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:
From 1st November 2019 Medicare Rebates will become available for two new item numbers (63531 and 63533) covering MRI for breast cancer.
- PRP Radiologists provide premium breast reporting services
- Available on both full and partial eligible MRI machines
- Specialists and consultant physicians are eligible to request these item numbers
- GP’s are not able to request these numbers
ITEM NO
DESCRIPTION
Item No
63531
MRI of both breasts where the patient has a breast lesion, the results of conventional imaging scanning are inconclusive for the presence of breast cancer and biopsy has not been possible.
Item No
63533
MRI of both breasts where the patient has been diagnosed with breast cancer, discrepancy exists between clinical assessment and conventional imaging assessment, and the results of the breast MRI may alter treatment planning.
Item No
63464
MRI of both breasts for breast cancer where
- A dedicated breast coil is used and
- The person is asymptomatic and under 50 years of age and
- The patient is at high risk of developing breast cancer due to one
of the following
- 3 or more Ist or 2nd degree relatives on the same side of the family that have been diagnosed with either breast or ovarian cancer
- 2 or more Ist or 2nd degree relatives on the same side of the family
that have been diagnosed with either breast or ovarian cancer if any
applies to one relative
- Has been diagnosed with bilateral breast cancer
- Has onset of breast cancer before the age of 40 years
- Had onset of ovarian cancer before the age of 50
- Has been diagnosed with both breast and ovarian cancer
- Has Ashkenazi Jewish Ancestry
- Is a male relative diagnosed with breast cancer
- One 1st or 2nd degree relative diagnosed with breast cancer at age 45 years or younger + another 1st or 2nd degree relative on the same side diagnosed with bone or soft tissue sarcoma at 45 years or younger
- Genetic testing has revealed high risk breast cancer gene mutation
Item No
63467
MRI scan of both breasts for detection of breast cancer where:
- A dedicated breast coil is used and
- The patient has had an abnormality detected as a result of a service described in item 63464 performed in the last 12 months
Item No
63487
MRI-performed under the professional supervision of an eligible provider at an eligible location, if;
- the patient is referred by a specialist or a consultant physician; and
- a dedicated breast coil is used; and
- the request for the scan identifies that:
- the patient has been diagnosed with metastatic cancer restricted to the regional lymph nodes; and
- clinical examination and conventional imaging have failed to identify the primary cancer (R) (K) (Anaes)
Item No
63489
MRI-guided biopsy, performed under the professional supervision of an eligible provider at an eligible location, if;
- the patient is referred by a specialist or a consultant physician; and
- a dedicated breast coil is used; and
- the request for the scan identifies that:
- the patient has a suspicious lesion seen in MRI but not on conventional imaging: and
- the lesion is not amenable to biopsy guided by conventional imaging; and
- a repeat ultrasound scan of the affected breast is performed:
- before the guided biopsy is performed; and
- as part of the service under this item (r) (K) (Anaes)
From 1st November 2019 Medicare Rebates will become available for two new item numbers (61524 and 61525) covering PET breast scans.
- PRP Radiologists provide premium breast reporting services
- PET is available at PRP Gosford
- Specialists and consultant physicians are eligible to request these item numbers
- GPs are not able to request these numbers
ITEM NO
DESCRIPTION
Item No
61524
Whole body 18F-FDG PET study where a patient is referred by a specialist or consultant physician, performed for the staging of locally advanced (Stage III) breast cancer in a patient considered suitable for active therapy.
Item No
61525
Whole body 18F-FDG PET study where a patient is referred by a specialist or consultant physician, performed for the evaluation of suspected metastatic, or suspected locally or regionally recurrent breast carcinoma in a patient considered suitable for active therapy.
From 1st August 2019 Medicare Rebates will become available for new item numbers covering Obstetric MRI scans for patients at ≥ 18 weeks gestation with suspected fetal central nervous system abnormality and diagnosis is indeterminate (items 63454(K) and 63460(NK)).
- PRP Radiologists provide premium obstetric reporting services
- Obstetric MRI Imaging is available at PRP Dee Why, Cumberland Moore Park and Norwest. All eligible requests will be Bulk Billed
- MRI Scan Time: Approx 45 minutes
- Specialist Obstetricians are eligible to request these item numbers
- GPs and other types of specialists and consultant physicians are not able to request these numbers
Item No
63454
≥18 weeks suspected foetal central nervous system abnormality (obstetrician referred / tertiary ultrasounds completed).
