Medicare indications

Government has set complex rules that apply to Medicare rebates for some of the procedures PRP Diagnostic Imaging performs. Information sheets are provided for these procedures, to establish if a patient is eligible for a Medicare rebate.

The Medicare rebates are available for the following:

Prostate MRI Update | 1 November 2021

PROSTATE MRI UPDATE | 1 NOVEMBER 2021

MRI PROSTATE

Item No

63541

· Referred by specialist in the speciality of urology, radiation oncology or medical oncology.

· The limit of one service each 12 months still applies.

Overview: The item has been amended to include an expanded population to allow patients at very high risk of prostate cancer due to family history and a high prostate specific antigen result to access the service. Some slight wording changes have also been made.

Service/Descriptor:

MRI scan of the prostate for the detection of cancer, requested by a specialist in the speciality of urology, radiation oncology or medical oncology:

if the request for the scan identifies that the patient is suspected of developing prostate cancer:

a) on the basis of a digital rectal examination; or

b) in the circumstances mentioned in clause 2.5.9A

Restrictions/requirements not listed in the item descriptor:

Clause 2.5.9A referred to in the descriptor contains the patient eligibility criteria. These are the essentially the same as the previous item but with an expanded population.

In summary:

· for a person 70 years or older, at least two PSA tests performed within an interval of 1- 3 months have a PSA concentration of greater than 5.5 μg/L and the free/total PSA ratio is less than 25%.

· for a person under 70 years, at least two prostate specific antigen (PSA) tests are performed within an interval of 1- 3 months have a PSA concentration of greater than 3.0 ng/ml, and the free/total PSA ratio is less than 25%, or the repeat PSA exceeds 5.5 μg/L; or

· for a person under 70 years, whose risk of developing prostate cancer based on relevant family history is at least double the average risk, at least two PSA tests performed within an interval of 1- 3 months have a PSA concentration greater than 2.0 ng/ml, and the free/total PSA ratio is less than 25%, or the repeat PSA exceeds 5.5 μg/L. Relevant family history is a first degree relative with or has had prostate cancer or suspected of carrying a BRCA 1 or BRCA 2 mutation.

Indication: Before this item was amended, patients with a high risk of developing prostate cancer as described had to have results from their PSA be above 2 micrograms per litre with a free/total PSA ratio of less than 25%. The item now also applies to high risk patients whose results from the repeat PSA test exceed 5.5 micrograms per litre, irrespective of free/total ratio result.

MRI PROSTATE – monitoring low risk diagnosed patients

Item No

63543

· Referred by specialist in the speciality of urology, radiation oncology or medical oncology.

Overview: The item has had minor description changes for administrative purposes. The frequency restrictions have also been clarified.

Service/Descriptor:

MRI scan of the prostate for the assessment of cancer, requested by a specialist in the speciality of urology, radiation oncology or medical oncology:

if the request for the scan identifies that the patient:

a) is under active surveillance following a confirmed diagnosis of prostate cancer by biopsy histopathology; and

b) is not undergoing, or planning to undergo, treatment for prostate cancer.

Restrictions/requirements not listed in the item descriptor:

A period of at least 12 months needs to have elapsed before benefits for a second service under 63543 are payable. Benefits are then only payable after a period of three years has elapsed from the date of the second scan and at least each three years thereafter. The previous restrictions used the date of diagnosis of prostate cancer as the reference for the timing intervals.

Benefits are not payable where the service is provided for the purposes of treatment planning or monitoring after treatment for prostate cancer.

Indication:

This item is used for monitoring low risk patients who have been diagnosed with prostate cancer and who have not been already treated or are not planning or undergoing treatment.

