Health Insurance (Diagnostic Imaging Services Table) Regulations 2000

1 Name of Regulations [see Note 1]

These Regulations are the Health Insurance (Diagnostic Imaging Services Table) Regulations 2000.

2 Commencement

These Regulations commence on 1 November 2000.

3 Health Insurance (1999–2000 Diagnostic Imaging Services Table) Regulations 1999 — repeal

The following Statutory Rules are repealed:

 1999 Nos. 255 and 345

 2000 Nos. 59 and 147.

4 Definitions

In these Regulations:

Act means the Health Insurance Act 1973.

this table means these Regulations.

5 Diagnostic imaging services table

The table of diagnostic imaging services set out in Schedule 1 is prescribed for the purposes of subsection 4AA (1) of the Act.

Schedule 1 Table of diagnostic imaging services

(regulation 5)

Part 1 Prescription of table

1 Prescription of table

For section 4AA of the Act, these Regulations prescribe a table of diagnostic imaging services that sets out:

(a) in Part 2 — rules for interpretation of the table; and

(b) in Part 3:

(i) items of diagnostic imaging services; and

(ii) the amount of fees applicable for each item.

Part 2 Rules of interpretation

2 General

(1) In this table, unless the contrary intention appears:

computed tomography means a service performed (with or without intravenous contrast):

(a) using a detector coupled to an X-ray tube that emits a finely collimated X-ray beam as it rotates within a gantry around a patient either in incremental or helical manner; and

(b) registering a resulting variable amount of X-rays and transforming that information into a cross-sectional image after the application of complex algorithms.

CT means computed tomography.

CT equipment includes the following components:

(a) a gantry;

(b) a couch;

(c) a computer;

(d) an operator station;

(e) a generator.

exclusion, in relation to a condition for which a MRI or MRA service is used, means use of the service as the initial imaging modality for diagnosis of the condition.

group of practitioners has the same meaning as in subsection 16A (10) of the Act.

item means:

(a) an item mentioned, by number, in column 1 of:

(i) Part 3; or

(ii) Part 3 of the pathology services table; or

(iii) Part 3 of the general medical services table; and

(b) in a reference immediately followed by a number — the item so numbered.

Note: Example A reference by number to any of items 11240, 11603 to 11612, 30361 and 30488 is a reference to the item so numbered in the general medical services table.

MRA means magnetic resonance angiography.

MRI means magnetic resonance imaging.

non-metropolitan hospital means a hospital that is located outside the Sydney, Melbourne, Brisbane, Adelaide, Perth, Greater Hobart, Darwin and Canberra major statistical divisions, as defined in the Australian Standard Geographical Classification 1999 published by the Australian Bureau of Statistics (publication number 1216.0 of 1999).

remote location means a place within Australia that is more than 30 kilometres by road from:

(a) a hospital that provides a radiology or computed tomography service under the direction of a specialist in the specialty of diagnostic radiology; or

(b) a free-standing radiology or computed tomography facility under the direction of a specialist in the specialty of diagnostic radiology.

report means a report prepared by a medical practitioner.

sequence, in relation to a scan, means a series of images collected at the same time with similar image parameters (not including a scan designed to establish patient position and subsequently used to plan other scans).

Note A number of words and expressions used in this table are defined in subsection 3 (1) of the Act. For instance:

Note:  diagnostic imaging service

Note:  general medical services table

Note:  specialist.

(2) A reference to a Group in the table includes every item in the Group and a reference to a Subgroup in the table includes every item in the Subgroup.

3 Meaning of (R) and (NR) in the table

(1) An item including the symbol (R) is an R-type diagnostic imaging service.

(2) An item including the symbol (NR) is an NR-type diagnostic imaging service.

4 Meaning of (S) in the table

An item including the symbol (S) applies only to a service provided by a specialist in the practice of diagnostic radiology.

5 Who may provide a diagnostic imaging service

Unless the contrary intention appears, the fee for a diagnostic imaging service mentioned in an item in this table applies, whether the service is provided by:

(a) a medical practitioner; or

(b) a person, other than a medical practitioner, who:

(i) is employed by a medical practitioner; or

(ii) provides the service under the supervision of a medical practitioner in accordance with accepted medical practice.

6 Administration of anaesthetics in connection with certain services

(1) This rule applies to an item in which the service described includes the formula:

Anaes. n = n1 B + n2 T

in which n, n1 and n2 appear as numbers.

