Commonwealth Numbered Regulations - Explanatory Statements

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HEALTH INSURANCE (GENERAL MEDICAL SERVICES TABLE) AMENDMENT REGULATIONS 2002 (NO. 1) 2002 NO. 76

STATUTORY RULES 2002 No. 76

Issued by the Authority of the Minister for Health and Ageing

Health Insurance Act 1973

Health Insurance (General Medical Services Table) Amendment Regulations 2002 (No. 1)

Section 133 of the Health Insurance Act 1973 (the Act) provides that the Governor-General may make regulations prescribing matters for the purposes of the Act.

The Act provides for payments of Medicare benefits in respect of professional services rendered to eligible persons. Section 9 of the Act provides that Medicare benefits shall be calculated by reference to the fees for medical services, including diagnostic imaging services, set out in prescribed Tables.

Subsection 4(1) of the Act provides that the regulations may prescribe a table of medical services, (other than diagnostic imaging services and pathology services) that sets out items of medical services, the amount of fees applicable in respect of each item and rules for interpretation of the table. The Health Insurance (General Medical Services Table) Regulations 2001 Statutory Rules No. 280 currently prescribe such a table.

The purpose of the Health Insurance (General Medical Services Table) Amendment Regulations 2002 (the Regulations) is to amend the current table of medical services. The amendments to the Regulations set out changes to certain items of medical services which are eligible for Medicare benefits, the amount of fees applicable in respect of each item and rules for interpretation of the table.

The amendments to the Regulations contain changes made as part of the ongoing management of the General Medical Services Table and also incorporate changes to items in the table resulting from ongoing reviews by the Medicare Benefits Consultative Committee. These reviews are designed to ensure that the table reflects current medical practice and encourages best practice.

The changes include the introduction of new items, for example, new case conferencing items for consultant physicians which will be better aligned with the corresponding General Practitioner Enhanced Primary Care case conferencing items. A number of items have also been amended, for example, the description of diabetes and asthma items now makes it clear that the items can only be claimed once per year per patient in respect of diabetes, and generally once per year per patient in respect of asthma unless special circumstances exist. Certain requirements for the effective management of the conditions must also be fulfilled.

Details of the amended Regulations are set out in the Attachment. The amended Regulations came into effect on 1 May 2002.

ATTACHMENT

DETAILS OF THE HEALTH INSURANCE (GENERAL MEDICAL SERVICES TABLE) REGULATIONS 2002 (NO. 1)

Regulation 1 provides for the Regulations to be referred to as the Health Insurance (General Medical Services Table) Amendment Regulations 2002 (No. 1).

Regulation 2 provides for the amended Regulations to commence on 1 May 2002.

Regulation 3 provides for the Health Insurance (General Medical Services Table) Regulations 2001 to be amended as set out in Schedule 1.

The General Medical Services Table is generally amended mid-year to reflect modem medical practice. Listed below are the relevant amendments that have been agreed to by the Minister for Health and Ageing relating to reviews undertaken by the Department with the medical profession. Minor amendments are also included for purposes of correction or clarification.

Schedule 1 - Table of General Medical Services

Part 1 - Rules of Interpretation

Item 1 introduces a new Rule I A applying to the General Medical Services Table stating that for any service listed in the Schedule to be eligible for a Medicare rebate, the service must be rendered in accordance with the provisions of the relevant Commonwealth or State or Territory laws.

Item 2 improves the presentation of a definition in sub-rule 45(1) for clarification purposes.

Item 3 italicises 'participation' to be consistent with the italicisation of 'organise and coordinate' in the heading in Rule 53.

Item 4 introduces a new Rule 55A which stipulates that certain items can only be claimed once per patient per year and lists the activities which must be undertaken at the appropriate intervals before completion of the minimum requirements for an annual cycle of care for patients with diabetes.

Item 5 amends Rule 56 to stipulate that certain items can only be claimed once per patient per year unless special circumstances apply and to clarify minimum requirements to be carried out and documented when treating asthma patients under an Asthma 3+ Visit Plan.

Item 6 deletes Rule 59 as there is now a flat fee for this item not a derived amount.

Item 7 amends Rule 62 to provide clarification on the fee structure of item 22060.

Item 8 amends Rule 63 to also provide clarification on the fee structure of item 22060.

The specific proposed amendments are as follows:

Insert new Rule 1A which states 'An item in Part 3 does not apply to a service provided in contravention of a law of the Commonwealth or of a State or Territory.'

In sub-rule 45(1) insert 'includes' in (a) and (b) rather than in the opening phrase to improve the presentation of the definition.

In Rule 53 italicise 'participation' to be consistent with the italicisation of 'organise and coordinate' in the heading.

Insert new Rule 55A which states that for any items in Subgroup 2 of Group A18 and Subgroup 2 of Group A19 items can only be claimed once per patient per year, and a professional attendance completes the minimum requirements for an annual cycle of care of a patient with established diabetes mellitus if the attendance involves provision of the following services at the frequency indicated:

Assess diabetes control by measuring HbA1c - at least once per year

Ensure that a comprehensive eye examination is carried out- at least once every two years

Measure weight and height and calculate BMI - at least once every six months

Examine feet - at least once every six months

Measure total cholesterol, triglycerides and HDL cholesterol - at least once every year

Test for microalbuminuria - at least once per year

Provide self-management education- patient education regarding diabetes management

Review diet - reinforce information about appropriate dietary choices

Review levels of physical activity - reinforce information about appropriate levels of physical activity

Check smoking status - encourage cessation of smoking (if relevant)

Review of medication - medication review.

