{"id":"F2026L00007","name":"Health Insurance (Section 4BA - Pathologist-Determinable Services) Determination 2025","slug":"health-insurance-section-4ba-pathologist-determinable-services-determination-2025","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":107600,"registerId":"commonwealth-F2026L00007-current","compilationNumber":null,"startDate":"2026-04-03","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"1","sectionType":"section","heading":"Name","content":"#### 1 Name\n\n This instrument is the Health Insurance (Section 4BA - Pathologist-Determinable Services) Determination 2025.","sortOrder":0},{"sectionNumber":"2","sectionType":"section","heading":"Commencement","content":"#### 2 Commencement\n\n (1) Each provision of this instrument specified in column 1 of the table commences, or is taken to have commenced, in accordance with column 2 of the table. Any other statement in column 2 has effect according to its terms.\n\n```html\n

Commencement information

Column 1

Column 2

Column 3

Provisions

Commencement

Date/Details

1. The whole of this instrument

1 March 2026.

1 March 2026

\n```\n\n> Note: This table relates only to the provisions of this instrument as originally made. It will not be amended to deal with any later amendments of this instrument.\n\n (2) Any information in column 3 of the table is not part of this instrument. Information may be inserted in this column, or information in it may be edited, in any published version of this instrument.","sortOrder":1},{"sectionNumber":"3","sectionType":"section","heading":"Authority","content":"#### 3 Authority\n\n This instrument is made under section 4BA of the Health Insurance Act 1973.","sortOrder":2},{"sectionNumber":"4","sectionType":"section","heading":"Schedules","content":"#### 4 Schedules\n\n Each instrument that is specified in a Schedule to this instrument is amended or repealed as set out in the applicable items in the Schedule concerned, and any other item in a Schedule to this instrument has effect according to its terms.","sortOrder":3},{"sectionNumber":"5","sectionType":"section","heading":"Definitions","content":"#### 5 Definitions\n\n> Note: A number of expressions used in this instrument are defined in interpretation section of the Health Insurance Act 1973, including the following:\n\n approved pathology practitioner;\n pathology service;\n pathology services table;\n accredited pathology laboratory\n\n (1) In this instrument:\n\n> Act means the Health Insurance Act 1973.\n\n> recognised pathologist means a medical practitioner recognised as a specialist in pathology for the purposes of the Act.\n\n (2) Unless the contrary intention appears, in this Determination a reference to a provision of the Act or regulations made under the Act as applied, adopted or incorporated in relation to specifying a matter is a reference to those provisions as in force from time to time and any other reference to provisions of an Act or regulations is a reference to those provisions as in force from time to time.","sortOrder":4},{"sectionNumber":"6","sectionType":"section","heading":"Services rendered to a patient of a pathologist","content":"#### 6 Services rendered to a patient of a pathologist\n\n For the purposes of section 4BA of the Act, a pathology service is a pathologist-determinable service if:\n (a) the service is described in an item in the pathology services table; and\n (b) the service is rendered, by or on behalf of, an approved pathology practitioner to a patient of that practitioner.","sortOrder":5},{"sectionNumber":"7","sectionType":"section","heading":"Services rendered where a different service was originally requested","content":"#### 7 Services rendered where a different service was originally requested\n\n For the purposes of section 4BA of the Act, a pathology service is a pathologist-determinable service if:\n (a) the service is rendered, by or on behalf of, an approved pathology practitioner; and\n (b) the approved pathology practitioner considers the service to be necessary, on the basis of information learned from another service:\n (i) that was rendered to the patient by, or on behalf of, that practitioner; and\n (ii) the request for which complied with paragraph 16A(4)(a) or (b) of the Act; and\n (c) the service is an item in the pathology services table that is mentioned in column 1 in the following table and, in relation to which, the pathology service originally requested was an item in the pathology services table that is mentioned in column 2 of the following table for that item of the table:\n\n```html\n

Services rendered where a different service was originally requested items of the pathology services table

Item

Column 1

Pathology service

Column 2

Originally requested service

1

72846, 72847, 72848, 72849, 72850, 72851, 72852, 73319, 73332, 73336, 73337, 73341, 73342, 73344, 73364, 73365, 73366, 73367, 73368, 73369, 73370, 73371, 73372, 73373, 73374, 73375, 73376, 73377, 73378, 73379, 73380, 73381, 73382, 73383, 73389, 73436, 73429, 73437, 73438, 73439