Cardiac Updates | 1 August 2020

Item No	Description
Item No 55126 Initial Echocardiogram Referred by: GP, Specialist, Consultant Physician Once in 24 months	Assessment of LV/ RV dysfunction, CCF, LVH & pulmonary hypertension. Valvular, aortic, pericardial, thromboembolic disease and other rare indications
Item No 55133 Serial Echocardiogram: Pericardial / cardiotoxic meds Referred by: GP, Specialist, Consultant Physician Nil time restriction	Serial pericarditis or pericardial effusion assessment LV function assessment due to cardiotoxic meds
Item No 55127 Serial Echocardiogram: Valvular assessment Referred by: Specialist, Consultant Physician Nil time restriction	Repeat valvular dysfunction assessment
Item No 55128 Rural providers only (Dubbo, Orange, Bathurst) Serial Echocardiogram: Valvular assessment Referred by: GP Nil time restriction	Repeat valvular dysfunction assessment
Item No 55129 Serial Echocardiogram: Structural or known CCF Referred by: Specialist, Consultant Physician Nil time restriction	Repeat for known heart failure or structural assessment
Item No 55134	Repeat Echocardiogram: Rare conditions Referred by: Specialist, Consultant Physician Nil time restriction
EXERCISE STRESS ECHOCARDIOGRAM
Item No 55141 Initial Exercise Stress Echocardiogram Referred by: GP, Specialist, Consultant Physician Once in 24 months	Symptoms of typical or atypical angina Suspected silent myocardial ischaemia ECG changes consistent with ischaemia Known CAD + symptoms suggestive of IHD Pre-op Assessment *see clinical req. below
Item No 55143 Serial Exercise Stress Echocardiogram Referred by: Specialist, Consultant Physician Once in 12 months	Had stress echo in previous 24 months Has evolving symptoms consistent with ischaemia
ECG
Item No 11704 ECG Referred by: GP, Specialist, Consultant Physician Once in 24 hours	Tracing and report
EXERCISE STRESS ECG
Item No 11729 Exercise Stress ECG Referred by: GP, Specialist, Consultant Physician Once in 24 months (incl. Stress Echo and Myocardial Perfusion Scan)	17yrs of age and above Symptoms consistent with cardiac ischaemia Arrhythmia and other cardiac disease exacerbated by exercise Suspected heritable arrhythmia – first degree relatives
Item No 11730 Exercise Stress ECG Referred by: GP, Specialist, Consultant Physician Once in 24 months	As above, for a patient under 17yrs of age
MONITORS
Item No 11716 Holter Monitor Referred by: GP, Specialist, Consultant Physician Once in 4 weeks	Syncope or pre-syncope Palpitations – episodes occurring › once a week Suspected or known TIA or stroke Suspected asymptomatic arrhythmia – expected frequency of › once a week
Item No 11717 Event Monitor Referred by: GP, Specialist, Consultant Physician 28 days of monitoring every 12 months	Unexplained palpitation or syncope. Other infrequent symptoms where rhythm disturbance is suspected
MYOCARDIAL PERFUSION SCAN
Item No 61329 Myocardial Perfusion Scan (Rest/Stress) Referred by: GP only Once in 24 months	Symptoms of cardiac ischaemia and one of the following: Not suitable for exercise or stress echo Has had a failed stress echo Preoperative assessment requires patient to have one of IHD, heart failure, stroke/TIA, renal dysfunction or IDDM
Item No 61345 Myocardial Perfusion Scan (Rest/Stress) Referred by: Specialist, Consultant Physician Once in 24 months	Symptoms of cardiac ischaemia and one of the following: Undue exertional dyspnoea of uncertain aetiology Not suitable for exercise or stress echo Has had a failed stress echo
Item No 61349 Repeat Myocardial Perfusion Scan (Rest/Stress) Referred by: Specialist, Consultant Physician Once in 12 months	CABG or stent in previous 24mths + symptoms of cardiac ischaemia and one of the following: Undue exertional dyspnoea of uncertain aetiology Not suitable for exercise or stress echo Has had a failed stress echo
Item No 61325 Rest Thallium Scan Referred by: Specialist, Consultant Physician Once in 24 months	For assessment of extent and severity of viable and non-viable myocardium on a patient with known CAD and left ventricular systolic dysfunction
*MBS eligible referral for Pre-operative assessment requires that the patient have one of the following: IHD, Heart Failure, Stroke/TIA, Renal dysfunction, IDDM.

