MEDICARE INFORMATION
There are strict criteria for Medicare payment of benefits for certain examinations requiring specific clinical indications as detailed below:
Item Number | Region | Clinical Indications |
|---|---|---|
SHOULDER/UPPER ARM ITEM NUMBER 55864 CLINICAL INDICATIONS Suspected rotator cuff tear Calcification Tendonitis Bursitis Capsulitis Biceps subluxation Mass lesion/ganglion AC joint pathology KNEE ITEM NUMBER 55880 CLINICAL INDICATIONS Tendon abnormality Bursa abnormality Meniscal pathology Injury to collateral ligaments Popliteal cysts/mass
GP REFERRED MRI FOR SPECIFIC CONDITIONS – ADULTS (AGED 16 YEARS OR OLDER) REGION Brain ITEM NUMBER 63551 CLINICAL INDICATIONS Chronic Headache Seizures REGION Cervical Spine ITEM NUMBER 63554 CLINICAL INDICATIONS Cervical Radiculopathy ITEM NUMBER 63557 CLINICAL INDICATIONS Cervical Spine Trauma KNEE (Aged 16-49 Only) ITEM NUMBER 63560 CLINICAL INDICATIONS Acute trauma with one of the following Inability to extend the knee and suspected Meniscal Tear Clinical findings suggesting acute Anterior Cruciate Ligament Tear (ACL)
GP REFERRED MRI FOR SPECIFIC CONDITIONS – PAEDIATRICS (AGED 16 YEARS OR UNDER) REGION BRAIN ITEM NUMBER 63507 CLINICAL INDICATIONS Headaches Seizures REGION PARANASAL SINUSES ITEM NUMBER 63507 CLINICAL INDICATIONS Sinus Pathology REGION KNEE* ITEM NUMBER 63513 CLINICAL INDICATIONS Internal Derangement REGION HIP ITEM NUMBER 63516 CLINICAL INDICATIONS Septic Arthritis Perthes Slipped Epiphysis REGION WRIST* ITEM NUMBER 63522 CLINICAL INDICATIONS Scaphoid Fracture REGION ELBOW* ITEM NUMBER 63519 CLINICAL INDICATIONS Fracture Avulsion Injury REGION CERVICAL SPINE THORACIC SPINE LUMBAR SPINE ITEM NUMBER 63510 CLINICAL INDICATIONS Pain Trauma
GASTROENTEROLOGIST REFERRED MRI FOR SPECIFIC CONDITIONS REGION ABDOMEN/PELVIS ITEM NUMBER 63740 CLINICAL INDICATIONS a) Evaluation of disease extent at time of initial diagnosis of Crohn's disease; b) Evaluation of exacerbation / suspected complications of known Crohn's disease; c) Evaluation of known or suspected Crohn's Disease in pregnancy; or d) Assessment of change in therapy in a patient with small bowel Crohn's disease. This item applies only once in a 12 month period where the service is provided for assessment of change to therapy in a patient with small bowel Crohn's disease REGION Abdomen/Pelvis ITEM NUMBER 63743 CLINICAL INDICATIONS a) Evaluation of pelvic sepsis and fistulas associated with established or suspected Crohn's disease; or b) Assessment of change to therapy of pelvis sepsis and fistulas from Crohn's disease. This item applies only once in a 12 month period where the service is provided for assessment of change to therapy of pelvis sepsis and fistulas from Crohn's disease
BONE MINERAL DENSITY CONDITIONS REGION BONE MINERAL DENSITY ITEM NUMBER 12306 CLINICAL INDICATIONS a) confirmation of a presumptive diagnosis of low bone mineral density made on the basis of one or more fractures occuring after minimal trauma; or b) monitoring of low bone mineral density proven by bone densitometry at least 12 months previously REGION BONE MINERAL DENSITY ITEM NUMBER 12312 CLINICAL INDICATIONS A) prolonged glucocorticoid therapy; ( ‘Prolonged glucocorticoid therapy’ is defined as the commencement of a dosage of inhaled glucocorticoid equivalent to or greater than 800 micrograms B) any condition associated with excess glucocorticoid secretion; (a supraphysiological glucocorticoid dosage equivalent to or greater than 7.5 mg prednisolone in an adult taken orally per day; for a period anticipated to last for at least 4 months. Glucocorticoid therapy must be contemporaneous with the current scan. Patients no longer on steroids would not qualify for benefits C) male hypogonadism; (Male hypogonadism is defined as serum testosterone levels below the age matched normal range D) female hypogonadism lasting more than 6 months before the age of 45; (Female hypogonadism is defined as serum oestrogen levels below the age matched normal range). other than a service associated with a service to which item 12306, 12315 or 12321 applies For any particular patient, once only in a 12 month period REGION BONE MINERAL DENSITY ITEM NUMBER 12315 CLINICAL INDICATIONS A) primary hyperparathyroidism; B) chronic liver disease; C) chronic renal disease; D) any proven malabsorptive disorder; (A malabsorptive disorder is defined as one or more of the following: 1) malabsorption of fat, defined as faecal fat; 2) bowel disease with presumptive vitamin D; 3) histologically proven Coeliac disease E) rheumatoid arthritis; F) any condition associated with thyroxine excess; REGION BONE MINERAL DENSITY ITEM NUMBER 12320 CLINICAL INDICATIONS a) the patient is 70 years of age or over; and b) either: 1) the patient has not previously had bone densitometry; or 2) the t-score for the patient’s bone mineral density is -1.5 or more. REGION BONE MINERAL DENSITY ITEM NUMBER 12321 CLINICAL INDICATIONS a) established low bone mineral density; or b) confirming a presumptive diagnosis of low bone mineral density made on the basis of one or more fractures occuring after minimal trauma. REGION BONE MINERAL DENSITY ITEM NUMBER 12322 CLINICAL INDICATIONS a) the patient is 70 years of age or over; and b) the t-score for the patient’s bone mineral density is less than -1.5 but more than -2.5;