(2) The service provided by the medical practitioner who administers the anaesthetic represented by the formula must be the service described in the general medical services table by the item having the number n.

7 Meaning of medical practitioner in certain items

In items 55028, 55030 and 55032, medical practitioner in the phrase referred by a medical practitioner or the referring medical practitioner includes a dental practitioner who is approved by the Minister under paragraph (b) of the definition of professional service in subsection 3 (1) of the Act.

8 Meaning of Amount under rule 8 in certain items

In item 59103:

Amount under rule 8 means an amount equal to the sum of:

(a) the fee set out in another item for the radiographic examination in conjunction with which a service mentioned in item 59103 is provided; and

(b) $21.30.

9 Ultrasound services — eligible services

(1) Items 55028 to 55854 (except items 55600 and 55603), if marked with the symbol (R), apply to an ultrasound service (the eligible service) only if the service is performed:

(a) under the professional supervision of a specialist or a consultant physician in the practice of his or her specialty who is available:

(ii) if necessary, to personally attend the patient; or

(b) under the professional supervision of a practitioner who:

(i) is not a specialist or consultant physician; and

(ii) meets the requirement of subrule (2); and

(iii) is available to monitor and influence the conduct and diagnostic quality of the examination and, if necessary, to personally attend the patient; or

(c) in the circumstance mentioned in subrule (3), and under the professional supervision of a practitioner who is available:

(ii) if necessary, to personally attend the patient; or

(d) if paragraph (a), (b) or (c) cannot be complied with:

(ii) in a location that is not less than 30 kilometres by the most direct road route from another practice where services that comply with paragraph (a) or (b) are available.

(2) The requirement of this subrule is that, between 1 September 1997 and 31 August 1999, at least 50 services were rendered by or on behalf of the practitioner at the location where the eligible service was rendered, and the rendering of those services entitled payment of medicare benefits.

(3) For paragraph (1) (c), the circumstance is that, between 1 September 1997 and 31 August 1999, at least 50 services were rendered in nursing homes or patients’ residences by or on behalf of the practitioner, and the rendering of those services entitled payment of medicare benefits.

9A Angiography services — meaning of (K) and (NK) in items

(1) An item that includes the symbol (NK) at the end of the item applies to a service that is performed on equipment that is at least 10 years old.

(2) An item that includes the symbol (K) at the end of the item applies to a service that is performed on equipment that is less than 10 years old.

(3) The date from which the age of equipment is worked out for this rule is:

(a) the date that the equipment was first installed in Australia; or

(b) if the equipment was imported as used equipment, the date of manufacture of the oldest component of the equipment.

10 Personal attendance for musculoskeletal ultrasound

Items 55800 to 55854 apply to a musculoskeletal ultrasound service only if:

(a) the medical practitioner responsible for the conduct and report of the examination personally attends during the performance of the scan and personally examines the patient; or

(b) the service is performed, because of medical necessity, in a location that is more than 30 kilometres by the most direct road route from another practice where services that comply with paragraph (a) are available.

11 Obstetric and gynaecological ultrasound — limits

The fees mentioned in items in the item range from 55700 to 55774 in Part 3 of this table are applicable to no more than 3 items of NR-type diagnostic imaging for the same patient in any 1 pregnancy.

12 Clinical indications

(1) For items where clinical conditions are listed, or where a clinical indication is required for performance of subsequent scans (item 55712, 55715, 55721, 55725, 55764, 55766, 55772 or 55774), the referral must identify the relevant clinical indication for the service.

(2) If the service is pathologist-determined, the clinical condition or indication must be recorded in the pathology practitioner’s clinical notes.

13 Referral forms from practitioners who have obstetric privileges at a non-metropolitan hospital

A referral form for an item in Subgroup 5 of Group I1 for a referral by a practitioner who has obstetric privileges at a non-metropolitan hospital must show his or her eligibility to refer for the service by specifying on the form ‘non-metropolitan obstetric privileges’.

14 Comparison ultra-sonography

For items in Subgroup 6 of Group I1, the fee applicable for the item includes any views of another part of the patient taken for comparison purposes.

15 Equipment

Items 55800 to 55854 apply only to an ultrasound service performed using an ultrasound system which has available on‑site a transducer capable of operation at at least 7.5 megahertz.

