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HEALTH INSURANCE (GENERAL MEDICAL SERVICES TABLE) REGULATIONS 2001 2001 NO. 280
EXPLANATORY STATEMENTSTATUTORY RULES 2001 No. 280
Issued by the Authority of the Minister for Health and Aged Care
Health Insurance Act 1973
Health Insurance (General Medical Services Table) Regulations 2001
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. Subsection 4(2) provides that, unless sooner repealed, regulations made under section 4 cease to be in force and are taken to be repealed on the day next following the 15th sitting day of the House of Representatives after the expiration of a period of 12 months commencing on the day on which the regulations are notified in the Gazette.
The purpose of the Health Insurance (General Medical Services Table) Regulations 2001 (the Regulations) is to prescribe a table of medical services for the 12 month period commencing on 1 November 2001. The new table will replace the table contained in the Health Insurance (General Medical Services Table) Regulations 2000. The Regulations set out the 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 Regulations contain the following changes made as part of the ongoing management of the general medical services table:
• no increase in Level A items in Group A1 and equivalent attendance items;
• a 4.3 per cent increase applies to Level B items in Group A1 and equivalent attendance items, and items 16500 - 16509, 30003 and 41704;
• a 9.6 per cent increase for level C and D items in Group A1 and equivalent attendance items;
• a 2.5 per cent increase to Groups A5, A14, A15 and all emergency after hours items (1, 2, 601, 602, 97, 98, 697, 698, 448 and 449)
• no increase for the Schedule fees for items in Group A2 (other unreferred attendances), Group A6 (group therapy), item 173 in Group A7 (acupuncture) and bone densitometry (items 12306 to 12321);
• a 1.6 per cent increase will apply to all other items except for Diagnostic Imaging and Pathology items (this amount is in line with the decision taken in the 2000/01 Budget to reduce the indexation level by 0.9 per cent to take account of the windfall gains associated with the introduction of the GST and the removal of the Wholesale Sales Tax); and
• a 1.5 per cent increase applies to items in Group I4 in the Diagnostic Imaging section of the book.
The Regulations will 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 to items include the insertion of new services and the deletion of obsolete services, for example, a range of new items for cervical screening, diabetes and asthma have been introduced to initiate Practice Incentives Program (PIP) payments for doctors who participate in the program. A number of items have also been amended, for example, items 42614 and 42615 for clearing obstructions in the nasolacrimal passage and items 42698, 42701 and 42702 for clear lens extraction for correction of anisometropia caused by the removal of a cataract in the other eye.
Also, for a period of two years commencing 1 November 2001, a Relative Value Guide (RVG) for Anaesthesia has been introduced into the MBS under a cost-neutral framework, as the basis for calculating Medicare benefits for anaesthesia services
Details of the Regulations are set out in the Attachment.
The Regulations commence on 1 November 2001.
ATTACHMENT
DETAILS OF THE HEALTH INSURANCE (GENERAL MEDICAL SERVICES TABLE) REGULATIONS 2001
Regulation 1 provides for the Regulations to be referred to as the Health Insurance (General Medical Services Table) Regulations 2001
Regulation 2 provides for the Regulations to commence on 1 November 2001.
Regulation 3 provides for the repeal of the Health Insurance (2000-2001 General Medical Services Table) Regulations 2000.
Regulation 4 provides definitions for the purposes of the Regulations.
Regulation 5 prescribes the new Table of General Medical Services and Rules of Interpretation as set out in Schedule 1.
The General Medical Services Table is redrafted each year commencing on the first of November. The redraft takes the form of duplicating all rules and services that have not been changed or amended from the previous Regulations. Listed below are the relevant changes and amendments that have been agreed to by the Minister for Health and Aged Care relating to the 2001-2002 Budget decisions and reviews undertaken by the Department with the medical profession.
Schedule 1 - Table of General Medical Services
Part 1 - Prescription of table
Proposed Rule 1 provides an explanation of how the table operates. The insertion of this Rule results in consequential renumbering of the rules of interpretation in Part 2.
Part 2 - Rules of Interpretation
Proposed Rule 2, part (1) - amends the definition of "comprehensive hyperbaric medicine facility" to limit services to medical conditions as described within the items.
Proposed Rule 2, part (1) - also includes a definition for "residential aged care facility" not previously defined.
Proposed Rules 7, 14, 29, 30, 31, 33, 34, 35 and 37 concerning derived fees are amended to reflect the general fee increase and include new items. Proposed rules 55, 59, 64 and 67 set out derived fees for new items.
Proposed Rule 9, part (1) is amended by inserting the word "single" between "a" and "medical".
Proposed Rule 19 is amended to expand the range of items covered by the definition of "report" due to the introduction of new items.
