Diagnostic procedures and investigations assessing rules in Medicare 011-42050000

Medicare Benefits Schedule (MBS) Category 2 Diagnostic Procedures and Investigations includes a wide range of services used to assess how body systems are working and to help diagnose, monitor or manage a patient’s condition.

Unlike diagnostic imaging services, many of the services in Category 2 measure electrical activity, organ function, circulation, breathing, hearing or other body responses.

Services contained in MBS Category 2 - Diagnostic Procedures and Investigations include:

• Neurology
• Ophthalmology
• Otolaryngology
• Respiratory
• Vascular
• Cardiovascular
• Gastroenterology & Colorectal
• Genito / urinary physiological investigations
• Allergy testing
• Other diagnostic procedures and investigations
• Non-imaging nuclear medicine

The Resources page has detailed descriptions and examples of these services.

When checking diagnostic procedure and investigation items, start with the MBS. The MBS gives the full service description, Schedule fee and any explanatory notes with extra information about the item. This should be read in conjunction with any relevant assessing rulings in QITI.

Diagnostic imaging has separate rules and multiple service rules. See Diagnostic imaging assessing rules in Medicare.

The Resources page contains a link to the MBS Online.

This subgroup contains neurology diagnostic procedures used to assess the function of the brain, central nervous system and peripheral nerves, including:

• tests that measure the brain’s electrical activity, such as:
  • electroencephalography (EEG)
  • electrocorticography (ECoG)
• neuromuscular studies, such as:
  • electromyography (EMG)
  • evoked response testing

The items differ based on factors such as the duration and setting of testing, the number of nerves examined, or the number of studies performed, with each service selected according to the level of complexity required.

Neurology items 11000-11027

Items 11000 -11027 are diagnostic and cannot be used for intraoperative monitoring.

Diagnostic services are performed to identify a condition; intraoperative monitoring is performed during a procedure to monitor patient function and guide treatment.

Medicare benefits are not payable for services under items 11000 - 11027 when the service is performed during surgery to monitor nerve or brain function.

Audiology services are in Subgroup 3 - Otolaryngology.

Audiology services are used to assess hearing, balance and auditory system function. These services can help investigate hearing loss, middle ear function, cochlear function, auditory nerve pathways and vestibular disorders.

Some audiology services have specific requirements. These may include:

• testing conditions
• calibrated equipment
• whether middle ear pathology has been excluded, where required by the item

Always check the item description and any relevant explanatory notes to confirm the service requirements and item restrictions.

Diagnostic audiology services by audiologists

MBS items 82300 to 82332 cover diagnostic audiology services provided by eligible audiologists. Most items require a written request from a medical practitioner. The exceptions are items 82301, 82302 and 82304, which are for programming an auditory implant or auditory implant sound processor.

These diagnostic audiology services help medical practitioners, including ear, nose and throat (ENT) specialists, diagnose, treat or manage ear disease and related conditions. They also support otolaryngology services provided by, or on behalf of, medical practitioners under MBS items 11300 to 11345, excluding item 11304.

Items 82300 to 82332 can only be claimed by audiologists who are registered with Services Australia.

See Audiologist - provider eligibility and registration.

The Resources page has a link to diagnostic audiology item information on the Services Australia website.

Bone densitometry services are in Subgroup 10 - Other diagnostic procedures and investigations.

A bone densitometry test, also called a bone mineral density (BMD) test, is used to detect osteoporosis or low bone mass. It uses dual-energy X-ray absorptiometry, commonly called DXA or DEXA, to measure the amount of calcium and other minerals in a segment of bone. A high mineral content indicates denser and stronger bones.

Medicare benefits for bone densitometry items 12306-12322 are:

• mostly restricted to one per 24 months, unless a patient has a specific medical condition or is undergoing treatment that may cause more rapid bone loss
• only available for confirming and monitoring established conditions and specific treatments
• only payable for tests performed on DEXA or quantitative computerised tomography (QCT) machines
• not available for screening tests

The item description lists the clinical indications, conditions and treatments that are eligible for Medicare benefits. Always check the item description and any relevant explanatory notes to confirm the service requirements, time dependencies and item restrictions.

