Health Insurance (1997-98 Pathology Services Table) Regulations

1 Citation [see Note 1]

These Regulations may be cited as the Health Insurance (1997-98 Pathology Services Table) Regulations.

2 Commencement

These Regulations commence on 1 November 1997.

3 Pathology services table

The table of pathology services in the Schedule is prescribed for subsection 4A (1) of the Health Insurance Act 1973.

4 Repeal of Health Insurance (1996-97 Pathology Services Table) Regulations

Statutory Rules 1996 No. 232 and Statutory Rules 1997 No. 54 are repealed.

Schedule Table of pathology service

(regulation 3)

Part 1 Rules of interpretation

1 Interpretation of Table

(1) In this Table:

patient episode means:

(a) a pathology service or pathology services (other than a pathology service to which paragraph (1) (b) refers) provided for a single patient whose need for the service or services was determined under subsection 16A of the Act:

(i) on the same day; or

(ii) if more than 1 test is performed on the 1 specimen within 14 days — on the same or different days.

whether the services:

(iii) are requested by 1 or more practitioners; or

(iv) are described in a single item or in more than 1 item; or

(v) are rendered by 1 approved pathology practitioner or more than 1 approved pathology practitioner; or

(vi) are rendered on the same or different days; or

(b) a pathology service to which rule 4 refers that is provided in the circumstances set out in that rule that relates to the service.

recognised pathologist means a medical practitioner recognised as a specialist in pathology by a determination under section 3D or subsection 61 (3) of the Act.

serial examinations means a series of examinations requested on 1 occasion whether or not:

(a) the materials are received on different days by the approved pathology practitioner; or

(b) the examinations or cultures were requested on 1 or more request forms by the treating practitioner.

the Act means the Health Insurance Act 1973.

(2) In these Rules, a reference to a request to an approved pathology practitioner includes a reference to a request for a pathologist-determinable service to which subsection 16A (6) of the Act applies.

(3) A reference in this Table by number to an item that is not included in this Table is a reference to the item that has that number in the general medical services table or the diagnostic imaging services table, as the case requires.

(4) A reference to a Group in the Table includes every item in the Group.

2 Precedence of items

(1) If a service is described:

(a) in an item in general terms; and

(b) in another item in specific terms;

only the item that describes the service in specific terms applies to the service.

(2) Subject to subrule (3), if:

(a) subrule (1) does not apply; and

(b) a service is described in 2 or more items;

only the item that provides the lower or lowest fee for the service applies to the service.

(3) If an item is expressed to include a pathology service that is described in another item, the other item does not apply to the service in addition to the first-mentioned item, whether or not the services described in the 2 items are requested separately.

3 Circumstances in which services rendered following 2 requests to be taken to have been rendered following 1 request

(1) In subrule 3 (2), service includes assay, estimation and test.

7 (2) Two or more pathology services (other than services to which, under rule 4, this rule does not apply) rendered for a patient following 2 or more requests are taken to have been rendered following a single request if:

(a) the services are listed in the same item; and

(b) the patient’s need for the services was determined under subsection 16A (1) of the Act on the same day even if the services are rendered by an approved pathology practitioner on more than one day.

4 Services to which rule 3 does not apply

(1) Rule 3 does not apply to a pathology service described in item 66201, other than an estimation of fructosamine or lithium, if:

(a) the service is rendered in relation to a single specimen taken on each of not more than 4 occasions in a period of 24 hours; and

(b) the service is rendered to a patient in a hospital unit where:

(i) the presence of 1 nurse is required for each group of not more than 4 patients; and

(ii) the condition of the patients is continuously observed in relevant respects; and

(c) in order to render the service, an approved pathology practitioner who is a recognised pathologist has to arrange for a member of the laboratory staff of the approved pathology authority concerned to undertake duties in respect of the service that are in addition to the usual duties of the staff member; and

(d) the account for the service is endorsed Rule 3 Exemption.