Note: There are no restrictions on the number of services that can be provided to a patient where clinically necessary. However the obstetric MRI service will not be available as a stand-alone screening test for fetal abnormalities, the patient must have had two separate obstetric ultrasound exams in either the second (between 17 and 22 weeks) or the third trimester (after 22 weeks) of the pregnancy (NB There will no longer be a requirement for specific ultrasound item numbers to be billed to Medicare prior to the MRI. Therefore patients will still be eligible for a rebateable MRI if prior scans are performed in a public hospital as a public patient). Specialist obstetricians who provide the pre-test tertiary ultrasounds must have certification in maternal fetal medicine or obstetrical and gynaecological ultrasound.
From 1st May 2019 Medicare Rebates will become available for new item numbers covering MRI liver scans for patients with known or suspected colorectal carcinoma (Item 63545) or hepatocellular carcinoma (Item 63546) and (Item 63496) the use of a hepatobiliary specific contrast agent with the liver MRI scans.
- PRP Radiologists provide premium liver reporting services
- MRI scans that meet Medicare requirements are rebateable on an MRI unit with both full and partially eligibility
- Specialists and consultant physicians are eligible to request these item numbers
- GPs are not able to request these numbers
Item No
63545
Known colorectal carcinoma, known liver lesion detected on CT or US, for characterisation.
Item No
63546
Patient with known or suspected HCC (hepatocellular carcinoma), including:
- chronic liver disease,
- a previously imaged liver lesion greater than 10mm, and
- assessed as Child-Pugh A or B liver function.
Item No
63496
Items 63545 & 63546 are to be performed with either:
- the new contrast agent item which permits the use of a hepatobiliary specific contrast agent, or;
- in cases where the use of a standard extracellular contrast agent is clinically indicated, the existing MRI modifying item 63491 can be used.
One of the key initiatives of the Diagnostic Imaging Reform Package is to expand patient access to MRI services across Australia. This includes increased access to MRI services for primary care patients 16 years and over by extending requesting rights to GPs for a small set of clinically appropriate indications. GPs are able to request three new Magnetic Resonance Imaging (MRI) Medicare services for patients 16 years of age and over. GPs are now not able to refer patients aged 50 years and over for knee MRIs.
Item No
63551
HEAD
referral by a medical practitioner (excluding a specialist or consultant physician) for a scan of head for a patient 16 years or older for any of the following:
- unexplained seizure(s)
- unexplained chronic headache with suspected intracranial pathology
Item No
63554
CERVICAL SPINE
referral by a medical practitioner (excluding a specialist or consultant physician) for a scan of spine for a patient 16 years or older for suspected: • cervical radiculopathy
Item No
63557
CERVICAL SPINE
referral by a medical practitioner (excluding a specialist or consultant physician) for a scan of spine for a patient 16 years or older for suspected:
- cervical spine trauma
Item No
63560
KNEE
referral by a medical practitioner (excluding a specialist or consultant physician) for a scan of knee following acute knee trauma for a patient 16 – 49 years with:
- inability to extend the knee suggesting the possibility of acute meniscal tear;
or - clinical findings suggesting acute anterior cruciate ligament tear
Details of the item descriptors and explanatory notes can be found at mbsonline.gov.au or you can download the Australian Government Department of Health Fact Sheet here
PRP Diagnostic Imaging is an eligible provider.
To view the options for patients under 16 years old, please click here.
- A Medicare rebate will be available for these items numbers performed at - PRP Bathurst, Charlestown, Dubbo, Frenchs Forest, Gosford, Hornsby, Maitland, Orange, Shellharbour, Tuggerah.
- Specialists and consultant physicians are eligible to request these items.
- GPs are not eligible to request these items.
ITEM NO
DESCRIPTION
63541
Diagnosis Item Number - 63541
For MBS item 63541 the patient must be suspected of having prostate cancer based on:
- A digital rectal examination (DRE) which is suspicious for prostate cancer; or
- in a person aged less than 70 years, at least two prostate specific antigen (PSA) tests performed within an interval of 1-3 months are greater than 3.0 ng/ml, and the free/total PSA ratio is less than 25% or the repeat PSA exceeds 5.5 ng/ml; or
- in a person aged less than 70 years, whose risk of developing prostate cancer based on family history is at least double the average risk , at least two PSA tests performed within an interval of 1-3 months are greater than 2.0 ng/ml, and the free/total PSA ratio is less than 25%; or
- in a person aged 70 years or older, at least two PSA tests performed within an interval of 1-3 months are greater than 5.5ng/ml and the free/total PSA ratio is less than 25%.