72813, 72816, 72817, 72818, 72823, 72824, 72825, 72826, 72827, 72828, 72830, 72836, 72838

2

73059, 73060, 73061

73045, 73047, 73049, 73051

3

73305

73300

4

73320

71147

5

66839

66838

6

73411, 73412, 73413

73410

7

66842

66839

\n```\n\n Note: Items 73319, 73332, 73336, 73337, 73341, 73342, 73344, 73436, 73437, 73438 and 73439 are specified in the Health Insurance (Section 3C Co-Dependent Pathology Services) Determination 2018.","sortOrder":6},{"sectionNumber":"8","sectionType":"section","heading":"Services described in items 69316, 69317, 69319, 69494, 69495, 69496, 69497 and 69498","content":"#### 8 Services described in items 69316, 69317, 69319, 69494, 69495, 69496, 69497 and 69498\n\n For the purposes of section 4BA of the Act, a pathology service that is described in items 69316, 69317, 69319, 69494, 69495, 69496, 69497 or 69498 of the pathology services table is a pathologist-determinable service if it is:\n (a) rendered, by or on behalf of, an approved pathology practitioner who is a recognised pathologist; and\n (b) a service that the approved pathology practitioner determines to be necessary on the basis of:\n (i) information provided by a treating practitioner in relation to a pathology service described in items 69303, 69306, 69312, 69318, 69321 or 69345 of the pathology services table, that was rendered to the patient by, or on behalf of, the approved pathology practitioner pursuant to a request that complied with paragraph 16A(4)(a) or (b) of the Act; or\n (ii) the nature or appearance of the pathology specimen collected for a pathology service described in items 69303, 69306, 69312, 69318, 69321 or 69345 of the pathology services table, that was rendered to the patient by, or on behalf of, the approved pathology practitioner pursuant to a request that complied with paragraph 16A(4)(a) or (b) of the Act; or\n (iii) information learned from a pathology service described in items 69303, 69306, 69312, 69318, 69321 or 69345 of the pathology services table, that was rendered to the patient by, or on behalf of, the approved pathology practitioner pursuant to a request that complied with paragraph 16A(4)(a) or (b) of the Act.","sortOrder":7},{"sectionNumber":"9","sectionType":"section","heading":"A service described in item 72860","content":"#### 9 A service described in item 72860\n\n For the purposes of section 4BA of the Act, a pathology service that is described in item 72860 of the Health Insurance (Section 3C Co-Dependent Pathology Services) Determination 2018 is a pathologist-determinable service if it is:\n (a) an initial service that is described in an item in Group P5 (other than item 72860), Group P6 or Group P7 of the pathology services table was rendered in a patient episode for the patient by, or on behalf of, the approved pathology practitioner pursuant to a request that complied with paragraph 16A(4)(a) or (b) of the Act; and\n (b) following the initial service, the treating practitioner determines that a service described in an item in Group P7 (the subsequent Group P7 service) is clinically necessary; and\n (c) following a request from the treating practitioner, an approved pathology practitioner at the accredited pathology laboratory, where the initial service was rendered, determines the accredited pathology laboratory is unable to perform the subsequent P7 service and consequently determines a service described under item 72860 is required to select appropriate tissue samples for referral to a different accredited pathology laboratory for performance of the subsequent P7 service; and\n (d) the subsequent P7 service and a service under item 72860 are rendered in a different accredited pathology laboratory, by or on behalf of, an approved pathology practitioner who is a recognised pathologist.\n\n \n\nSchedule 1—Repeals\n\nHealth Insurance (Pathologist-determinable Services) Determination 2015\n\n1 The whole of the instrument\n\nRepeal the instrument.","sortOrder":8}],"analysis":{"flash_summary_failed":{"failed":true,"reason":"A positive credit balance is required for all requests, including BYOK, so fallback providers remain available. Add credits at https://vercel.com/d?to=%2F%5Bteam%5D%2F%7E%2Fai%3Fmodal%3Dtop-up to continue.","source":"analysis-cron"},"kimi_summary":{"content_quality":"ok","complexity_score":4,"scope_assessment":{"changed":false,"description":"The legislation maintains its original narrow purpose: specifying which pathology services can be pathologist-determined under section 4BA of the Health Insurance Act 1973. While it updates specific test item numbers and adds new categories (particularly section 9 regarding item 72860), these are evolutionary refinements within the established framework rather than scope expansion. The 2025 version replaces the 2015 Determination with equivalent structural provisions."