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This instrument is the Health Insurance (Pathology Services Table) Regulations 2020.
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The Regulations set the Medicare fee schedule for hundreds of pathology services—blood, chemical, microbiology, immunology, tissue/cytology, genetics, infertility/pregnancy and basic tests—defining item numbers, fees and specimen‑collection charges. They govern who gets rebates, bulk‑billing rules, limits on test frequency, annual indexation and higher incentives for rural areas. This directly affects patients’ out‑of‑pocket costs, how pathology providers and requesting doctors claim rebates, and coverage of modern genetic testing.
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Direct links to the current provisions in Health Insurance (Pathology Services Table) Regulations 2020.
This instrument is the Health Insurance (Pathology Services Table) Regulations 2020.
This instrument is made under the Health Insurance Act 1973.
For the purposes of section 4A of the Health Insurance Act 1973, Schedule 1 is prescribed as a table of pathology services.
Sourced from the Federal Register of Legislation (legislation.gov.au), CC BY 4.0.
This instrument is the Health Insurance (Pathology Services Table) Regulations 2020.
This instrument is made under the Health Insurance Act 1973.
For the purposes of section 4A of the Health Insurance Act 1973, Schedule 1 is prescribed as a table of pathology services.
Schedule 1—Pathology services table
Note: See section 4.
The Dictionary in Part 4 defines certain words and expressions that are used in this Schedule, and includes references to certain words and expressions that are defined elsewhere in this Schedule.
If the description of a pathology service in an item in this Schedule does not include the methodology for the service, the methodology by which the service may be carried out includes assay, estimation and test.
Note: A pathology service is deemed to include any necessary interpretation, analysis or reporting—see subsection 3(5A) of the Act.
A reference in this Schedule to an item includes a reference to an item relating to a health service that, under a determination in force under subsection 3C(1) of the Act, is treated as if there were an item in the table that relates to the service.
(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 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.
Two or more pathology services (other than services to which, under clause 1.2.3, 1.2.4 or 1.2.5, 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, 74991, 75861, 75862, 75863 or 75864; 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) 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 the purposes of 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 clozapine, ticlopidine hydrochloride, methotrexate, gold, sulfasalazine 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) cisplatin or ciclosporin 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) Clause 1.2.2 does not apply to a pathology service described in item 65060, 65070, 65120, 65123, 65126, 65129, 65150, 65153 or 65156 if: (a) the service is rendered in relation to one or more specimens taken on any of not more than 6 occasions in 24 hours; and (b) the service is rendered to an inpatient of a hospital; and (c) the service is rendered in relation to each specimen as soon as possible after the specimen is taken; and (d) the pathology provider of the service writes on the account for the service that the service has a “rule 3 exemption”. (2) Clause 1.2.2 does not apply to a pathology service described in item 65109 or 65110 if: (a) the service is rendered: (i) for a service described in item 65109—on one of not more than 5 occasions in 24 hours; and (ii) for a service described in item 65110—on one of not more than 2 occasions in 24 hours; and (b) the service was requested on a separate occasion to any other occasions on which the service was requested in that period; and (c) the pathology provider of the service writes on the account for the service that the service has a “rule 3 exemption”.
Clause 1.2.2 does not apply to a pathology service described in item 66500, 66503, 66506, 66509, 66512, 66584 or 66800 if: (a) the service is rendered in relation to one or more specimens taken on any of not more than 6 occasions in 24 hours; and (b) the service is rendered to an inpatient of a hospital; and (c) the service is rendered in relation to each specimen as soon as possible after the specimen is taken; and (d) the pathology provider of the service writes on the account for the service that the service has a “rule 3 exemption”.
(1) 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) 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) applies to each designated test rendered by the referring APP; and (b) subject to subclause (5), item 65158, 65181, 66652, 66697, 66715, 66724, 66790, 66805, 66817, 66821, 66827, 69401, 69498, 71092, 71156 or 71170 (as the case may be) applies to 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—item 65157, 65180, 66651, 66696, 66714, 66723, 66789, 66804, 66816, 66820, 66826, 69400, 69497, 71090, 71154 or 71169 (as the case may be) applies; and (b) for each subsequent designated test (if any) that is rendered by the receiving APP—subject to subclause (6), item 65158, 65181, 66652, 66697, 66715, 66724, 66790, 66805, 66817, 66821, 66827, 69401, 69498, 71092, 71156 or 71170 (as the case may be) applies to each test rendered. (5) For the purposes of paragraph (3)(b), the maximum number of designated tests to which the relevant item applies is as follows: (a) for item 66652, 66715, 66790, 66817, 66821 or 66827—2 less the number of designated tests rendered by a referring APP; (b) for item 65158, 66805, 69498 or 71092—3 less the number of designated tests rendered by a referring APP; (c) for item 71156 or 71170—4 less the number of designated tests rendered by a referring APP; (d) for item 65181 or 66724—5 less the number of designated tests rendered by a referring APP. (6) For the purposes of paragraph (4)(b), the maximum number of designated tests to which the relevant item applies 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).
Except as stated in clause 1.2.6, an item applies only to one approved pathology practitioner for a single patient episode.
(1) If a medical practitioner (other than a specialist or consultant physician), participating midwife or participating nurse practitioner requests a set of pathology services to which clause 1.2.9 applies, the pathology services in the set are to be treated as individual pathology services in accordance with this clause. (2) If the fee mentioned in an item that describes any of the services in the set 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. (3) If the fees mentioned in 2 or more items that describe any of the services in the set 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. (4) If pathology services are to be treated as one pathology service under paragraph (2)(c) or (3)(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) This clause applies to a set of pathology services if: (a) the set consists of services that are described in at least 4 different items, other than an item mentioned in subclause (2); and (b) all of the services in the set are requested in a single patient episode; and (c) each of the services in the set relates to a patient who is not an admitted patient of a hospital; and (d) none of the services in the set is referred to in item 66900, 69484, 73070, 73071, 73072, 73074, 73075 or 73076. (2) For the purposes of paragraph (1)(a), the items are as follows: (a) 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); (b) 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, 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, 66834, 66837, 69325, 69328, 69331, 69379, 69383, 69400, 69401, 69451, 69489, 69492, 69497, 69498, 69500, 71076, 71090, 71092, 71096, 71148, 71154, 71156, 71169, 71170, 73309, 73312, 73315, 73318, 73321 or 73324. (3) For the purposes of paragraph (2)(b), an approved pathology authority is related to another approved pathology authority 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.
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 laboratory test performed in the same patient episode; or (iii) included in results from an earlier laboratory test that have been kept by the approved pathology authority.
An item in this Schedule does not apply to a service described in the item if the service is rendered to a patient at the same time as, or in connection with, an injection of blood or a blood product that is autologous.
An item in this Schedule does not apply to a service described in the item if the service is rendered to a patient at the same time as, or in connection with, the harvesting, storage, in
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