Commonwealth Numbered Regulations - Explanatory Statements

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HEALTH INSURANCE (GENERAL MEDICAL SERVICES TABLE) REGULATIONS 2003 2003 NO. 255

Subsection 133(1) of the Health Insurance Act 1973 (the Act) provides that the Governor-General may make regulations, not inconsistent with the Act, prescribing all matters required or permitted by the Act to be prescribed, or necessary or convenient to be prescribed for carrying out or giving effect to the Act.

The Act provides, in part, 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 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 Subsection 4(2) provides that, unless sooner repealed, regulations made under section 4 cease to be in force and are taken to be repealed on the day following the 15^th sitting day of the House of Representatives, after the expiration of a period of 12 months commencing on the day on which the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.

A table of medical services is currently prescribed by the Health Insurance (General Medical Services Table) Regulations 2002 (the 2002 Regulations). The table has been amended twice, by Statutory Rules 2002 No 254 and 2003 No. 69.

The purpose of the Regulations is to repeal the 2002 Regulations and the amending regulations, and to prescribe a new table of medical services for the 12 month period commencing on 1 November 2003. The new table sets 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 new table effectively reproduces the table contained in the 2002 Regulations, but reflect a 2.5% increase in fees for most items.

The Regulations also incorporates changes to items in the table resulting from reviews by the Medical Services Advisory Committee and 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.

Details of the Regulations are set out in the Attachment.

The Act specifies no conditions that need to be met before the power to make the proposed Regulations may be exercised.

The proposed Regulations would commence on 1 November 2003.

ATTACHMENT

DETAILS OF THE HEALTH INSURANCE (GENERAL MEDICAL SERVICES TABLE) REGULATIONS 2003

Regulation 1 provides for the Regulations to be referred to as the Health Insurance (General Medical Services Table) Regulations 2003.

Regulation 2 provides for the Regulations to commence on 1 November 2003.

Regulation 3 provides for the repeal of the Health Insurance (General Medical Services Table) Regulations 2002.

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 amendments (including new items) resulting from reviews of certain services undertaken by the Department with the medical profession.

Schedule 1 - Table of General Medical Services

Part 2 - Rules of Interpretation

The following amendments to rules and insertion of new rules have been included:

Rule 12 (2) has been amended to include new items 11004, 11005, 11237, 11602, 11604, 11605, 11610, 11611 and 11614 as these items are services that may be provided by persons other than medical practitioners. Rule 12 (2) has been further amended to exclude 15360, 15363 and 15541 which cannot be performed by persons other than medical practitioners. The rule has also been amended to delete items 11603, 11606, 11609, 11618, 11621 and 11624 which have been deleted from the GMST.

A proposed new Rule 76 has been inserted entitled "Meaning of qualified medical acupuncturist in items 193, 195, 197 and 199" to define the meaning of a "qualified medical acupuncturist" in the acupuncture items performed by general practitioners.

Part 3 - Services and Fees

Reviews of the services in the Table undertaken since November 2002 relate to acupuncture, optometry, neurology, ophthalmology, vascular investigations, radiation oncology, intravascular brachytherapy, anaesthetics, general surgery, plastic surgery, cryotherapy, gynaecology and transurethral needle ablation.

The following amendments to items and insertion of new items have been included:

Acupuncture

Items 193, 195, 197 and 199 have been amended to include the text "qualified medical acupuncturist" to reflect that these items may only be performed by a general practitioner who fulfils the definition of a "qualified medical acupuncturist".

Optometry

A change has been made to the Group A10 heading to replace the word "consultations" with "services" as with the introduction of new items, optometry services are no longer limited to consultations.

A new item (10915) has been introduced to create an item for the examination of the eyes of a patient with diabetes mellitus, separate from examinations of patients with other progressive disorders (item 10914) to assess whether they are receiving appropriate eye care. Item references in items 10900, 10907 - 10914, and 10921 - 10929 have been amended to reflect the introduction of the new item.

Two new items (10940 and 10941) have been introduced to enable optometrists to perform computerised perimetry in the same way ophthalmologists do, and at the same fee level. These are diagnostic items, whereas previously optometrists provided consultation items only. Items 10940 and 10941 cannot be claimed with items 10916 or 10918. Item references in items 10916 and 10918 have been amended to reflect this restriction.