Relevant family history is a first degree relative with prostate cancer or suspected of carrying a BRCA 1, BRCA 2 mutation.
Note: Benefits are payable on one occasion in any 12 month period.
63543
Active Surveillance Item Number – 63543
For MBS item 63543 the below clinical criteria must be met:
- the patient is under active surveillance following a confirmed diagnosis of prostate cancer by biopsy histopathology; and
- the patient is not planning or undergoing treatment for prostate cancer.
Note: Benefits are payable for patients who have not had a diagnostic mpMRI, and are placed on active surveillance following confirmed diagnosis; or 12 months following diagnosis and then every 3rd year thereafter or at any time, if there is any concern clinically or with PSA progression. The item is not to be used for the purposes of treatment, planning or for monitoring after treatment.
ITEM NO
DESCRIPTION
61647
Whole body 68Ga‑DOTA‑peptide PET study (including any associated computed tomography scans for anatomic localisation and attenuation correction), if:
- a gastro‑entero‑pancreatic neuroendocrine tumour is suspected on the basis of biochemical evidence with negative or equivocal conventional imaging; or
- both:
(i) a surgically amenable gastro‑entero‑pancreatic neuroendocrine tumour has been identified on the basis of conventional techniques; and
(ii) the study is for excluding additional disease sites (R)
ITEM NO
DESCRIPTION
63395
MRI scan of the cardiovascular system for assessment of myocardial structure and function involving:
- dedicated right ventricular views; and
- 3D volumetric assessment of the right ventricle; and
- reporting of end‑diastolic and end‑systolic volumes, ejection fraction and BSA‑indexed values;
if the request for the scan indicates that:
- the patient presented with symptoms consistent with arrhythmogenic right ventricular cardiomyopathy (ARVC);
or
- investigative findings in relation to the patient are consistent with ARVC
NOTE: benefits are payable once in 12 months (R) (K) (Contrast) (Anaes.)
63396
MRI scan of the cardiovascular system for assessment of myocardial structure and function involving:
- dedicated right ventricular views; and
- 3D volumetric assessment of the right ventricle; and
- reporting of end‑diastolic and end‑systolic volumes, ejection fraction and BSA‑indexed values;
if the request for the scan indicates that: - the patient presented with symptoms consistent with arrhythmogenic right ventricular cardiomyopathy (ARVC); or
- investigative findings in relation to the patient are consistent with ARVC
NOTE: benefits are payable once in 12 months (R) (K) (Contrast) (Anaes.)
63397
MRI scan of the cardiovascular system for assessment of myocardial structure and function involving:
- dedicated right ventricular views; and
- 3D volumetric assessment of the right ventricle; and
- reporting of end‑diastolic and end‑systolic volumes, ejection fraction and BSA‑indexed values;
if the request for the scan indicates that the patient: - is asymptomatic; and
- has one or more first degree relatives diagnosed with confirmed arrhythmogenic right ventricular cardiomyopathy (ARVC)
NOTE: benefits are payable once in 36 months (R) (K) (Contrast) (Anaes.)
63398
MRI scan of the cardiovascular system for assessment of myocardial structure and function involving:
- dedicated right ventricular views; and
- 3D volumetric assessment of the right ventricle; and
- reporting of end‑diastolic and end‑systolic volumes, ejection fraction and BSA‑indexed values;
if the request for the scan indicates that the patient: - is asymptomatic; and
- has one or more first degree relatives diagnosed with confirmed arrhythmogenic right ventricular cardiomyopathy (ARVC)
NOTE: benefits are payable once in 36 months (R) (K) (Contrast) (Anaes.)
ITEM NO
DESCRIPTION
63547
MRI scan of both breasts for the detection of cancer, if
- a dedicated breast coil is used; and
- the request for the scan identifies that:
(i) the patient has a breast implant in situ; and
(ii) anaplastic large cell lymphoma has been diagnosed
NOTE: benefits are payable once in a patient's lifetime (R) (K) (Contrast) (Anaes.)
63548
MRI scan of both breasts for the detection of cancer, if
- a dedicated breast coil is used; and
- the request for the scan identifies that:
(i) the patient has a breast implant in situ; and
(ii) anaplastic large cell lymphoma has been diagnosed
NOTE: benefits are payable once in a patient's lifetime (R) (K) (Contrast) (Anaes.)
including medicare updates | 1 November 2017
ITEM NO
INDICATIONS
EXPLANATORY NOTES
12320
1 service per 60 consecutive months.