Regional and Rural Cardiac Updates | 15 September 2020

Item No	Description
Item No 55126 Initial Echocardiogram Referred by: GP, Specialist, Consultant Physician Once in 24 months	Assessment of LV/ RV dysfunction, CCF, LVH & pulmonary hypertension Valvular, aortic, pericardial, thromboembolic disease and other rare indications
Item No 55133 Serial Echocardiogram: Pericardial / cardiotoxic meds Referred by: GP, Specialist, Consultant Physician Nil time restriction	Serial pericarditis or pericardial effusion assessment LV function assessment due to cardiotoxic medications (Herceptin/Anthracyclines/Clozapine)
Item No 55127 Serial Echocardiogram: Valvular assessment Referred by: Specialist, Consultant Physician Nil time restriction	Repeat valvular dysfunction assessment
Item No 55128 Rural providers only (Dubbo, Orange, Bathurst) Serial Echocardiogram: Valvular assessment Referred by: GP Nil time restriction	Repeat valvular dysfunction assessment
Item No 55129 Serial Echocardiogram: Structural or known CCF Referred by: Specialist, Consultant Physician Nil time restriction	Repeat for known heart failure or structural assessment
Item No 55134	Repeat Echocardiogram: Rare conditions Referred by: Specialist, Consultant Physician Nil time restriction
EXERCISE STRESS ECHOCARDIOGRAM
Item No 55141 Initial Exercise Stress Echocardiogram Referred by: GP, Specialist, Consultant Physician Once in 24 months	Symptoms of typical or atypical angina Suspected silent myocardial ischaemia ECG changes consistent with ischaemia Known CAD + symptoms suggestive of IHD Pre-op Assessment *see clinical req. below
Item No 55143 Serial Exercise Stress Echocardiogram Referred by: Specialist, Consultant Physician Once in 12 months	Had stress echo in previous 24 months Has evolving symptoms consistent with ischaemia
ECG
Item No 11704 ECG Referred by: GP, Specialist, Consultant Physician Once in 24 hours	Tracing and report
EXERCISE STRESS ECG
Item No 11729 Exercise Stress ECG Referred by: GP, Specialist, Consultant Physician Once in 24 months (incl. Stress Echo and Myocardial Perfusion Scan)	17yrs of age and above Symptoms consistent with cardiac ischaemia Arrhythmia and other cardiac disease exacerbated by exercise Suspected heritable arrhythmia – first degree relatives
Item No 11730 Exercise Stress ECG Referred by: GP, Specialist, Consultant Physician Once in 24 months	As above, for a patient under 17yrs of age
MONITORS
Item No 11716 Holter Monitor Referred by: GP, Specialist, Consultant Physician Once in 4 weeks	Syncope or pre-syncope Palpitations – episodes occurring › once a week Suspected or known TIA or stroke Suspected asymptomatic arrhythmia – expected frequency of › once a week
Item No 11717 Event Monitor Referred by: GP, Specialist, Consultant Physician 28 days of monitoring every 12 months	Unexplained palpitation or syncope. Other infrequent symptoms where rhythm disturbance is suspected
MYOCARDIAL PERFUSION SCAN
Item No 61398 Myocardial Perfusion Scan (Rest/Stress) Referred by: GP only Once in 24 months	Patient exhibits symptoms of cardiac ischaemia chest pain with specific features, pre-operative assessment under limited indications, follow up of CTCA or ECG abnormalities and some other specified criteria MPS Item Number 61398 specific to rural NSW (excludes areas 1 and 2 of the Modified Monash Model)
Item No 61406 Myocardial Perfusion Scan (Rest/Stress) Referred by: Specialist, Consultant Physician Once in 24 months	Patient exhibits symptoms of cardiac ischaemia MPS Item Number 61406 specific to rural NSW (excludes areas 1 and 2 of the Modified Monash Model)
Item No 61410 Repeat Myocardial Perfusion Scan (Rest/Stress) Referred by: Specialist, Consultant Physician Once in 12 months	CABG or stent in previous 24mths + symptoms of cardiac ischaemia

*MBS eligible referral for Pre-operative assessment requires that the patient have one of the following: IHD, Heart Failure, Stroke/TIA, Renal dysfunction, IDDM.

MRI Specialists Rebates | Breast - 1 November 2019

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)

Specialists Rebates | PET Breast - 1 November 2019

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.

MRI Specialists Rebates | Obstetric - 1 August 2019

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

Description

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.

MRI Specialists Rebates | Liver - 1 May 2019

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	Description
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.

MRI GP Rebates | Head, Neck & Knee - 1 Nov 2018

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	Description
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.

PRP Diagnostic Imaging is an eligible provider.

To view the options for patients under 16 years old, please see below.

Prostate MRI Scans – 1 July 2018

A Medicare rebate will be available for these items numbers performed at – PRP Bathurst, Charlestown, Dee Why, 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

Item No
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.

Item No
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.

PET Medicare Updates - 1 May 2018

Item No

Description

Item No
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)

Breast MRI Updates - 1 May 2018

Item No

Description

Item No
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.)

Item No

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.)

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