Proposed Rule 39 is amended to redefine sleep medicine practitioners following the introduction of "paediatric" sleep studies items.
Proposed Rules 43, 44, 45, 47, 48, 52 and 53 are amended to reflect amendments to the enhanced primary care items covering health assessments, care planning and case conferences.
The specific proposed amendments are as follows:
Amend Rule 43, part (3) (a): delete the words "signed by the patient; and"
Add part (3)(c ) "offering the patient's carer (if any, and if the practitioner considers it appropriate and the patient agrees) a copy of the report or extracts of the report relevant to the carer."
Amend Rule 44, part (2) (a) to read: "discussing the preparation of the plan with the patient and the patient's carer (where appropriate in the medical practitioner's view and with the patient's agreement); and"
Amend Rule 44, part (2) (e) to read: " offering a copy of the plan (and evidence of the contribution made to the plan by members of the team) to the patient and, if appropriate, and with the patient's agreement, to the patient's carer."
Delete Rule 44, part (2) (f).
Amend Rule 45 to include in the list of examples for paragraph (b): asthma educators, diabetes educators and mental health workers.
Amend Rule 45 to include part (2) to define "family carer".
Amend Rule 47, part (2) (a) to read: "discussing the review of the plan with the patient and the patient's carer, (if any, and if the practitioner considers it appropriate and if the patient agrees); and"
Amend Rule 47, part (2) (c) to read: "offering a copy of relevant parts of the revised multidisciplinary care plan (if any) to the patient and the patient's carer (if any, and if the practitioner considers it appropriate and the patient agrees), and giving copies to persons who, under the revised plan, will give the patient the treatment, service and care mentioned in the plan."
Delete Rule 47, part (2) (d).
Amend Rule 48, part (1), to read: "For items 726, 728 and 730, a contribution to a multidisciplinary community care plan,...."
Amend Rule 52 to include in the list of examples for paragraph (b): asthma educators, diabetes educators and mental health workers.
Amend Rule 52 to include part (2) to define "family carer".
Amend Rule 53 (f) to read: "offering the patient and the patient's carer, (if any, and if the practitioner considers it appropriate the patient agrees), and giving each other member of the team, a summary of the conference;"
Add Rule 53 (g): "discussing the outcomes of the conference with the patient and the patient's carer (if any, and if the practitioner considers it appropriate and the patient agrees)."
Add Rule 54 to define "living in a community setting" for the purposes of new item 900.
In addition to the above amendments, minor drafting changes are proposed for correction or clarification.
Part 3 - Services and Fees
There have been 14 major reviews of the services in the table by the Department. These reviews relate to services provided under the practice incentive payments program, consultant physician attendances, Domiciliary Medication Management Review (DMMR), fee increases for other medical practitioners (OMP) after hours emergency services, enhanced primary care explanatory notes, cardio-thoracic items, Relative Value Guide for Anaesthetics, brachytherapy for prostate services, sleep studies, ophthalmology, oral and maxillofacial services, diagnostic imaging services, pathology, hyperbaric oxygen therapy and management of labour where patient's care is transferred to another medical practitioner.
New Incentive Items (PIP)
A range of new items for cervical screening, diabetes and asthma has been introduced which mirror existing consultation items and will be used to initiate Practice Incentives Program (PIP) payments for doctors who participate in the program. The following item numbers, which include both general practitioner and other non-referred attendances, relate to provision of these services:
• Items 2501, 2503, 2504, 2506, 2507, 2509, 2600, 2603, 2606, 2610, 2613 and 2616 relate to taking of a cervical smear from an unscreened or significantly underscreened woman (see explanatory note A.27 for requirements).
• Items 2517, 2518, 2521, 2522, 2525, 2526, 2620, 2622, 2624, 2631, 2633 and 2635 relate to the completion of an annual diabetes care program (see explanatory note A.28 for requirements)
• Items 2546, 2547, 2552, 2553, 2558, 2559, 2664, 2666, 2668, 2673, 2675 and 2677 relate to the completion of an Asthma 3+ Visit Plan (see explanatory note A.29 for requirements).
New Domiciliary Medication Management Review (DMMR)
A new Item (Item 900) has been introduced to the Medicare Benefits Schedule (MBS) for GP participation with pharmacists in collaborative Domiciliary Medication Management Review (DMMR) for patients living in the community setting. DMMR is also referred to as Home Medicines Review.
Under DMMR, a GP assesses a patient's medication management needs and following that assessment refers the patient to their preferred community pharmacy. With the patient's consent, the GP provides relevant clinical information that is required for the review. The community pharmacy coordinates the pharmacy component of the DMMR, including an interview with the patient in the patient's home (preferred location for the review).
