Referrers

Referrers

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Medicare Indications

The Government has set complex rules that apply to Medicare rebates for a number of procedures that PRP Diagnostic Imaging perform. Information sheets are provided to establish if a patient is eligible for a Medicare rebate.

Medicare rebates are available for the following:

Bone Mineral Densitometry

Unfortunately, not all patients are eligible for a Medicare rebate for bone mineral densitometry.

1. Item number 12306 is charged for confirmation of a presumptive diagnosis of low bone mineral density made on the basis of:

  • 1 or more fractures occurring after minimal trauma;
  • For the monitoring of osteoporosis proven by bone densitometry at least 12 months previously.

2. Item number 12312 is charged for the diagnosis and monitoring of bone loss associated with 1 or more of the following conditions:

  • Prolonged glucocorticoid therapy;
  • Conditions associated with excess glucocorticoid secretion;
  • Male hypogonadism;
  • Female hypogonadism lasting more than 6 months before age 45. 

3. Item number 12315 is charged for the diagnosis and monitoring of bone loss associated with 1 or more of the following conditions:

  • Primary hyperparathyroidism;
  • Chronic liver disease;
  • Chronic renal disease (excluding kidney stones);
  • Proven malabsorptive disorders;
  • Rheumatoid arthritis;
  • Conditions associated with thyroxine excess.

4. Item number 12321 is charged for the measurement of bone density 12 months following significant change in therapy for established low bone density or confirmation of a presumptive diagnosis of low bone mineral density made on the basis of:

  • 1 or more fractures occurring after minimal trauma.

5. Item number 12323 is charged for the diagnosis and monitoring of bone loss in ALL patients aged 70 years and over. This number takes precedence over any other bone density number and should therefore be used in all patients over 70 years of age because there is no time restriction on this service.

Shoulder and Knee Ultrasound

Medicare will only provide a rebate if the referral specifically includes one of the suspected pathologies:

Shoulder Ultrasound

Benefits are payable when referred with suspicion of the following clinical conditions:

  • evaluation of injury to tendon, muscle or tendon/muscle junction including tears, calcification or tendinosis;
  • rotator cuff tear/calcification/tendinosis of biceps, subscapular, supraspinatus or infraspinatus;
  • biceps subluxation;
  • capsulitis and bursitis;
  • evaluation of mass, including ganglion;
  • occult fracture;
  • acromioclavicular joint pathology.

Knee Ultrasound

Benefits are payable when referred with suspicion of the following clinical conditions:

  • abnormality of tendons or bursae about the knee;
  • meniscal cyst, popliteal fossa cyst, mass or pseudomass;
  • nerve entrapment, nerve or nerve sheath tumour.

Benefits are not payable when referred for non-specific knee pain alone or other knee conditions including:

  • meniscal and cruciate ligament tears;
  • assessment of chondral surfaces.
Nuchal Translucency Ultrasound

Your patient may be eligible for a Medicare rebate when any of the following features are present and stated on the referral:

1. The patient is 11 weeks 4 days to 13 weeks 6 days gestation by Ultrasound and referred by a medical practitioner, and

2. One or more of the following conditions are present:

  • abdominal pain or mass;
  • abdominal wall scarring;
  • advanced maternal age;
  • alloimmunisation;
  • autoimmune disease;
  • bowel stoma;
  • cardiac disease;
  • diabetes mellitus;
  • diminished symptoms of pregnancy;
  • drug dependency;
  • high risk pregnancy;
  • hyperemesis gravidarum;
  • hypertension;
  • inflammatory bowel disease;
  • liver or renal disease;
  • maternal infection;
  • poor obstetric history;
  • pregnancy after assisted reproduction;
  • previous caesarean section;
  • previous post-dates delivery;
  • previous spinal or pelvic trauma or disease;
  • risk of fetal abnormality;
  • risk of miscarriage;
  • significant maternal obesity;
  • suspected or known cervical incompetence;
  • suspected or known uterine abnormality;
  • suspicion of ectopic pregnancy;
  • thrombophilia;
  • toxaemia of pregnancy;
  • uncertain dates.
Digital Mammography

Requesting doctors must include relevant clinical indications / history for all mammography procedures, otherwise patients are not eligible for a Medicare rebate.

For patients to be eligible for a Medicare rebate, you must include your reasons to suspect malignancy in the breasts because of:

  • the past occurrence of breast malignancy in the patient or in a member of the patient's family (blood relative).

OR

  • symptoms or indications of malignancy found on an examination of the patient by a medical practitioner.
Physiotherapists and Chiropractors

Physiotherapists and Chiropractors may request diagnostic imaging, however only certain items are entitled to a Medicare rebate:

  • examination of the hip joint;
  • examination of the pelvic girdle;
  • examination of the cervical spine;
  • examination of the thoracic spine;
  • examination of the lumbosacral spine;
  • examination of the four regions of the spine;
  • examination of the sacrococcygeal region;
  • examination of two regions of the spine;
  • examination of three regions of the spine.

For more information please contact our Medical Liaison Officers

Email mlos@prpimaging.com.au or Fax 02 8078 4565