(2) Rule 3 does not apply to any of the following pathology services:

(a) estimation of prothrombin time (INR) in respect of a patient undergoing anticoagulant therapy;

(b) quantitative estimation of lithium in respect of a patient undergoing lithium therapy;

(c) a service described in item 65007 in relation to a patient undergoing chemotherapy for neoplastic disease or immunosuppressant therapy;

(d) a service described in item 65007 in relation to clozaril, ticlopidine hydrochloride, methotrexate, gold, sulfasalazine or penicillamine therapy of a patient;

(e) a service described in item 66201 in relation to methotrexate therapy of a patient;

(f) quantitative estimation of urea, creatinine and electrolytes in relation to:

(i) cis-platinum therapy of a patient; or

(ii) chronic renal failure of a patient being treated in a dialysis program conducted by a recognised hospital;

(g) quantitative estimation of albumin and calcium in relation to therapy of a patient with vitamin D, its metabolites or analogues;

if:

(h) under a request for a service, other than a request for a service described in paragraph (a), no more than 6 tests are requested; and

(i) the tests are performed within 6 months of the request; and

(j) the account for the service is endorsed Rule 3 Exemption.

5 Item taken to refer only to the first service of a particular kind

For an item in Group P1 (Haematology):

(a) if pathology services of a kind referred to in item 65017 or 65019 are rendered for a patient during a period when the patient is in hospital, the item applies only to the first pathology service of that kind rendered for the patient during the period; and

(i) tests (except tests mentioned in item 65023) are carried out in relation to a patient episode; and

(iii) in response to a request made within 14 days of the patient episode, further tests (except tests mentioned in item 65023) are carried out on the stored material;

6 Certain items not to apply to a service referred by one pathology practitioner to another

(1) In this rule:

designated pathology service means a pathology service in respect of tests relating to a single patient episode that are:

(a) tests of the kind described in item 66235; or

(b) tests of the kind described in item 66405; or

(c) tests of the kind described in item 69229.

(2) This rule applies in respect of a designated pathology service where:

(a) an approved pathology practitioner (practitioner A) in an approved pathology authority:

(i) has been requested to render the designated pathology service; and

(ii) is unable, because of the lack of facilities in, or expertise or experience of the staff of, the laboratory of the authority, to render 1 or more (but not all) of the tests included in the service; and

(iii) requests an approved pathology practitioner (practitioner B) in another approved pathology authority to render the test or tests that practitioner A is unable to render; and

(iv) renders each test included in the service, other than the test or tests in respect of which the request mentioned in subparagraph (iii) is made; and

(b) the tests mentioned in subparagraph (a) (iv) that practitioner A renders are not tests constituting a service described in item 66239, 66415 or 69239.

(3) Where this rule applies in respect of a designated pathology service:

(a) item 66235, 66237, 66405, 66407, 66409, 66411, 66413, 69229, 69231, 69233, 69235 or 69237 (as the case requires) applies in respect of the test or tests rendered by practitioner A; and

(b) where practitioner B renders a service under a request referred to in subparagraph (2) (a) (iii) — subject to subrule (4), the amount specified in item 66241, 66417 or 69241 (as the case requires) is payable for each test that the service comprises.

(4) For paragraph (3) (b), the maximum number of tests to which item 66241, 66417 or 69241 applies is:

(a) for item 66241:

3 – X; or

(b) for item 66417 or 69241:

6 – X;

where X is the number of tests rendered by practitioner A in relation to the designated pathology service in respect of which the request mentioned in that paragraph is made.

(5) Items in Group P10 (Patient episode initiation) do not apply to the second-mentioned approved pathology practitioner in subrule (2).

7 Items not to be split

Except as stated in rule 6, the amount specified in an item is payable only to one approved pathology practitioner in respect of a single patient episode.