},"complexity_factors":["Multiple cross-references to external instruments including the Health Insurance Act 1973, the pathology services table, and the Health Insurance (Section 3C Co-Dependent Pathology Services) Determination 2018","Nested conditional logic in sections 7-9 with multiple cumulative requirements (e.g., section 9 has four separate conditions that must all be satisfied)","Extensive use of defined terms from parent legislation (4 terms explicitly noted, plus implied references to 'treating practitioner', 'patient episode', 'Group P5/P6/P7')","Detailed item number tables in section 7 with 40+ specific Medicare Benefits Schedule item numbers that must be cross-referenced","Technical medical terminology requiring domain knowledge (e.g., 'Group P7', 'accredited pathology laboratory', 'patient episode')","Incorporation by reference provisions (section 5(2)) that dynamically link to legislation 'as in force from time to time'"],"plain_english_summary":"This Determination lets pathologists and approved pathology practitioners initiate specific Medicare-funded pathology tests without a new treating‑doctor request by listing which tests and the conditions that must be met. It affects pathologists, lab practitioners, patients and treating doctors by enabling timely follow‑up and specialised testing when abnormalities are found, while tightly controlling which tests can be self‑authorised to reduce inappropriate billing."},"flash_summary":{"complexity_score":7,"scope_assessment":{"changed":true,"description":"This instrument repeals the earlier Health Insurance (Pathologist-determinable Services) Determination 2015 (Schedule 1) and replaces it with updated, item-specific rules and conditions. It both enumerates new and existing Medicare item numbers as pathologist-determinable (ss6–8) and imposes additional constraints: certain items require determination by a recognised pathologist (s8), others depend on information from prior services or specimen appearance (s7–8), and item 72860 adds an inter-laboratory referral rule tied to laboratory capability (s9). These changes narrow and specify the circumstances in which pathology practitioners may decide additional services without a new treating-practitioner request."},"complexity_factors":["Cross-references to the Health Insurance Act (authority under s4BA and reliance on paragraph 16A(4)) require alignment with existing Act definitions and request rules (see ss3, 6, 7).","Extensive, item-level listing of Medicare pathology service numbers in ss7–8 demands precise compliance and billing systems to map items to conditions.","Conditional authorisations depend on factual predicates learned from prior services or specimen appearance, creating case-by-case clinical judgement points (see s7(b), s8(b)).","Some services are limited to being determined only by a recognised pathologist, introducing differing practitioner thresholds and credential checks (see s8(a)).","Item 72860 includes a multi-step inter-laboratory referral procedure requiring accredited laboratories to assess capability and transfer samples, adding operational coordination (see s9(c)).","Repeal of the 2015 Determination (Schedule 1) creates a transition from prior rules to the new list and conditions, with potential administrative migration costs (Schedule 1).","Fixed commencement date (1 March 2026) sets an implementation deadline for practitioners, labs and payers to update procedures and IT systems (see s2).","Interpretation clause treats adopted provisions as in force from time to time, increasing the need to track future amendments to referenced Acts/regulations (see s5(2))."],"plain_english_summary":"Sets which pathology Medicare items are treated as “pathologist‑determinable” under section 4BA of the Health Insurance Act, and specifies when approved pathology practitioners (including recognised pathologists) may determine extra tests without a fresh treating‑practitioner request. The instrument lists specific Medicare item numbers and ties authorisation to prior test information, specimen appearance or laboratory capability, and includes an inter‑laboratory referral rule. Affects approved pathology practitioners, recognised pathologists, accredited pathology laboratories, treating practitioners, patients and Medicare billing by changing who decides and when benefits apply."}},"importantCases":[],"_links":{"self":"/api/acts/health-insurance-section-4ba-pathologist-determinable-services-determination-2025","history":"/api/acts/health-insurance-section-4ba-pathologist-determinable-services-determination-2025/history","analysis":"/api/acts/health-insurance-section-4ba-pathologist-determinable-services-determination-2025/analysis","conflicts":"/api/acts/health-insurance-section-4ba-pathologist-determinable-services-determination-2025/conflicts","importantCases":"/api/acts/health-insurance-section-4ba-pathologist-determinable-services-determination-2025/important-cases","documents":"/api/acts/health-insurance-section-4ba-pathologist-determinable-services-determination-2025/documents"}}