CT CORONARY ANGIOGRAM CONDITIONS ITEM NUMBERREGIONCLINICAL INDICATIONS REGION CTCA ITEM NUMBER 57360 CLINICAL INDICATIONS Patient not known to have coronary artery disease who has stable or acute symptoms consistent with coronary ischaemia and is at low to intermediate risk of an acute coronary event (Not applicable more than once in 5 years.) Patient meets the criteria for selective coronary angiography under MBS Item No 38244, 38247, 38248 or 38249. CT Coronary angiography will be performed as an alternative assessment. REGION CTCA ITEM NUMBER 57364 CLINICAL INDICATIONS Stable symptoms and newly recognised left ventricular systolic dysfunction of unknown aetiology Will require the assessment of one or more bypass grafts. Will be undergoing non-coronary cardiac surgery Requires exclusion of coronary artery anomaly or fistula
NUCLEAR MEDICINE MYOCARDIAL PERFUSION / VIABILITY SCAN CONDITIONS REGION MIBI ITEM NUMBER 61345 CLINICAL INDICATIONS Patient has symptoms of Cardiac Ischemia and must meet 1 of the criteria Stress echo unlikely to be adequate due to: (a)body habitus, including obesity, (b) arrhythmia, including atrial fibrillation Unable to exercise adequately for maximal exercise test Failed previous stress echo (in last 24 months) Repeat within 24 mths if patient has undergone Revascularisation since Myocardial Perfusion and or has ongoing or evolving symptoms
MRI SCAN OF CARDIOVASCULAR SYSTEM FOR ASSESSMENT OF MYOCARDIAL STRUCTURE AND FUNCTION CONDITIONS REGION Cardiac ITEM NUMBER 63395 CLINICAL INDICATIONS Symptoms or Investigations consistent with ARVC (Arrythmogenic Right Ventricular Cardiomyopathy) REGION Cardiac ITEM NUMBER 63397 CLINICAL INDICATIONS Asymptomatic with 1 or more first degree relatives with ARVC REGION Cardiac ITEM NUMBER 63399 CLINICAL INDICATIONS a. The patient has suspected myocarditis after receiving a mRNA COVID-19 vaccine; and b. the patient had symptom onset within 21 days of a mRNA COVID-19 vaccine administration; and c. the results from the following examinations are inconclusive to form a diagnosis of myocarditis: (i) echocardiogram; and (ii) troponin; and (iii) chest X-ray. Applicable not more than once in a patient’s lifetime (R) (Contrast)
TRANSTHORACIC ECHOCARDIOGRAM REGION CARDIAC ITEM NUMBER 55126 CLINICAL INDICATIONS Initial transthoracic echocardiographic examination of the heart, Referred by GP or Specialist every 2 years To investigate any of the following: (i) symptoms or signs of cardiac failure; (ii) suspected or known ventricular hypertrophy or dysfunction; (iii) pulmonary hypertension; (iv) valvular, aortic, pericardial, thrombotic or embolic disease; (v) heart tumour; (vi) symptoms or signs of congenital heart disease; (vii) other rare indications. REGION CARDIAC ITEM NUMBER 55127 CLINICAL INDICATIONS Repeat serial transthoracic echocardiographic examination of the heart, Can be billed every 12 months. (a) is for the investigation of known valvular dysfunction; and (b) is requested by a specialist or consultant physician REGION Cardiac ITEM NUMBER 55129 CLINICAL INDICATIONS Repeat serial transthoracic echocardiographic examination of the heart , Can be billed every 12 months (a) valvular dysfunction is not the primary issue for the patient (although it may be a secondary issue); and (b) the service is for the investigation of any of the following: (i) symptoms or signs of cardiac failure; (ii) suspected or known ventricular hypertrophy or dysfunction; (iii) pulmonary hypertension; (iv) aortic, thrombotic, embolic disease or pericardial disease (excluding isolated pericardial effusion or pericarditis); (v) heart tumour; (vi) structural heart disease; (vii) other rare indications; and (c) the service is requested by a specialist or consultant physician;
TRANSTHORACIC ECHOCARDIOGRAM REGION CARDIAC ITEM NUMBER 55126 CLINICAL INDICATIONS Initial transthoracic echocardiographic examination of the heart, Referred by GP or Specialist every 2 years To investigate any of the following: (i) symptoms or signs of cardiac failure; (ii) suspected or known ventricular hypertrophy or dysfunction; (iii) pulmonary hypertension; (iv) valvular, aortic, pericardial, thrombotic or embolic disease; (v) heart tumour; (vi) symptoms or signs of congenital heart disease; (vii) other rare indications. REGION CARDIAC ITEM NUMBER 55127 CLINICAL INDICATIONS Repeat serial transthoracic echocardiographic examination of the heart, Can be billed every 12 months. (a) is for the investigation of known valvular dysfunction; and (b) is requested by a specialist or consultant physician REGION Cardiac ITEM NUMBER 55129 CLINICAL INDICATIONS Repeat serial transthoracic echocardiographic examination of the heart , Can be billed every 12 months (a) valvular dysfunction is not the primary issue for the patient (although it may be a secondary issue); and (b) the service is for the investigation of any of the following: (i) symptoms or signs of cardiac failure; (ii) suspected or known ventricular hypertrophy or dysfunction; (iii) pulmonary hypertension; (iv) aortic, thrombotic, embolic disease or pericardial disease (excluding isolated pericardial effusion or pericarditis); (v) heart tumour; (vi) structural heart disease; (vii) other rare indications; and (c) the service is requested by a specialist or consultant physician;