16 Items 55800 to 55854 — multiple scans

The fee mentioned in items 55800 to 55854 is payable once only for a service described in any of those items regardless of the number of regions scanned in performing the service.

17 Computed tomography services — meaning of (K) and (NK)

(1) In any of items 56001 to 57355, the symbol (K) means:

(a) for CT equipment that was first installed and used as new equipment at a site in Australia:

(i) the service was rendered earlier than 10 years after the earliest date on which any component of the equipment was first installed and ready for use; or

(ii) the service was performed in a remote location; or

(b) for CT equipment imported as pre-used equipment:

(i) the service was rendered earlier than 10 years after the earliest date of manufacture of any component of the equipment; or

(ii) the service was rendered in a remote location.

(2) In any of items 56001 to 57355, the symbol (NK) means the service was rendered 10 years or more after:

(a) for CT equipment that was first installed and used as new equipment in Australia — the earliest date on which any component of the equipment was first installed and ready for use; or

(b) for CT equipment imported as pre-used equipment — the earliest date of manufacture of any component of the equipment.

(3) In this rule:

CT equipment imported as pre-used equipment means equipment that has been used to perform CT services before being imported into Australia.

installed and ready for use, in relation to a component, means ready for immediate income-producing purposes whether or not it is so used.

18 CT services — eligible services

Items 56001 to 57355 apply only to a computed tomography service performed:

(a) under the professional supervision of a specialist in the specialty of diagnostic radiology who is available:

(ii) if necessary, to personally attend on the patient; or

(b) if paragraph (a) cannot be complied with:

19 Computed tomography services — exclusion of acoustic neuroma

If an axial scan is performed for the exclusion of acoustic neuroma, item 56001 or 56007 applies instead of any other item in this table that might be taken to describe the service.

20 Computed tomography — assessment of headache

(1) If the service described in item 56007 or 56047 is used for the assessment of headache of a patient to whom this rule applies, the fee mentioned in the item applies only if:

(a) a scan without intravenous contrast medium has been performed on the patient; and

(b) the service is required because the result of the scan is abnormal.

(2) This rule applies to a patient who:

(a) is under 50 years; and

(b) is (apart from the headache) otherwise well; and

(c) has no localising symptoms or signs; and

(d) has no history of malignancy or immunosuppression.

21 Mammography services — eligible services

Items 59300 to 59318 apply only to a mammography service performed:

(a) under the professional supervision of a specialist in the specialty of diagnostic radiology who is available:

(ii) if necessary, to personally attend on the patient; or

(b) if paragraph (a) cannot be complied with:

22 Preparation of patients for radiological procedures

Items 60903 to 60927 apply only to the preparation of a patient for a radiological procedure for a service to which any of items 59900 to 59970 apply by:

(a) injecting opaque or contrast media; or

(b) removing fluid and replacing it with air, oxygen or other contrast media; or

(c) a similar method.

23 Meaning of angiography suite in item 61109

In item 61109:

angiography suite means a room that contains only equipment designed for angiography that is able to perform digital subtraction or rapid-sequence film angiography.

24 Nuclear scanning services

Items 61302 to 61499 apply only if:

(a) the performance of the service does not involve the use of positron-emission radio-isotopes or a Positron Emission Tomography (PET) scanner; and

(b) the service is performed:

(i) by a specialist or consultant physician whose name is included in a register, given to the Commission by the Joint Nuclear Medicine Specialist Credentialling and Accreditation Committee of the Royal Australasian College of Physicians and the Royal Australian and New Zealand College of Radiologists, of participants in the Joint Nuclear Medicine Specialist Credentialling Program of the Committee; or

(ii) by a person acting on behalf of a specialist or consultant physician mentioned in subparagraph (i); and

(c) the final report of the service is compiled by the specialist or consultant physician who performed the preliminary examination of the patient and the estimation and administration of the dosage of radiopharmaceuticals.

25 Meaning of Amount under rule 25 in item 61462

In item 61462:

Amount under rule 25 means an amount equal to the sum of:

(a) the fee set out in the item in Group I4 in conjunction with which a service mentioned in item 61462 is performed; and

(b) $113.55.

26 Multiple services

(1) If a medical practitioner renders 2 or more diagnostic imaging services for the same patient on the same day, the fees set out in the items that apply to the services, other than the item with the highest fee, are reduced by $5.00.