Neurology

Two new items (11004 and 11005) have been introduced to cover prolonged video or ambulatory encephalography (EEG) monitoring. Item 11003 has been amended to include the two new items 11004 and 11005 in the list of services that cannot be claimed at the same time.

Ophthalmology

Amendments have been made to items 11222 and 11225 to replace in point (a), "(where surgery is being considered)" with "(where surgery may be required within a 6 month period)". This period has been introduced for clinical reasons so that no more than six months elapse between the test and the surgery if required. A further amendment has been made to replace point (c) with the following text "(c) monitoring for ocular disease or disease of the visual pathways which may be caused by systemic drug toxicity, where there may also be other disease such as glaucoma or neurological disease;". This change has clarified the intent of the items.

A new item 11237 has been introduced for simultaneous ultrasonic echography by both unidimensional and bidimensional techniques for the assessment of intraocular tumours.

Item 11240 has been amended so that after the text "unidimensional, for" the text "the measurement of 1" has been inserted, and after "eye" the text "prior to lens surgery on that eye" appears. Item 11241 has been amended so that the text "for both eyes" has been replaced with "for bilateral eye measurement prior to lens surgery on both eyes". These changes are to clarify that the items are specifically for the measurement of the axial length of the eye prior to intraocular lens implantation.

Item 42656 has been modified so that "where there have been 2 previous graft operations" is replaced with "second and subsequent procedures". This change has been made in recognition that any surgery past the initial is equally as clinically complex, and the higher fee will now apply to the second and subsequent corneal transplants.

Item 42671 has been deleted and replaced with item 42672 which has been introduced to clearly indicate the new requirements of the service and impose a new restriction that the item should only be performed as an independent procedure.

Item 42674 has been deleted and replaced with item 42673 which has been introduced to clearly indicate the new requirements of the service and to specify that the item should be performed in conjunction with other anterior segment surgery.

Item 42821 has been modified so the text "Retrobulbar Transillumination" has been replaced with "Ocular Transillumination, for the diagnosis and measurement of intraocular tumours". This amendment better defines the procedure, and restricts its use to the diagnosis and measurement of intraocular tumours.

Vascular Investigations

Items 11603 and 11606 have been deleted as has been item 11609. Services previously claimed under these items have been separated out into six new items (items 11602, 11604, 11605, 11610, 11611 and 11614) to better reflect current practice.

Item 11602 has been introduced to separately identify venous examinations using Doppler techniques.

Item 11604 has been introduced to separately identify venous examinations using plethysmographic techniques other than photoplethysmography.

Item 11605 has been introduced to separately identify complex venous examinations where photoplethysmography is appropriate.

Item 11610 has been introduced to separately identify arterial studies of the lower extremities using Doppler or plethysmographic techniques.

Item 11611 has been introduced to separately identify arterial studies of the upper extremities using Doppler or plethysmographic techniques.

Item 11614 has been introduced to separately identify arterial studies of the head using Doppler techniques.

Item 11612 has been amended so that the new item description is consistent with the descriptions of the six new items and so the activity to be undertaken in this item is more clearly defined.

Items 11618 - 11624 have been deleted as they represent obsolete practice.

Radiation Oncology

The term "cancer" has been replaced with the text "diseases and conditions" in items 15224, 15239, 15254 and 15269 to ensure that patients with non-cancerous conditions are able to be treated with radiotherapy, where the treatment has an established place in curative and palliative management.

Items 15500, 15503, 15506 and 15513 have been amended to include the use of computer tomography (CT) simulation in radiotherapy planning to reflect current practice and the existing range of technologies that can be used to perform services under these items.

Intravascular Brachytherapy

New items 15360 and 15363 have been introduced to cover the administration of radiation therapy using catheter based intravascular brachytherapy (IVB). Items differ according to the half-life of the isotope used.

Item 15541 has been introduced to cover the planning (computerised radiation dosimetry) associated with catheter based IVB.

These items must be used in conjunction with one of the new IVB cardiology items (items 35347, 35350, 35353 or 35356) and must be performed by a radiation oncologist in association with a cardiologist.

Items 35347, 35350, 35353 and 35356 have been introduced to cover the cardiology component of the catheter-based IVB procedure. Items differ according to the components or combination of components they include. All items include services associated with performing IVB and balloon angioplasty, and items 35350, 35353 and 35356 include a combination of intravascular ultrasound (IVUS) and/or percutaneous transluminal rotational atherectomy (PTCRA).