Amend Rule 56 to state that for any items in Subgroup 3 of Group A18 or Subgroup 3 of Group A19 items can only be claimed once per patient per year, unless clinically indicated and insert 'minimum' before requirements in the opening sentence. In addition:

In (b) insert 'documented' before 'diagnosis' and before 'assessment of severity'.

In (c) insert 'the patient's use of before 'asthma related medication'.

In (d) (ii) insert 'self-management' before education.

Insert a new sub-para (e) which reads 'review of asthma action plan'.

Omit Rule 59.

In sub-rule 62 replace the existing (1) with

(1) An item in the range 23010 to 24136 applies to perfusion in addition to any other item that applies to the perfusion.

In sub-rule 63 replace the existing (2) with

(2) An item in the range 25000 to 25020 applies to perfusion in addition to any other item that applies to the perfusion.

Part 3 - Services and Fees

There has been ongoing review of the services in the table by the Department over the past six months, relating to case conferencing, diabetes and asthma, hyperbaric medicine, anaesthetics, obstetrics and gynaecology, urology, and cardio-thoracic procedures.

Case Conferencing

Item 9 introduces twelve new items (820, 822, 823, 825, 826, 828, 830, 832, 834, 835, 837, 838) to replace existing items 801 to 815, with an appropriate fee structure, to better align case conferencing items for consultant physicians with the corresponding General Practitioner Enhanced Primary Care case conferencing items. The purpose of the amendments is to improve the effectiveness of the items and make it easier for both professional groups to work together, thereby encouraging better coordinated care for patients.

Diabetes and Asthma

New diabetes and asthma items were introduced into the Schedule in November 2001, which mirror existing consultation items and which are used to initiate Practice Incentives Program (PIP) payments for doctors who participate in the program. As noted earlier in this Attachment, a new rule in respect of diabetes has been introduced and the terms of the existing rule for asthma have been made more specific, to clarify how often items can be claimed and what activities must be undertaken before claiming. Item 10 corrects a reference to 'consulting' rather than 'conducting' rooms in items 2546 to 2559, clarifies that the requirements are 'minimum' requirements, and correctly titles the Asthma 3+ Visit Plan where the word 'plan' had a lower case 'p'.

Hyperbaric Medicine

Item 12 amends item 13020 to clarify that the item may be claimed for the prevention of osteoradionecrosis, in addition to the treatment of the condition.

Anaesthetics

In November 2001, the Relative Value Guide (RVG) for Anaesthetists was introduced into the MBS on a cost neutral basis for a trial period of two years. The essential difference between the RVG and the system that was previously in place is that the fees under the RVG are calculated on the basis of the actual time taken for an anaesthetic as opposed to an average time system that existed previously. As part of the review process following implementation, a number of anomalies have been identified which are now being corrected.

Item 11 amends item 11601 to remove reference to this service being performed in association with anaesthesia because it is outside the Relative Value Guide.

Items 13 to 18 provide clarification on the use of anaesthetic items 20300, 20403, 20420, 20520, 20940 and 20943.

Item 19 introduces new items 20956, 20958, and 20960 to more specifically address anaesthesia for those services, thus enabling a more appropriate fee to be allocated.

Item 20 provides clarification on the use of anaesthetic item 21402.

Item 21 corrects the heading of Sub-group 13.

Item 22 provides clarification on the use of anaesthetic item 21941.

Item 23 introduces new item 21942 to more specifically address anaesthesia for this service, thus enabling a more appropriate fee to be allocated.

Item 24 provides clarification on the use of item 22012.

Item 25 provides clarification on the use of item 25015.

item 26 corrects the description of item 35618 by deleting an inappropriate reference.

In relation to fees for anaesthesia items, the fee for item 21170 has been amended equivalent to 8 units following advice from the profession that this is more complex than the closed procedure (item 21160) which only attracts the fee equivalent of 4 units (Item 35 refers). The fee for item 21884 has been changed to correct a misprint. Item 22060 has been amended to facilitate gap processing by health funds for this service.

Obstetrics and Gynaecology

Item 27 amends item 35633 to clarify that it can be used for hysteroscopic sterilisation following queries about inappropriate use of the item for sterilisation.

Indexation of Item 16518 was overlooked in the November 2001 changes to the Schedule and this has now been rectified (Item 35 refers).

Urology

Item 28 amends item 37604 to preclude it from being claimed in association with sperm harvesting for IVF purposes until such time as this issue has been considered by the Medicare Services Advisory Committee.

Item 29 amends items 37616 and 37619 to preclude them from being claimed in association with sperm harvesting for IVF purposes until such time as this issue has been considered by the Medicare Services Advisory Committee.

Cardio-Thoracic Procedures

Several changes were made to the cardio-thoracic area of the Schedule, on a cost neutral basis, effective from November 2001. Since that time it has become apparent that the rebate associated with those changes is less than cost-neutral where multiple services are involved. Item 30 introduces eight new items to address this situation, comprising six items (38225, 38228, 38231, 38234, 38237, 38240) reflecting those clinical situations where multiple procedures are performed, one new item (38243) to cover complex clinical situations where another practitioner is required to place the catheters prior to farther interventional procedures taking place, and one new item (38246) to cover situations where the same practitioner does both the diagnostic angiography and any coronary interventional procedure during the same occasion of service. Existing items 38215, 38218, 38220 and 38222 are amended to include a reference to all relevant items.

Item 31 amends the item descriptor for cardio-thoracic item 38742 to clarify the intent of the item specifying open exposure in the description.

Item 32 clarifies the description of item 45557.

Minor Amendments

Item 33 corrects a misprinted fee in items 51300, 51303, 51800 and 51803.

Item 34 corrects typographical errors in several rules of interpretation.

Item 35 corrects misprints and makes minor clarification of the wording of several items. The fee for item 21170 has been amended based on advice from the profession.