Health Insurance (Pathology Services Table) Regulation 2012
RepealedCTH
This Act has been repealed and is no longer in force. It is retained for historical reference.
Jurisdiction
Commonwealth
Act Number
246 of 2012
Collection
legislative instrument
Plain English Summary
9/10 complexity
This regulation defines the Medicare Benefits Schedule for pathology: a list of 700+ specific lab services (blood tests, biopsies, genetic screens, etc.) each with a fixed Medicare rebate. It governs how providers bill, how practitioners request tests, and how patients access subsidised pathology.
It matters because it enforces episode-based billing, frequency limits, and fee‑splits for referred tests, and includes hospital exemptions—shaping lab revenue, clinical documentation requirements, and patient access to subsidised testing.
Zoe can write the in-depth analysis on top of the summary above: how it works, who it affects and what each part actually does.
Current sections
Direct links to the current provisions in Health Insurance (Pathology Services Table) Regulation 2012.
10
Div 1
2 General application provisions
Division 1.2 General application provisions
1.2.1 Precedence of items
1.2.2 Circumstances in which services rendered following 2 requests to be taken to have been rendered following one request
1.2.3 Services to which clause 1.2.2 does not apply
1.2.4 Referral of designated tests by one pathology practitioner to another
1.2.5 Items not to be split
1.2.6 Certain pathology services to be treated as one service
1.2.7 Meaning of general practitioner and set of pathology services
1.2.8 Satisfying requirements described in pathology service
Part 2
Services and fees
Part 2 Services and fees
Div 2
1 Group P1—Haematology
Division 2.1 Group P1—Haematology
2.1.1 Services to which clause 1.2.2 does not apply
2.1.2 Item taken to refer only to the first service of a particular kind
Division 2.2 Group P2—Chemical
2.2.1 Creatinine ratios
2.2.2 Services to which clause 1.2.2 does not apply
2.2.3 Limitation on certain items
2.2.4 Serum B12 and red cell folate testing
2.2.5 Thyroid function testing
2.2.6 Limitation on certain items
2.2.7 Nutritional and toxicity metals testing
Division 2.3 Group P3—Microbiology
2.3.1 Meaning of serial examinations or cultures
2.3.2 Antigen detection
2.3.3 Investigation for hepatitis serology
2.3.4 Limitation on certain items
2.3.5 Hepatitis C viral RNA testing
Division 2.4 Group P4—Immunology
2.4.1 Limitation on certain items
2.4.2 Tests in Group P4 relating to antibodies
2.4.3 HLA‑B27 typing
2.4.4 Antineutrophil cytoplasmic antibody tests
Division 2.5 Group P5—Tissue pathology
2.5.1 Tests on biopsy material
Division 2.6 Group P6—Cytology
2.6.1 Tests on biopsy material
Division 2.7 Group P7—Genetics
2.7.1 Haemochromatosis testing
2.7.2 HLA‑B27 typing
Division 2.8 Group P8—Infertility and pregnancy tests
2.8.1 Limitation on item 73523
Division 2.9 Group P9—Simple basic pathology tests
Division 2.10 Group P10—Patient episode initiation
2.10.1 Items in Group P10 (Patient episode initiation) not to apply in certain circumstances
Division 2.11 Group P11—Specimen referred
2.11.1 Items in Group P11 not to apply in certain circumstances
2.11.2 Application of an item in Group P11 to a service excludes certain other items
2.11.3 Circumstances in which an item in Group P11 does not apply
Division 2.12 Group P12—Management of bulk‑billed services
2.12.1 Application of items 74990 and 74991
Division 2.13 Group P13—Bulk billing incentive for episodes consisting of a P10 service
Part 3 Abbreviations
Part 4 Complexity levels for histopathology items
Dictionary
Notes
1
Name of regulation \[see Note 1\]
1 Name of regulation [see Note 1]
This regulation is the Health Insurance (Pathology Services Table) Regulation 2012.
4
Dictionary
4 Dictionary
The Dictionary at the end of this regulation defines certain words and expressions and includes references to certain words and expressions that are defined elsewhere in this regulation.
5
Pathology services table
5 Pathology services table
For subsection 4A (1) of the Act, this regulation prescribes a table of pathology services set out in Schedule 1.
Sch 1
Pathology services table
Schedule 1 Pathology services table
(section 5)
More sections below
Source text: opening excerpt
Sourced from the Federal Register of Legislation (legislation.gov.au), CC BY 4.0.