8 Certain tests on stored material to be treated as part of the same patient episode

For items in Group P2 (Chemical):

(a) if a pathology service that involves the measurement of a substance in urine requires calculation of a substance/creatinine ratio, the service is taken to include the measurement of creatinine necessary for the calculation; and

(i) tests are carried out in relation to a patient episode; and

(iii) in response to a request made within 14 days of the patient episode, further tests are carried out on the stored material;

9 Item 66317

The amount specified in item 66317 is not payable in respect of a pathology service described in the item unless at least one of the following paragraphs applies:

(a) if the HDL cholesterol or apolipoprotein B/A1 ratio of the patient is requested to be determined because the patient has a serum cholesterol level >5.5 mmol/L — the determination is performed on the sample that the serum cholesterol level determination for the patient was performed;

(b) if the HDL cholesterol or apolipoprotein B/A1 ratio of the patient is requested to be determined because the patient has a fasting serum triglyceride level >2.0 mmol/L — the determination is performed on the sample that the serum triglyceride level determination for the patient was performed;

(c) the pathologist who renders the service has a written statement from the medical practitioner who requested the service that the patient is on a lipid lowering drug.

10 Thyroid function testing

(1) For item 66329:

abnormal level of TSH means a level of TSH that is outside the normal reference range in respect of the particular method of assay used to determine the level.

(2) Except where paragraph (a) of item 66329 is satisfied, the amount specified in the item is not payable in respect of a pathology service described in the item unless the pathologist who renders the service has a written statement from the medical practitioner who requested the service that satisfies subrule (3).

(3) The written statement from the medical practitioner must indicate:

(a) that the tests are required for a particular purpose, being a purpose specified in paragraph (b) of item 66329; or

(b) that the medical practitioner who requested the tests suspects the patient has pituitary dysfunction; or

(c) that the patient is on drugs that interfere with thyroid hormone metabolism or function.

11 Meaning of serial examinations or cultures

For an item in Group P3 (Microbiology):

(a) serial examinations or cultures means a series of examinations or cultures requested on 1 occasion whether or not:

(i) the materials are received on different days by the approved pathology practitioner; or

(ii) the examinations or cultures were requested on 1 or more request forms by the treating practitioner; and

(i) tests are carried out in relation to a patient episode; and

(iii) in response to a request made within 14 days of the patient episode, further tests are carried out on the stored material;

12 Investigation for hepatitis and syphilis serology

(1) A medicare benefit is not payable in respect of more than one of items 69266, 69267, 69268, 69269, 69270, 69271, 69272, 69273, 69274, 69275, 69276, 69277, 69278, 69279, 69280, 69281 and 69283 in a patient episode.

(2) For items 69279 and 69283, currently elevated transaminase level means a level of alanine aminotransferase or aspartate aminotransferase above the normal reference range in respect of the particular method of assay used to determine the level, as disclosed by a test carried out on a sample taken for the investigation or on a sample taken within the previous 7 days.

13 Tests in Group P4 (Immunology) relating to antibodies

For items in Group P4 (Immunology), in items 71119, 71121, 71123 and 71125, if:

(a) tests are carried out in relation to a patient episode; and

(b) specimen material from the patient episode is stored; and

(c) in response to a request made within 14 days of the patient episode, further tests are carried out on the stored material;

14 Tests on biopsy material — Group P5 (Tissue Pathology) and Group P6 (Cytology)

(1) For items in Group P5 (Tissue Pathology):

(a) biopsy material means all tissue (other than a bone marrow biopsy) received by an approved pathology practitioner from an operation, or a group of operations, performed on a patient at the same time; and

(i) a pathology service that comprises the examination of biopsy material is rendered under any of those items; and

(ii) a further pathology service mentioned in any of those items is also rendered using that biopsy material;

those pathology services are taken to be 1 pathology service; and

(c) cytology means microscopic examination of 1 or more stained preparations of cells separated naturally or artificially from their normal environment by methods recognised as adequate to demonstrate their structure to a degree sufficient to enable an opinion to be formed about whether they are likely to be normal, abnormal but benign, or abnormal and malignant but, in accordance with customary laboratory practice, does not include examination of a blood film and a bone marrow aspirate; and

(d) separately identified specimen means an individual specimen collected, identified so that it is clearly distinguished from any other specimen, and sent for testing by or on behalf of the treating practitioner responsible for the procedure in which the specimen was taken.