These items must be used in conjunction with the new IVB radiation therapy items (either 15360 plus 15541 or 15363 plus 15541) and must be performed by a radiation oncologist in association with a cardiologist.

Anaesthetics

Perioperative nerve block items 22040 and 22045 have been modified to include "hip" after the text "...in conjunction with". This has the effect of expanding these items to include hip surgery.

General Surgery

Items 30071 - 30094 have been amended to include the word "Diagnostic" in relation to the types of biopsy mentioned in each item. And the text ", where the biopsy specimen is sent for pathological examination" has been inserted in each item. This change is to ensure that appropriate clinical practice is observed by requiring the specimen to be sent to pathology for examination.

Item 30185 has been introduced for the removal of ten or more palmar of plantar warts by methods other than ablative techniques alone.

Items 30186, 30189 and 30192 have been amended to clarify the intention of these items. Item 30186 has been amended to include the text "warts (less than 10), definitive" and "excluding ablative methods alone". Item 30189 has been modified to include after "molluscum contagiosum", the text "(1 or more)", and item 30192 has been modified to include solar keratoses and to replace the text "by galvanocautery or electrodesiccation or cryocautery" with "by ablative technique".

The words "(other than by shave excision)" have been inserted in items 31205 - 31240 to clarify that shave excision is excluded as a method for removing a tumour, cyst, ulcers or scars under these items.

The words "and where the initial specimen removed is sent for histological examination and malignancy confirmed, and any subsequently excised specimen is sent for histological examination" has replaced "and where the specimen excised is sent for histological examination and confirmation of malignancy has been obtained" in items 31255 - 31290. This better reflects the intent of the items, that only the `definitive' excision for the removal of confirmed basal cell carcinomas and squamous cell carcinomas can be claimed under these items.

Items 31300 - 31335 include the text "(with an adequate margin and as a result, no further surgery is indicated at the site of the primary tumour)," after "definitive surgical excision" to reflect the intent of the items. The excised specimen must be sent for histological examination and malignancy confirmed before claiming a "definitive" excision in the first instance. If the initial excision is not "definitive" it cannot be claimed under these items.

Plastic Surgery

Lipectomy items 30165 - 30177, free tissue transfer items 45564 and 45565, and breast reconstruction item 45533 have been amended to promote more appropriate use of items for the closure of the abdomen in association with free tissue transfer (items 45564 and 45565) and breast reconstruction (item 45533). This service is now covered by the new item 30178. Items 30165, 30174 and 30177 include the text "not being a service associated with a service to which item 45533, 45564 or 45565 applies". Items 30168 and 30171 include the text "not being a service associated with a service to which item 45533, 45564 or 45565 applies and not being a service to which item 30165 applies". Item 45533 includes the text ", not being a service associated with a service to which item 30165, 30168, 30171, 30174 or 30177 applies" and items 45564 and 45565 include the text "30165, 30168, 30171, 30174, 30177" after the word "item".

New item 30178 has been added to describe the appropriate service performed for closing the abdomen after a breast reconstruction (item 45533) or free tissue transfer (items 45564 and 45565).

Item 30180 has been amended to replace the term "wedge" with "partial" to better describe the service performed.

Items 31521, 31527 and 45585 have been altered to exclude the claiming of benefits for liposuction for gynaecomastia in association with mastectomy items. The words "not being a service associated with a service to which item 45585 applies" have been added to items 31521 and 31527, and the words "not being a service associated with a service to which item 31521 or 31527 applies" have been added to item 45585.

Item 45568 has been introduced to allow for patients to claim for the removal of tissue expanders and fibrous capsule excision in areas other than the breast.

Cryotherapy

The term "cryotherapy" replaces the term "cryosurgery" in item 32135 and the term "cryoneurotomy" in item 39323, for purposes of consistency in the GMST.

Gynaecology

Item 35616 includes the text "or thermal balloon" to include treatment by thermal balloon. The item currently only provides for treatment by microwave.

Transurethral Needle Ablation (TUNA)

Items 37201 and 37202 previously existed under Ministerial Determination (Health Insurance (Transurethral Needle Ablation) Determination HS/07/2002) and have now been included in the GMST.

In addition to the above amendments, minor drafting changes to items have been made for correction and clarification.