1 Health Insurance (Pathology Services Table) Regulation 2012
Health Insurance (Pathology Services Table) Regulation 2012
Select Legislative Instrument 2012 No. 246 as amended
made under the
Health Insurance Act 1973
This compilation was prepared on 1 January 2013
taking into account amendments up to SLI 2012 No. 297
Prepared by the Office of Parliamentary Counsel, Canberra
Contents
1 Name of regulation [see Note 1]
4 Dictionary
5 Pathology services table
Schedule 1 Pathology services table
Part 1 Preliminary
Division 1.1 Interpretation
1.1.1 Abbreviations
Division 1.2 General application provisions
1.2.1 Precedence of items
1.2.2 Circumstances in which services rendered following 2 requests to be taken to have been rendered following one request
1.2.3 Services to which clause 1.2.2 does not apply
1.2.4 Referral of designated tests by one pathology practitioner to another
1.2.5 Items not to be split
1.2.6 Certain pathology services to be treated as one service
1.2.7 Meaning of general practitioner and set of pathology services
1.2.8 Satisfying requirements described in pathology service
Part 2 Services and fees
Division 2.1 Group P1—Haematology
2.1.1 Services to which clause 1.2.2 does not apply
2.1.2 Item taken to refer only to the first service of a particular kind
Division 2.2 Group P2—Chemical
2.2.1 Creatinine ratios
2.2.2 Services to which clause 1.2.2 does not apply
Division 2.8 Group P8—Infertility and pregnancy tests
2.8.1 Limitation on item 73523
Division 2.9 Group P9—Simple basic pathology tests
Division 2.10 Group P10—Patient episode initiation
2.10.1 Items in Group P10 (Patient episode initiation) not to apply in certain circumstances
Division 2.11 Group P11—Specimen referred
2.11.1 Items in Group P11 not to apply in certain circumstances
2.11.2 Application of an item in Group P11 to a service excludes certain other items
2.11.3 Circumstances in which an item in Group P11 does not apply
Division 2.12 Group P12—Management of bulk‑billed services
2.12.1 Application of items 74990 and 74991
Division 2.13 Group P13—Bulk billing incentive for episodes consisting of a P10 service
Part 3 Abbreviations
Part 4 Complexity levels for histopathology items
Dictionary
Notes
1 Name of regulation [see Note 1]
This regulation is the Health Insurance (Pathology Services Table) Regulation 2012.
4 Dictionary
The Dictionary at the end of this regulation defines certain words and expressions and includes references to certain words and expressions that are defined elsewhere in this regulation.
5 Pathology services table
For subsection 4A (1) of the Act, this regulation prescribes a table of pathology services set out in Schedule 1.
Schedule 1 Pathology services table
(section 5)
Part 1 Preliminary
Division 1.1 Interpretation
1.1.1 Abbreviations
(1) The abbreviations in Part 3 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 must be written in full.
Division 1.2 General application provisions
1.2.1 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 subclause (3), if:
(a) subclause (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.
1.2.2 Circumstances in which services rendered following 2 requests to be taken to have been rendered following one request
(1) In subclause (2):
service includes assay, estimation and test.
(2) Two or more pathology services (other than services to which, under clause 1.2.3, 2.1.1 or 2.2.2, this clause 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) that item is not item 74990 or 74991; and
(c) 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 1 day.
1.2.3 Services to which clause 1.2.2 does not apply
(1) Clause 1.2.2 does not apply to a pathology service described in subclause (2) if:
(a) under a request for a service, other than a request for a service described in paragraph (2) (a), no more than 6 tests are requested; and
(b) the tests are performed within 6 months of the request; and
(c) the pathology provider of the service writes on the account for the service that the service has a rule 3 exemption.
(2) For subclause (1), the pathology services are:
(a) estimation of prothrombin time (INR) for a patient undergoing anticoagulant therapy; and
(b) quantitative estimation of lithium for a patient undergoing lithium therapy; and
(c) a service described in item 65070 in relation to a patient undergoing chemotherapy for neoplastic disease or immunosuppressant therapy; and
(d) a service described in item 65070 in relation to
clozaril, ticlopidine hydrochloride, methotrexate, gold, sulphasalazine or penicillamine therapy of a patient; and
(e) a service described in any of items 66500 to 66512, in relation to methotrexate or leflunomide therapy of a patient; and
(f) quantitative estimation of urea, creatinine and electrolytes in relation to:
(i) cis‑platinum or cyclosporin therapy of a patient; or
(ii) chronic renal failure of a patient being treated
in a dialysis program conducted by a recognised hospital; and
(g) quantitative estimation of albumin and calcium in relation to therapy of a patient with vitamin D, its metabolites or analogues; and
(h) quantitative estimation of calcium, phosphate, magnesium, urea, creatinine and electrolytes for a cancer patient receiving bisphosphonate infusions.
1.2.4 Referral of designated tests by one pathology practitioner to another
(1) In this clause:
designated test means a pathology test relating to a patient episode that is a test of a kind mentioned in item 65150, 65175, 66650, 66695, 66711, 66722, 66785, 66800, 66812, 66819, 66825, 69384, 69494, 71089, 71153 or 77165.
(2) This clause applies if one or more designated tests are referred by a referring APP to a receiving APP in another approved pathology authority.