(2) For Groups P5 and P6 of the Pathology Services Table, services in Group P6 include any services described in Group P5 on the material submitted for a test in Group P6.

(3) For subrule (2), any sample submitted for cytology from which a cell block is prepared does not qualify for a Group P5 item.

(4) If more than 1 of the services mentioned in items 72813, 72816, 72817, 72823, 72824, 72825, 72830 and 72836 are performed in a single patient episode, a medicare benefit is payable only for the item performed that has the highest schedule fee.

(5) If more than 1 histopathological examinations are performed on separate specimens, of different complexity levels, from a single patient episode, a medicare benefit is payable only for the examination that has the highest schedule fee.

(6) In items 72813, 72816, 72817, 72823, 72824, 72825, 72830 and 72836 a reference to a complexity level is a reference to the level given to a specimen type mentioned in Part 4 of this Table.

15 Items in Groups P10 (Patient episode initiation) and P11 (Specimen referred) not to apply in certain circumstances

(1) For this rule and items in Groups P10 (Patient episode initiation) and P11 (Specimen referred):

institution means a place at which residential accommodation or day care is, or both residential accommodation and day care are, made available to:

(a) disadvantaged children; or

(b) juvenile offenders; or

(c) aged persons; or

(d) chronically ill psychiatric patients; or

(e) homeless persons; or

(f) unemployed persons; or

(g) persons suffering from alcoholism; or

(h) persons addicted to drugs; or

(i) physically or mentally handicapped persons;

but does not include:

(j) a hospital; or

(k) a nursing home; or

(l) accommodation for aged persons that is attached to a nursing home or situated within a nursing home complex;

licensed collection centre has the same meaning as in Part IIA of the Act.

prescribed laboratory means a laboratory operated by:

(a) the Commonwealth; or

(b) a State or internal Territory; or

(c) an authority of a State or internal Territory; or

(d) an Australian tertiary education institution.

specimen collection centre has the same meaning as in Part IIA of the Act.

treating practitioner has the same meaning as in paragraph 16A (1) (a) of the Act.

(2) If a service described in an item in Group P10 or P11 is rendered by, or on behalf of, an approved pathology practitioner who is a recognised pathologist, the relevant one of those items does not apply to the service if:

(a) the service is rendered upon a request made in the course of an out-patient service at a recognised hospital; or

(b) the service is rendered upon a request made for a patient who is a private patient in a recognised hospital when the request is made; or

(c) the pathology equipment of a recognised hospital, or a prescribed laboratory, is used rendering the service; or

(d) a member of the staff of a recognised hospital, or a prescribed laboratory, participates in the service in the course of the member’s employment with the hospital or laboratory.

(3) An item in Group P10 or P11 does not apply to a pathology service to which subsection 16A (7) of the Act applies.

(4) An item in Group P10 or P11 does not apply to a pathology service unless at least one item in Groups P1 to P8 also applies to the service.

(5) Subject to subrule (7), if one item in Group P10 applies to a patient episode, no other item in the Group applies to the patient episode.

(6) An item in Group P11 applies only to the approved pathology practitioner or approved pathology authority to whom the specimen mentioned in the item was referred.

(7) If, in respect of the same patient episode:

(a) services referred to in 1 or more items in Group P5 and 1 or more of Groups P1, P2, P3, P4, P6, P7 and P8 are rendered by an approved pathology practitioner in the laboratory of another approved pathology authority; and

(b) services referred to in 1 or more items in Group P6 and 1 or more of Groups P1, P2, P3, P4, P5, P7 and P8 are rendered by another approved pathology practitioner in another approved pathology authority;

the fee specified in the applicable item in Group P10 is payable to both approved pathology practitioners.

(8) If more than one specimen is collected from a person on the same day for the provision of pathology services:

(a) in accordance with more than one request; and

(b) in or by a single approved pathology authority;

only a single amount specified in the applicable item in Group P10 is payable for the services.

(9) The amount specified in item 73921 is payable only once in respect of a single patient episode.