Following the home interview, the GP discusses the results of the review with the reviewing pharmacist including suggested medication management strategies. The GP then develops a written medication management plan following discussion in a second consultation with the patient. The plan is used as the basis for ongoing monitoring and follow-up of the patient as required.
Fee Increase for Other Medical Practitioners (OMP) After Hours Emergency Services
A 50% increase in Schedule fees will apply to Emergency Attendance - After Hours for Other Non-Referred Attendances (items 97,98, 697 and 698). This is in response to the increase in the fees for Emergency Attendance - After Hours for General Practitioners (items 1, 2, 601, 602), implemented in the 1 May 2001 supplement to the 1 November 2000 MBS, and will to maintain the relativities between the general practitioner and other non-referred attendances as priced in the 1 November 2000 MBS.
Changes to Enhanced Primary Care Explanatory Notes
The notes for guidance have been amended to cover the involvement of a patient's informal or family carer in the EPC Items.
Other additions to the notes provide guidance on involving carers in EPC services (or components thereof) other than as a formal member of a multidisciplinary care team, and on providing reports from EPC services to carers, where appropriate and with the patient's agreement.
Records of health assessments (which must be kept by the medical practitioner) are no longer required to be signed by the patient. Where a component of the health assessment is conducted in the patient's home (including by a third party acting under the supervision of the practitioner) the notes make clear that the relevant item for a health assessment in the home should be claimed.
Cardio-Thoracic
Several changes have been made to the cardio-thoracic area of the Schedule. Two new items (38220 and 38222) have been introduced to cover placement of catheters and injection of opaque material into free coronary grafts or mammary grafts. There have also been some changes to the existing coronary angiography items 38215 and 38218.
Relative Value Guide for Anaesthetics
For a trial period of two years commencing 1 November 2001, the Relative Value Guide (RVG) for Anaesthesia has been introduced into the Medicare Benefits Schedule under a cost-neutral framework, as the basis for calculating Medicare benefits for anaesthesia services. These services are listed in Group T10 of the Medicare Benefits Schedule.
The RVG is based on an anaesthetic unit system which reflects both the difficulty of the service and the total time taken for the service.
The RVG groups anaesthesia services within anatomical regions. These items are listed in the MBS under Group T10, Subgroups 1-16 Anaesthesia for radiological and other therapeutic and diagnostic services are grouped separately under Subgroup 17. Also included in the RVG format are certain additional monitoring and therapeutic services, such as blood pressure monitoring (item 22012) and central vein catheterisation (item 22020) when performed in association with the administration of anaesthesia. These services are listed at subgroup 19. The RVG also provides for assistance at anaesthesia under certain circumstances. These items are listed at subgroup 26.
Details of the new arrangements are contained in explanatory note T.10 in Category 3 of the Schedule.
Brachytherapy for Prostate Cancer
A range of new items has been introduced for brachytherapy for prostate cancer following a Medical Services Advisory Committee (MSAC) recommendation that public funding should be made available for the procedure under specific circumstances.
Two new items (15338 and 37220) have been included to cover the procedural portion of the service for both the urologists and the radiation oncologists. Two further items (15513 and 15539) have been developed for the radiation oncologists' responsibilities for planning, dosimetry and simulation etc.
Sleep Studies
A number of new and amended items for sleep studies have been introduced into the Schedule in recognition of the unique difference between paediatric and adult sleep studies, in particular, the frequency of which a wider range of underlying conditions are studied in a paediatric facility compared to an adult facility.
Four new items are proposed - two items (12210 and 12215) for children aged 0-12 years old and two items (12213 and 12217) for children aged 13 to 18. These changes also result in minor amendments to the adult sleep studies items (12203 and 12207) making it clear that they are specifically to be used for adults over the age of 18 years.
Ophthalmology
The following changes have been made to Ophthalmology items:
• deletion of items 11206 and 11209 and introduction of new items 11204, 11205, 11210 and 11211 to cover electrodiagnostic testing; amendments to items 11222 and 11225 for computerised perimetry; and amendments to item 11240 with the introduction of 11241,11242 and 11243 for measurement of orbital contents.
• amendments to items 42614 and 46215 for clearing obstructions in the nasolacrimal passage and items 42698,42701 and 42702 for clear lens extraction for correction of anisometropia caused by the removal of a cataract in the other eye; and a new item 42771 for cyclodestructive procedures for third or subsequent treatments within a two year period.
Oral and Maxillofacial Services
Various changes have been introduced following further review of oral and maxillofacial services by approved dental practitioners. Twenty-five items have been deleted (52031, 52136-52137, 52150-52156, 52160-52176, 52320, 52432-52434, 52448, 52454, 52470-52478, 53007, 53050, 53066), and three items have been amended in recognition of current practice (items 52035, 53054 and 53060).