The bone densitometry items include both the:

• measurement of 2 or more sites
• interpretation and provision of a report

The interpretation and report for all bone densitometry services must be provided by a specialist or consultant physician.

The Resources page has a table outlining the bone densitometry MBS items.

Requested service

Bone densitometry services must be requested by a medical practitioner to a specialist or consultant physician. Requests must specify the indication for the test.

A specialist or consultant physician can self-determine a bone densitometry service for a patient referred to them for management, if the service meets the requirements of items 12306, 12312, 12315, 12320, 12321 or 12322.

Sleep study services are in Subgroup 10 – Other diagnostic procedures and investigations.

A sleep study, known as polysomnography (PSG), monitors and records various body functions during sleep including:

• brain activity
• eye movement
• heart rate
• breathing patterns
• oxygen levels
• body movement

A sleep study can be performed in a laboratory (attended) or a patient’s home (unattended).

Medicare benefits are available for sleep studies, depending on the type of study and clinical indications. A patient must meet strict eligibility criteria and have a valid referral from an eligible medical practitioner.

Requirements

Sleep study MBS items require the:

• continuous monitoring and recording of specified parameters
• interpretation of the data, and
• preparation of a report by an appropriately qualified practitioner

Practitioners are required to ensure they can meet the PSG requirements of the current professional guidelines. MBS note DN.1.17 outlines the applicable guidelines.

Always check the item description and any relevant explanatory notes to confirm the service requirements, clinical indications, time dependencies and item restrictions.

The Resources page has a:

• link to MBS note DN.1.17
• table outlining the MBS sleep study items

Electrocardiography services, commonly known as ECG services, are in Subgroup 6 - Cardiovascular.

An ECG records the electrical activity of the heart and can help assess heart rhythm, heart rate and signs of heart disease. Electrocardiography is the process of recording this activity, while an electrocardiogram is the recording or trace produced. ECG is commonly used to refer to both the test and the recording. The terms ECG and EKG are often used interchangeably.

During an ECG, small electrodes are placed on the patient’s chest, arms and legs. The electrodes detect the heart’s electrical signals, which are displayed as a trace for review.

Common ECG tests include:

• Resting ECG: the patient lies still for a few minutes while the ECG is recorded
• Ambulatory ECG: the patient wears leads connected to a portable monitor while continuing their usual activities
• Cardiac stress test: the patient exercises while the ECG records how the heart responds to physical activity

MBS items 11704, 11705, 11707 and 11714 cover 12-lead ECG services. A 12-lead ECG records the heart’s electrical activity from 12 different views. The items differ depending on whether the service includes a trace, a formal report, a clinical note, or a combination of these. Item 11713 is for a signal averaged ECG recording using at least 3 leads.

The Resources page has a table outlining the ECG MBS items.

Ambulatory electrocardiogram (AECG) services are in Subgroup 6 - Cardiovascular.

An AECG records a patient’s heart rhythm while they continue their usual daily activities. The patient wears a small portable monitor that records the heart’s electrical activity over a set period. After the recording period, the information is reviewed and a report is prepared.

An AECG may also be referred to as a Holter monitor or 24-hour ECG.

MBS items 11716 to 11735 cover AECG services. The service must be completed in full, including preparation of the report, before it can be claimed.

The Resources page has a table outlining the AECG MBS items.

The Training & Support page has links to AECG eLearning and infographics.

Diagnostic procedure and investigation services may interact with diagnostic imaging multiple service rules (DIMSR).

For DIMSR purposes, most diagnostic procedure and investigation services are treated as non-consultation services.

If an R-type diagnostic imaging service and a non-consultation service are provided to the same patient by the same practitioner on the same day, DIMSR C may reduce the Schedule fee of the diagnostic imaging service with the highest fee.

See Diagnostic imaging assessing rules in Medicare for information about DIMSR.

Some diagnostic procedure and investigation items require a referral, request or specific clinical indication.

Always check the item description and relevant explanatory note before assessing a service.

See Referrals for assessing in Medicare.