(2) If a medical practitioner renders at least 1 R-type diagnostic imaging service and at least 1 consultation service for the same patient on the same day, the highest fee, set out in the items that apply to diagnostic imaging services rendered by the practitioner for that patient on that day, is reduced:

(a) if the fee for the relevant consultation is at least $40.00 — by $35.00; or

(b) if that fee is less than $40.00 but more than $15.00 — by $15.00; or

(c) if that fee is less than $15.00 — by the amount of that fee.

(3) For subrule (2), if more than 1 consultation has occurred, the relevant consultation is the consultation having the highest fee set out in the items that apply to the consultation.

(4) If a medical practitioner renders at least 1 R-type diagnostic imaging service and at least 1 non-consultation service for the same patient on the same day, the highest fee that applies to any diagnostic imaging services performed by the medical practitioner for the same patient on the same day, is reduced by $5.00.

(5) If a medical practitioner renders an R-type diagnostic imaging service, a consultation and a non-consultation service for the same patient on the same day, the sum of the reductions under subrules (2) and (4) must not exceed the highest fee that applies to any diagnostic imaging services rendered by the medical practitioner for the same patient on the same day.

(6) This rule does not apply to diagnostic imaging services that are rendered in a remote area by a medical practitioner for whom a remote area exemption under section 23DX of the Act is in force for that area.

(7) In this rule:

consultation means a service under an item listed in Groups A1 to A9 of the general medical services table.

highest fee means the highest fee specified for an item in the first claim submitted to the Commission in relation to the services concerned.

non-consultation service means a service under an item listed in the general medical service table other than in Groups A1 to A9.

27 MRI and MRA services — eligible services

Items 63000 to 63946 apply only to a MRI or MRA service performed:

(a) on request, in accordance with rule 28, by a specialist or consultant physician; and

(b) in a permissible circumstance, in accordance with rule 29; and

(c) with eligible equipment, in accordance with rule 31 or 31A.

28 Request for MRI and MRA services — requirements

Items 63000 to 63946 apply only to a service in respect of which the request:

(a) was made in writing; and

(b) identified the clinical indications for the service.

29 MRI and MRA services — permissible circumstances for performance

For rule 27, a service is performed in a permissible circumstance only if it is performed:

(a) under the professional supervision of an eligible provider who is available to monitor and influence the conduct and diagnostic quality of the examination, including, if necessary, by personal attendance on the patient; or

(b) if paragraph (a) is not complied with:

30 MRI and MRA services — eligible provider

(1) For rule 29, an eligible provider is a specialist in diagnostic radiology who satisfies the Commission that:

(a) he or she is a participant in the Royal Australasian College of Radiologists’ Quality and Accreditation Program; and

(b) the equipment he or she proposes to use for providing services of the kind mentioned in Group I5 in the diagnostic imaging services table (the proposed equipment) is eligible equipment in accordance with rule 31 or 31A.

(2) If the equipment the eligible provider proposes to use is eligible equipment in accordance with rule 31, the Commission must have been given a statutory declaration:

(a) stating the matters mentioned in paragraphs (1) (a) and (b); and

(b) specifying the location of the proposed equipment; and

(c) specifying the kinds of diagnostic imaging procedures offered at that location; and

(d) if the proposed equipment has been installed at that location and is equipment to which subrule 31 (3) or (4) applies, stating the date that it was installed (the installation date); and

(e) if paragraph (d) applies, and the installation date was 12 May 1998 — stating the time at which the equipment was installed.

(3) If paragraph (2) (d) applies, and the equipment was not installed before 7.30 pm on 12 May 1998, Eastern Standard Time, the specialist must have given the Commission, with the statutory declaration, a copy of the contract for the purchase or lease of the equipment.

(4) The Commission may request a specialist to:

(a) give the Commission documents to support statements made in the statutory declaration; and

(b) answer questions put to the specialist by the Commission about those statements.

Note The documents may include the contract for purchase or lease of the proposed equipment, if not already given to the Commission under subrule (3).

31 MRI and MRA services — eligible equipment

(1) For rule 27, equipment that complies with this rule is eligible equipment.

(2) The equipment must be located in Australia in a medical practice, or the radiology department of a hospital, that offers a comprehensive range of diagnostic imaging procedures.

