Commonwealth Numbered Regulations - Explanatory Statements

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HEALTH INSURANCE (GENERAL MEDICAL SERVICES TABLE) AMENDMENT REGULATIONS 2004 (NO. 2) 2004 NO. 77

EXPLANATORY STATEMENT

STATUTORY RULES 2004 NO. 77

Issued by the Authority of the Minister for Ageing

Health Insurance Act 1973

Health Insurance (General Medical Services Table) Amendment Regulations 2004 (No. 2)

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 payment 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. The Health Insurance (General Medical Services Table) Regulations 2003 (the Principal Regulations) currently prescribe such a table.

The purpose of the Regulations is to amend the Principal Regulations as part of the ongoing management of the General Medical Services Table. The Regulations also incorporate changes to items in the table resulting from reviews by the Medicare Benefits Consultative Committee. These reviews are designed to ensure that the table reflects current medical practice and encourages best practice.

The changes include additions to rules of interpretation and amendments to a number of items to reflect current clinical practice.

The Medical Services Advisory Committee has assessed the evidence supporting the safety, effectiveness and cost-effectiveness of a number of new medical technologies. Consequently, seven new items are introduced for four new technologies, namely:

•       capsule endoscopy (item 11820) to detect causes of bleeding in the small bowel;

•       thyrotropin alfa-rch (item 12201) to detect thyroid cancer remnants;

•       transanal endoscopic microsurgery (items 32103, 32104 and 32106) to remove tumours in the rectum; and

•       radiofrequency ablation (items 50950 and 50952) to treat tumours of the liver.

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 Regulations may be exercised.

The Regulations commence on 1 May 2004.

ATTACHMENT

DETAILS OF THE HEALTH INSURANCE (GENERAL MEDICAL SERVICES TABLE) AMENDMENT REGULATIONS 2004 (No. 2)

Regulation 1 provides for the Regulations to be referred to as the Health Insurance (General Medical Services Table) Amendment Regulations 2004 (No. 2).

Regulation 2 provides for the Regulations to commence on 1 May 2004.

Regulation 3 provides for Schedule 1 to amend the Health Insurance (General Medical Services Table) Regulations 2003 (the Principal Regulations).

Schedule 1 - Amendments

Part 1 - Amendments of Schedule 1, Part 2 (Rules of Interpretation)

Item [1]

This item inserts item 12201 in subrules 10 (2) and 11 (3), to appropriately refer to all professional attendance items.

Item [2]

This item omits item 11706 from subrule 12 (2), as this item is being deleted from the Services and Fees Table (see item [9] below).

Item [3]

This item corrects a reference to the appropriate section of the Health Insurance Act 1973 in rule 16A following a legislative change to the definition of a "prescribed dental patient".

Item [4]

This item substitutes a new subrule 41 (2) to stipulate patient eligibility for a new service, the adult health check for Aboriginal and Torres Strait Islander peoples. The 'adult health check' item is being introduced for people of Aboriginal or Torres Strait Islander descent, aged at least 15 years old and less than 55 years old, and who are not in-patients of a hospital or day-hospital facility, or a care recipient in a residential aged care facility. The terms of the existing subrule 41 (2) is being remade as new subrule 41 (3).

Item [5]

This item amends rule 43 to reflect a small change in phrasing implemented under rule 43A (see item [6] below).

Item [6]

This item introduces a new rule 43A, which outlines the meaning of 'adult health check' in new item 710 (see item [7] below). The Rule specifies each of the activities and responsibilities associated with providing the service.

Part 2 - Amendments of Schedule 1, Part 3 (Services and Fees)

Reviews of the services in the table undertaken since November 2003 relate to adult health checks for Aboriginal and Torres Strait Islander peoples, optometry, cardiovascular, gastroenterology and colorectal procedures, general surgery, colorectal surgery, tunnelled cuffed catheter, uterine artery embolisation, gynaecological and urological surgery, kidney surgery, cardio-thoracic surgery, and plastic and reconstructive surgery. The following items give effect to the outcomes of those reviews.

Item [7]

This item introduces new item 710 for an adult health check for Aboriginal and Torres Strait Islander peoples. This item could not be claimed for a patient in respect of whom, in the preceding 18 months, a payment had been made under this item.

Item [8]

This item corrects item 10907 which was incorrectly described in the Principal Regulations.

Item [9]

This item deletes item 11706 to remove an obsolete procedure from the Medicare Benefits Schedule (MBS) table.

Item [10]

This item introduces a new item 11820 for capsule endoscopy to investigate episodes of obscure gastrointestinal bleeding in certain circumstances. Patients eligible for this item have to be aged 18 years or over, have recurrent or persistent bleeding and be anaemic or have active bleeding. Additional conditions are stipulated in the item which must be met before claiming this item.

