features and had no high grade dysplasia; or

(ii) one or 2 sessile serrated lesions, each of which was 10 mm or greater in diameter or had dysplasia; or

(iii) a hyperplastic polyp that was 10 mm or greater in diameter; or

(iv) 3 or more sessile serrated lesions, each of which was less than 10 mm in diameter and had no dysplasia; or

(v) one or 2 traditional serrated adenomas, of any size;

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

Applicable once in any 3 year period

(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)

Multiple Operation Rule

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

(a) revealed 10 or more adenomas; or

(b) included a piecemeal, or possibly incomplete, excision of a large, sessile polyp;

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

Applicable 4 times in any 12 month period

(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)

Multiple Operation Rule

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

(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)

Multiple Operation Rule

Endoscopic examination of the colon to the caecum by colonoscopy:

(a) for the treatment of bleeding, including one or more of the following:

    (i) radiation proctitis;

    (ii) angioectasia;

    (iii) post‑polypectomy bleeding; or

(b) for the treatment of colonic strictures with balloon dilatation

Applicable only once on a day under a single episode of anaesthesia or other sedation

(Anaes.)

Fee: $534.45 Benefit: 75% = $400.85 85% = $454.30

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

Multiple Operation Rule

Endoscopic examination of the colon to the caecum by colonoscopy, other than:

(a) a service to which item 32222, 32223, 32224, 32225 or 32226 applies; or

(b) a service associated with a service to which item 32230 applies

Applicable once

(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)

Multiple Operation Rule

Removal of one or more polyps during colonoscopy, in association with a service to which item 32222, 32223, 32224, 32225, 32226, or 32228 applies

(Anaes.)

Fee: $307.25 Benefit: 75% = $230.45 85% = $261.20

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