(3) For a medical practice or hospital located in a non-metropolitan area:

(a) the equipment must have been installed in a medical practice, or hospital, in Australia before 7.30 pm on 12 May 1998, Eastern Standard Time; or

(b) if the equipment was uninstalled at the time and on the day mentioned in paragraph (a), it must:

(i) have been purchased or leased (under a contract, in writing, that did not contain an option to cancel) before that time on that day; and

(ii) on or before 18 October 1999, be in use for services for which a medicare benefit is claimed; or

(c) the equipment must be replacement equipment for equipment mentioned in paragraph (a) or (b).

Note Equipment relocated to a new location may continue to comply with subrule (3). However, to continue to be eligible equipment, the equipment would have to continue to comply with subrule (2).

(4) For a medical practice or hospital located in a metropolitan area the equipment must:

(a) have been installed in a medical practice, or hospital, in Australia before 7.30 pm on 12 May 1998, Eastern Standard Time; or

(b) if uninstalled at that time on that day, have been purchased or leased (under a contract, in writing, that did not contain an option to cancel) before 10 February 1998; or

(c) be replacement equipment for equipment mentioned in paragraph (a) or (b).

Note Equipment relocated to a new location may continue to comply with subrule (4). However, to continue to be eligible equipment, the equipment would have to continue to comply with subrule (2).

(5) Equipment mentioned in paragraph (3) (a) or (b) or (4) (a) or (b) ceases to be eligible equipment when replaced by other equipment.

(6) The Commission must have been given, before 11 October 1999:

(a) the statutory declaration, under subrule 30 (2), in relation to the equipment; and

(b) if paragraph (3) (b) or (4) (b) applies, the copy contract mentioned in subrule 30 (3).

(7) For this rule:

comprehensive, in relation to a range of diagnostic imaging procedures, means that the range includes x‑ray, ultrasound and computed tomography (CT) procedures.

medical practice means a practice conducted by a sole practitioner, a practice conducted by a group of practitioners within the meaning of subsection 16A (9) or (10) of the Act or a practice conducted by a medical entrepreneur.

metropolitan area includes any location within any of the Sydney, Melbourne, Brisbane, Adelaide, Perth, Greater Hobart, Darwin or Canberra major statistical divisions, as defined in the Australian Standard Geographical Classification 1999 published by the Australian Bureau of Statistics (publication number 1216.0 of 1999).

31A MRI and MRA services — eligible equipment

For rule 27, eligible equipment is equipment other than equipment to which rule 31 applies:

(a) that is registered under the scheme, administered by the Department, titled ‘MRI Additional Units Eligibility Scheme’, as in force on 27 June 2001; and

(b) in relation to which the registration has not been cancelled or otherwise ceased to have effect.

Note The MRI Additional Units Eligibility Scheme is the scheme of that title published in Gazette No. GN 20 on 23 May 2001, as amended by amendments published in Gazette No. SG 226 on 27 June 2001.

32 MRI and MRA services — meaning of scan

In items 63000 to 63946:

scan means a minimum of 3 sequences.

33 MRI and MRA services — descriptions of purpose of services

The description of a service mentioned in an item in Group I5 means, as applicable:

(a) the exclusion of a condition; or

(b) the further investigation of a condition, using the service as the secondary imaging modality:

(i) when the diagnosis is uncertain; or

(ii) to assess the severity of the condition; or

(c) the monitoring of a condition, using the service following confirmed diagnosis to assess progress of a condition following treatment.

Note For exclusion of a condition, see rule 2.

34 MRI or MRA services — related services that can be claimed in a 12 month period

(1) The fee mentioned in an item does not apply if:

(a) the item is mentioned in subrule (2); and

(b) the service mentioned in the item is provided to a person who, in the 12 months before the service, has been provided with the maximum number of those services mentioned in subrule (2) for that item.

(2) For subrule (1), the items and maximum number of services are:

(a) for items 63000 to 63024, 63050 to 63062, 63100 to 63133, 63150 to 63162, 63300 to 63315, 63350 to 63365, 63400 to 63430, 63450 to 63480, 63500 to 63524, 63550 to 63574, 63600 to 63627, 63650 to 63680, 63700 to 63721, 63750 to 63756, 63870, 63900 to 63909, 63920 and 63930 — 1 service; and

(b) for items 63200 to 63221, 63250 to 63256, 63745, 63800 to 63806 and 63850 to 63868 — 2 services.