16 Application of an item in Group P11 (Specimen referred) to a service excludes certain other items

If item 73921 applies to a patient episode, none of the items in Group P10 applies to any pathology service rendered by the approved pathology authority or approved pathology provider who claimed item 73921 in respect of the patient episode.

17 Circumstances in which an item in Group P11 (Specimen referred) does not apply

(1) An item in Group P11 does not apply to a referral if:

(a) a service in respect of the same patient episode has been carried out by the referring approved pathology authority; and

(b) the approved pathology authority to which the referral is made is related to the referring approved pathology authority.

(2) An approved pathology authority is related to another approved pathology authority for subclause (1) if:

(a) both approved pathology authorities are employed (including employed under contract) by the same person, whether or not the person is also an approved pathology authority; or

(b) either of the approved pathology authorities is employed (including employed under contract) by the other; or

(c) both approved pathology authorities are corporations and are related corporations within the meaning of the Corporations Law; or

(d) the approved pathology authorities are partners (whether or not either or both of the approved pathology authorities are individuals and whether or not other persons are in partnership with either or both of the approved pathology authorities).

18 Abbreviations

(1) The abbreviations in Part 3 of this Table may be used to identify particular pathology services or groups of pathology services.

(2) The names of services or drugs not listed in Part 3 of this Table must be written in full.

19 Certain pathology services to be treated as one service

(1) In this rule:

general practitioner means a medical practitioner who:

(a) is not a consultant physician in any specialty; and

(b) is not a specialist in any specialty.

set of pathology services means a group of pathology services:

(a) that consists of services that are described in at least 4 different items; and

(b) all of which are requested in a single patient episode; and

(c) each of which relates to a patient who is not an admitted patient of a hospital; and

(d) none of which is referred to:

(i) in item 66241, 66417, 69241, 73053 or 73055; or

(ii) in an item in Group P10 (Patient episode initiation) or Group P11 (Specimen referred).

(2) If a general practitioner requests a set of pathology services, the pathology services in the set are to be treated as individual pathology services in accordance with this rule.

(3) If the fee specified in one item that describes any of the services in the set of pathology services is higher than the fees specified in the other items that describe the services in the set:

(a) the pathology service described in the first-mentioned item is to be treated as one pathology service; and

(b) either:

(i) the pathology service in the set that is described in the item that specifies the second-highest fee is to be treated as one pathology service; or

(ii) if 2 or more items that describe any of those services specify the second-highest fee — the pathology service described in the item that specifies the second-highest fee, and has the lowest item number, is to be treated as one pathology service; and

(c) the pathology services in the set, other than the services that are to be treated as one pathology service under paragraphs (a) and (b), are to be treated as one pathology service.

(4) If the fees specified in 2 or more items that describe any of the services in the set of pathology services are the same, and higher than the fees specified in the other items that describe the services in the set:

(a) the pathology service in the set that is described in the item that specifies the highest fee, and has the lowest item number, is to be treated as one pathology service; and

(b) the pathology service in the set that is described in the item that specifies the highest fee, and has the
second-lowest item number, is to be treated as one pathology service; and

(c) the pathology services in the set, other than the services that are to be treated as one pathology service under paragraphs (a) and (b), are to be treated as one pathology service.

(5) If pathology services are to be treated as one pathology service under paragraph (3) (c) or (4) (c), the fee for the one pathology service is the highest fee specified in any of the items that describe the pathology services that are to be treated as the one pathology service.

20 HIV viral RNA load testing

For items 69259 and 69260, no more than a maximum of 6 episodes for either item 69259 or item 69260, or any combination for both items, can be claimed in a 12 month period.

21 Hepatitis C viral RNA testing

For item 69284:

Hepatitis C sero-positive, for a patient, means 2 different assays of Hepatitis C antibodies are positive.

serological status is uncertain, for a patient, means any result where 2 different assays of Hepatitis C antibodies are inconclusive.

22 Haemochromatosis testing

For item 66435:

elevated serum ferritin, for a patient, means a level of ferritin above the normal reference range in respect of the particular method of assay used to determine the level.