Patients 70 years and over who have not had a previous BMD.
Patients aged 70 years and over with a T score above -1.5.
MBS change 1.11.17
12322
1 service per 24 consecutive months
Patients aged 70 years and over with moderate to marked osteopenia. (T score between -1.5 and -2.5).
MBS change 1.11.17
PATIENTS DIAGNOSED WITH OSTEOPOROSIS WILL CONTINUE TO BE TESTED USING OTHER CLINICALLY APPROPRIATE MBS BONE DENSITOMETRY ITEMS.
12306
1 service per 24 months
- The confirmation of a presumptive diagnosis of low bone mineral density made on the basis of 1 or more fractures occurring after minimal trauma, or
- For the monitoring of low bone mineral density proven by bone densitometry at least 12 months previously.
Low bone mineral density is present when the bone mineral density falls more than 1.5 standard deviations below the age matched mean or more than 2.5 standard deviations below the young normal mean for the same site same gender.
12312
1 service per 12 consecutive months
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; or
- female hypogonadism lasting more than 6 months before the age of 45.
a. ‘Prolonged glucocorticoid therapy’ is defined as a dosage of inhaled glucocorticoid equivalent to or greater
than 800 micrograms beclomethasone dipropionate or budesonide per day; or
b. 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 going at the time of the scan. Patients no longer on steroids would not qualify for benefits.
12315
1 service per 24 consecutive months
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;
- proven malabsorptive disorders;
- rheumatoid arthritis; or
- conditions associated with thyroxine excess.
A malabsorptive disorder is defined as one or more of the following:
a. malabsorption of fat, defined as faecal fat estimated at greater than 18 gm per 72 hours on a normal fat diet;
or
b. bowel disease with presumptive vitamin D malabsorption
as indicated by a sub-normal circulating 25-hydroxyvitamin D level; or
c. histologically proven Coeliac disease.
12321
1 service per 12 consecutive months
For the measurement of bone density 12 months following a significant change in therapy for:
- established low bone mineral density; or
- the confirmation of a presumptive diagnosis of low bone mineral density made on the basis of 1 or more fractures occurring after minimal trauma.
Item 12321 is intended to allow for bone mineral density measurement following a significant change in therapy - e.g. a change in the class of drugs - rather than for a change in the dosage regimen.
medicare updates | 1 November 2017
SERVICE
ITEM NO
DESCRIPTION OF CHANGE
SPINE
X-RAY
ONE REGION
58100
58103
58106
58109
These items amended to restrict allied health practitioners to requesting one of these items for the same patient on the same day.
SPINE
X-RAY
TWO REGION
58112
These items amended to restrict allied health practitioners to requesting one of these items for the same patient on the same day.
SPINE
X-RAY
THREE REGION
58121
Requesting rights for these items restricted to medical practitioners, physiotherapists and osteopaths.
Chiropractor referrals are not claimable from Medicare.
Alternatively, the patient may opt to have three (or four) region x-ray in one day. Two regions would be rebatable. The patient would need to pay a $25 flat fee for the non-rebatable regions.
SPINE
X-RAY
FOUR REGION
58120
Requesting rights for these items restricted to medical practitioners, physiotherapists and osteopaths.
Chiropractor referrals are not claimable from Medicare.
Alternatively, the patient may opt to have three (or four) region x-ray in one day. Two regions would be rebatable. The patient would need to pay a $25 flat fee for the non-rebatable regions.
New MRI Enterography items for the evaluation of:
- small bowel Crohn’s disease
- anal fistulas and pelvic sepsis in established or suspected Crohn’s disease
Please note that these scans are Medicare-eligible for Specialist referral only on fully or partially licensed magnets.
Item No
63740
MRI to evaluate small bowel Crohn’s disease
- Evaluation of disease extent at time of initial diagnosis of Crohn’s disease.
- Evaluation of exacerbation/suspected complications of known Crohn’s disease.
- Evaluation of known or suspected Crohn’s disease in pregnancy.
- Assessment of change to therapy in patients with small bowel Crohn’s disease. (This can only be claimed once in a 12 month period.)
Item No
63743
MRI for fistulising perianal Crohn’s disease
- Evaluation of pelvic sepsis and fistulas associated with established or suspected Crohn’s disease.
- Assessment of change to therapy of pelvic sepsis and fistulas from Crohn’s disease. (This can only be claimed once in a 12 month period.)
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.
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.
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.
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 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