Changes to Diagnostic Imaging Services
Reporting requirements - a provision has been introduced which means that the report must be included as part of each diagnostic imaging service. Please refer to Section DIA.1 of the explanatory notes for the Diagnostic Imaging Services Table.
Diagnostic imaging services with an anaesthesia component - the anaesthesia formula has been removed from all relevant items. The term `Anaes' has been inserted into these items to denote them as eligible services for the purposes of attracting an anaesthetic service. Additional items have been identified as eligible services for the purposes of attracting an anaesthesia service. Please refer to Section DIA.7 of the explanatory notes for the Diagnostic Imaging Services Table.
Ultrasound - new rules for the accreditation of medical sonographers have been introduced. Item 55112 has been replaced with three new items, these being 55113, 55114 & 55115. A fee reduction of five percent was applied to all cardiac items on 1 July 2001. Additional subgroup restrictors were applied to items 55116, 55117 and 55118 on 1 July 2001. Twelve vascular ultrasound have been deleted (55240, 55242, 55245,55247, 55250, 55254, 55258, 55260, 55263, 55265, 55268 & 55272). Three new items have been inserted (55292, 55294 & 55296). Please refer to Section DIH of the explanatory notes for the Diagnostic Imaging Services Table.
Computed tomography - a rule has been introduced which excludes the payment of Medicare benefits for computed tomography scans rendered using a hybrid positron emission tomography/computed tomography scanner. A number of items for scans of the spine have been replaced with new items (56220 to 56240) which specify the region of the spine to be scanned. The fees for computed tomography scans of facial bones, paranasal sinuses and the brain have been revised (items 56030, 56036, 56070 & 56076). The fees for the existing spiral angiography items (57350 & 57355) have been revised and two new spiral angiography items have been inserted (57351 & 57356). Please refer to Section DII of the explanatory notes for the Diagnostic Imaging Services Table.
Diagnostic radiology - item 57936 has been replaced with four new orthopantomography items (57948 to 57957) which require the clinical indication for the referral. Existing items for diagnostic radiology scans of the spine (58112 & 58115) have been revised to refer to specific regions of the spine to be scanned. A new item has been inserted providing for scans of four regions of the spine has been inserted (58108). A restriction has been introduced between items 59903 and 59912, and a new item inserted (55925) for occasions where both these items would have otherwise been claimed. Six cardiac angiography items have been deleted (59900, 59906, 59915, 59918, 59921 & 59924) and the descriptors for items 59903 and 59912 have been adjusted. A new set of items were introduced from 1 July 2001 to cover cardiac angiography services provided on older equipment. Please refer to Section DIJ of the explanatory notes for the Diagnostic Imaging Services Table.
Nuclear medicine - a 1.5 percent fee increase has been applied to all nuclear medicine item fees.
Magnetic resonance imaging - the requirements for eligible providers have been revised and the criteria for eligible equipment have been updated in line with amendments to the eligibility requirements. The limits on the number of scans of the musculoskeletal system have been clarified (subgroups 17, 18, 19 & 21). Please refer to Section DIL of the explanatory notes for the Diagnostic Imaging Services Table.
Changes to Pathology Services
Three new items have been included in the Pathology Services Table covering investigation of cardiac or skeletal muscle damage (66519) and detection of Epstein Barr Virus (69472 and 69474).
A number of items have been amended as follows:
- Item 66500 (general chemistry) - addition of total cholesterol and triglycerides
- Item 66536 (HDL cholesterol) - removal of restrictions
- Item 69375 (herpes simplex virus, varicella zoster virus or cytomegalovirus) - inclusion of testing by `nucleic acid amplification technique'
- Item 69443 (HCV genotype) - amended to allow for 1 episode in a 12 month period
- Item 72855 and 72856 (biopsy material) - addition of tissue imprint and smear
- Items 66521 - 66533 (lipids) have been deleted
A number of Rules have been amended as follows:
- Rule 4 (2) - addition of patients undergoing cyclosporin therapy
- Rule 8 - inclusion of an exception for item 66500 to allow for claiming of creatinine ratio when testing another substance in urine
- Rule 9 has been deleted
A number of abbreviations have also been amended or deleted and two new abbreviations for Hepatitis C (quantitation) - THCV and (genotype) - GHCV have been added.
Three new complexity levels for breast have been added - microdochectomy (6); large bowel (including rectum), biopsy, and confirmation or exclusion of Hirschsprung's Disease (5); lymph node - biopsy, for lymphoma or lymphoproliferative disorder (5).
One complexity level has been deleted for sinus, front nasal, ethmoidectomy (6).