Item [11]

This item introduces a new item 12201 for the detection of recurrent well-differentiated thyroid cancer in patients for whom thyroid hormone therapy withdrawal is medically contra-indicated. The item description outlines specific circumstances under which the item could be claimed.

Item [12]

This item amends the terminology used in item 13842. The word 'cannulisation' is changed to the more grammatically correct term 'cannulation' in the item description to ensure consistency with other items in the MBS table.

Item [13]

This item amends item 30096 to define the method of biopsy as an open procedure, and to require the biopsy specimen to be sent for pathological examination.

Item [14]

This item amends item 30186 to clarify that this item does not attract a flat fee of $39.45 for the removal of any number of warts from one to nine, nor does it attract a fee of $39.45 per wart, but rather that the multi-operations rule described in Section 1.5 of the Health Insurance Act 1973 applies to this item for the treatment of more than one wart.

Item [15]

This item amends item 30419 to prevent benefits being paid under this item if radiofrequency ablation is performed under item 50950 or 50952 on the same patient on the same day.

Item [16]

This item amends item 31200 to exclude shave excision as a method of removal for tumours, cysts, ulcers and scars, which reflects the original intent of the item.

Item [17]

This item amends item 31340 to insert the requirement that the excised specimen be sent for histological confirmation, thus aligning this item with other items with which it may be claimed.

Item [18] and [19]

These items amend item 32024 and 32025 to prevent benefits being paid if transanal endoscopic microsurgery (TEMS) is performed under new items 32103, 32104 and 32106 on the same patient on the same day.

Item [20]

This item introduces two new items 32103 and 32104 to cover TEMS for the removal of rectal tumours less than 4cm and 4cm or greater in diameter (respectively), where the removal of a rectal tumour is unable to be performed during colonoscopy or local excision. TEMS items are restricted against each other and against the alternative open procedure of anterior resection (items 32024 and 32025).

Item [21]

This item introduces new item 32106 to cover TEMS for the removal of rectal tumours requiring dissection within the peritoneal cavity where other procedures for the removal of a rectal tumour are not suitable. TEMS items are restricted against each other and against the alternative open procedure of anterior resection (items 32024 and 32025).

Item [22]

This item amends two items 32159 and 32162 to cover excision of the lower half and the upper half (respectively) of the anal sphincter to treat an anal fistula. There is currently no item to cover the insertion of a Seton suture, only to adjust one (item 32166). This item is able to be claimed for treatment by excision, by the insertion of a Seton suture or by a combination of both procedures.

Item [23]

This item introduces two new items 34538 and 34539. Item 34538 covers central vein catheterisation by percutaneous technique to administer haemodialysis or parenteral nutrition using a subcutaneous tunnelled cuffed catheter or similar device. Item 34539 covers the removal of a tunnelled cuffed catheter or similar device in a hospital or approved day-hospital.

Item [24]

This item amends item 35321 to clarify that this embolisation item does not cover uterine artery embolisation for fibroid treatment.

Item [25] to [29] and Items [32] to [34]

These items amend items 35576, 35580, 35584, 35590, 35593, 35599, 35600, 35602 and 35605, and 37042, 37043 and 37044 to clarify that the items cover surgery with or without the use of mesh and to ensure that only these items are claimed when mesh is used in prolapse and incontinence gynaecological surgery.

Item [30]

This item introduces two new items 36526 and 36527 to cover the radical surgical removal of a kidney where the practitioner clinically suspects malignancy of tumours of specified sizes, but cannot confirm diagnosis by biopsy prior to surgery.

Item [31]

This item amends item 36564 to define the method of biopsy as either by open procedure or by laparoscopic approach reflecting current clinical practice.

Item [35]

This item amends item 38436 to clarify that for thoracoscopy, the insertion of an intercostal catheter only needs to be performed where necessary.

Item [36]

This item introduces a new item 40905 to cover craniotomy performed in association with items 45767, 45776, 45782 and 45785 for the correction of craniofacial abnormalities.

Item [37]

This item introduces two new items 50950 and 50952 to cover percutaneous radiofrequency ablation for nonresectable hepatocellular carcinoma. Item 50950 is restricted against items 30419 and 50952 to prevent benefits being paid for different treatments on the same tumour. Item 50952 is introduced to cover open or laparoscopic radiofrequency ablation for nonresectable hepatocellular carcinoma when the percutanious route is not accessible or at an open procedure where a primary liver tumour is located in a nonresectable region of the liver. Item 50952 is restricted against items 30419 and 50950 to prevent benefits being paid for different treatments on the same tumour.


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