(3) If a referring APP has rendered one or more designated tests:
(a) the amount mentioned in item 65150, 65153, 65175, 65176, 65177, 65178, 66650, 66695, 66698, 66701, 66704, 66707, 66711, 66722, 66725, 66728, 66731, 66785, 66800, 66803, 66812, 66819, 66825, 69384, 69387, 69390, 69393, 69396, 69494, 69495, 71089, 71091, 71153, 71155, 71157, 77165, 71166 or 71167
(as the case may be) is payable for each designated test rendered by the referring APP; and
(b) subject to subclause (5), the amount mentioned in item 65158, 65181, 66652, 66697, 66715, 66724, 66790, 66805, 66817, 66821, 66827, 69401, 69498, 71092, 71156 or 71170 (as the case may be) is payable for each designated test rendered by the receiving APP.
(4) If a referring APP has not rendered a designated test:
(a) for the first designated test that is rendered by the receiving APP—the amount mentioned in item 65157, 65180, 66651, 66696, 66714, 66723, 66789, 66804, 66816, 66820, 66826, 69400, 69497, 71090, 71154 or 71169 (as the case may be) is payable; and
(b) for each subsequent designated test (if any) that is rendered by the receiving APP—subject to subclause (6), the amount mentioned in item 65158, 65181, 66652, 66697, 66715, 66724, 66790, 66805, 66817, 66821, 66827, 69401, 69498, 71092, 71156 or 71170 (as the case may be) is payable for each test rendered.
(5) For paragraph (3) (b), the maximum number of designated tests for which the fee mentioned in the relevant item is payable is as follows:
(a) for item 66652, 66715, 66790, 66817, 66821 or 66827:
(b) for item 65158, 66805, 69498 or 71092:
(c) for item 71156 or 71170:
(d) for item 65181 or 66724:
where:
X is the number of designated tests rendered by a referring APP.
(6) For paragraph (4) (b), the maximum number of designated tests for which the fee mentioned in the relevant item is payable is as follows:
(a) for item 66652, 66715, 66790, 66817, 66821 or 66827—1;
(b) for item 65158, 66805, 69498 or 71092—2;
(c) for item 71156 or 71170—3;
(d) for item 65181 or 66724—4.
(7) Items in Group P10 (Patient episode initiation) do not apply to a receiving APP in subclause (2).
1.2.5 Items not to be split
Except as stated in clause 1.2.4 the amount mentioned in an item is payable only to one approved pathology practitioner for a single patient episode.
1.2.6 Certain pathology services to be treated as one service
(1) In this clause:
general practitioner has the meaning given by subclause 1.2.7 (1).
set of pathology services has the meaning given by subclause 1.2.7 (2).
(2) If a general practitioner, participating midwife or participating nurse 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 clause.
(3) If the fee mentioned in an item that describes any of the services in the set of pathology services is higher than the fees mentioned 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 mentions 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 mentions the second‑highest fee—the pathology service described in the item that mentions 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 mentioned 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 mentioned 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 mentions 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 mentions 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 mentioned in any of the items that describe the pathology services that are to be treated as the one pathology service.
1.2.7 Meaning of general practitioner and set of pathology services
(1) In clause 1.2.6:
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.
(2) In clause 1.2.6 and subject to subclause (3):
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 in item 66900, 69484, 73053 or 73055.
(3) In clause 1.2.6, an item mentioned in this subclause is to be excluded from a set of pathology services:
(a) if a service is requested by an approved pathology practitioner of an approved pathology authority and rendered by another approved pathology practitioner of an approved pathology authority that is not related to the approved pathology authority of the first mentioned approved pathology practitioner—item 65079, 65082, 65157, 65158, 65166, 65180, 65181, 66606, 66609, 66610, 66639, 66642, 66651, 66652, 66663, 66666, 66696, 66697, 66714, 66715, 66723, 66724, 66780, 66783, 66789, 66790, 66792, 66804, 66805, 66816, 66817, 66820, 66821, 66826, 66827, 66832, 69325, 69328, 69331, 69379, 69383, 69400, 69401, 69419, 69451, 69489, 69492, 69497, 69498, 69500, 71076, 71090, 71092, 71096, 71148, 71154, 71156, 71169, 71170, 73309, 73312, 73315, 73318, 73321 or 73324; and
(b) an item in Group P10 (Patient episode initiation), Group P11 (Specimen referred), Group P12 (Management of bulk‑billed services) or Group P13 (Bulk billing incentive for episodes consisting of a P10 service).
(4) An approved pathology authority is related to another approved pathology authority for paragraph (3) (a) 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 connected entities within the meaning of the Corporations Act 2001; 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); or
(e) both approved pathology authorities are operated by the Commonwealth or an authority of the Commonwealth; or
(f) both approved pathology authorities are operated by the same State or internal Territory or an authority of the same State or internal Territory.
1.2.8 Satisfying requirements described in pathology service
Unless the contrary intention appears, a requirement contained in the description of a pathology service in Part 2 is satisfied if:
(a) for a requirement for information—the information:
(i) is included in the request for the service; or
(ii) was supplied in writing on an earlier occasion to
the approved pathology authority that rendered
the service, and has been kept by the approved pathology authority; or
(b) for a requirement for laboratory test results—the results are:
(i) included in the request for the service; or
(ii) obtained from another laborator
This is an opening excerpt, not the complete document.