Anaesthetic services assessing rules in Medicare 011-42060010

Anaesthesia is the procedure of inducing insensibility to sensation and pain.

An anaesthetic is administered during operative procedures and can be either a:

• general anaesthetic which renders the patient unconscious
• regional or field nerve blocks where a substantial part of the body is anaesthetised, and the patient remains conscious
• neuroleptic anaesthetic which renders the patient semi-conscious

Anaesthetic services are listed under Category 3 Therapeutic Procedures of the Medicare Benefits Schedule (MBS). The Resources page contains a link to MBS Online.

When searching for information about anaesthetic services in the MBS, refer to the item number in the first instance. This will provide:

• a full description of the item
• the item’s schedule fee, and
• advise if there is an explanatory note containing additional information about the item

Alternately, search the MBS using key words.

All relevant explanatory notes including QITI need to be reviewed before Service Officers provide advice.

If clarification of the item description or explanatory note is needed, refer to an appropriate Service Centre Manager, Team Coach or Team Program Adviser.

Regional or field nerve blocks

Regional or field nerve blocks are a form of anaesthetic used to anaesthetise a substantial segment of the body for an operation or procedure. They are commonly used during labour, as an anaesthetic for minor procedures and may be used where the patient’s condition prevents the use of a general anaesthetic.

Benefits are not payable for nerve blocks which are not of a major nature. The descriptions of the various items cover those blocks that are deemed to be major blocks, for example, item 18264 (pudendal nerve).

Major nerve blocks

A major nerve block is interpreted as the anaesthetising of either:

• a substantial segment of the body supplied by a large nerve
• an area supplied by a smaller nerve, where the technique demands expert anatomical knowledge and a high degree of precision

Local (non-major) nerve blocks

Nerve blocks not meeting the above criteria are considered to be local anaesthetics which do not attract benefits when performed in association with a surgical procedure.

For example:

• digital ring analgesia
• local infiltration into tissue surrounding a lesion
• paracervical (uterine) blocks
• sciatic blocks
• blocks of individual nerves of arm or leg
• blocks of various nerves of the head and/or face

A number of services have been included in the Medicare Benefits Schedule (MBS) for the control of post-operative pain.

Items 22031 – 22041 apply for post-operative pain where the service is provided in association with anaesthesia and surgery as outlined in the item descriptors. Benefit is not payable where nerve block items other than those listed above are used for the control of post-operative pain in association with anaesthesia and surgery.

Items 18222 and 18225 apply where top-up is required to maintain regional anaesthesia or analgesia when the service is performed by a health professional other than the operating surgeon. This does not preclude benefits for an obstetrician performing an epidural block during labour.

See also: MBS explanatory note for these items. The Resources page contains a link to MBS Online.

Epidural anaesthesia is covered by the following Group T7 Medicare Benefits Schedule (MBS) items:

• 18216, 18219
• 18226, 18227 for after hours services

Whether administered by the medical practitioner undertaking the confinement or by another medical practitioner.

Subsequent top-ups for the control of pain are covered by either item 18222 or 18225.

Where an epidural block is topped up in the operating theatre for the purposes of Caesarean section, Medicare benefits for that anaesthetic service should be paid under item 20850, Initiation of management of anaesthesia for Caesarean section.

Benefits would also be payable for the epidural anaesthetic performed earlier in labour for pain relief.

Note: Service officers must check the claim and patient history to ensure separate times are noted before overriding any restrictions.

To bill Relative Value Guide (RVG) items, health professionals must record the start and end times for all procedures billed under RVG items range:

• 23010 - 24136

Start and end times are to be recorded in patient notes and not as part of the claim.

Claims for after hours emergency items for anaesthesia, assistant anaesthesia or perfusion must include text or notation including all of the following:

• start time
• end time
• total time

This affects claims including items:

• 25025
• 25030, and
• 25050

The Resources page contains other additional invoice or claim requirements for after hours emergency items for anaesthesia in MBS Note TN.10.6.

When the block is not associated with an operation, for example, during labour or for intractable pain, benefit is payable under Group T7 of the Schedule.

From 1 March 2022, there are certain items that include the following phrase in their description:

• 'not in association with a service to which an item in Group T8 applies, unless the nerve block is performed using a targeted percutaneous approach'

Where a block is administered to a patient on the same day as an anaesthetic for an operation, the invoice/receipt or claim must show:

• that the services were provided on separate occasions, or
• performed using a targeted percutaneous approach (for relevant items with this wording in their description)

Before overriding any restrictions, Service Officers must check the claim and patient history for:

• separate times, or
• supported text stating 'targeted percutaneous approach’ or ‘TPA’