Discontinued and abandoned surgery assessing rules in Medicare 011-42060030

Reasons for a procedure to be discontinued or abandoned can include:

• medical reasons, such as a deterioration in the patient's condition
• technical difficulties in performing intended surgery such as equipment failure

Medicare benefits are not payable unless the procedure has commenced, meaning the patient is:

• in the procedure room, or on the bed or operation table where the procedure is to be performed
• anaesthetised or operative site is sufficiently anaesthetised for the procedure to commence, and
• positioned or the operative site is prepared with antiseptic or draping

Where surgery is completed, but is considered unsuccessful, the full MBS item number is payable.

Details of the intended surgery or the reason for discontinuing are not required to support claims submitted to Medicare. Health professionals must maintain a clinical record of this information, which may be subject to audit.

Text must be supplied with claims to advise which surgical items are completed and which are abandoned.

The Resources page has a link to explanatory note TN.8.5 for further information.

Item 30001 is in:

• Category 3 - Therapeutic Procedures
• Group T8 - Surgical Operations
• Subgroup 1 - General

Item 30001 must be co-claimed with an item from Group T8, it is a derived fee item that applies 50% of the scheduled fee for the co-claimed T8 item.

Text must be supplied with claims to advise which surgical items are completed and which are abandoned.

For the system to calculate the correct scheduled fee the 2 items are required to be claimed in the correct order with item 30001 directly below the T8 procedure that was abandoned.

Depending on the intended services and the progress of the operative procedure, different claiming scenarios will apply based on what stage the procedure is abandoned:

• When the operation is discontinued before an MBS item in Group T8 has started, (regardless of whether a single operation or a multiple operation was intended) the surgeon should only bill for the intended item with the highest scheduled fee and it should be co-claimed with item 30001
• When an MBS item in Group T8 has commenced, but the operative procedure is discontinued before any item number has been completed, all intended items can be billed, and each item must be co-claimed with item 30001
• When a service or services described in an MBS item in Group T8 are completed, but other intended procedures are discontinued or abandoned each:
• completed item should be billed as normal,
• item that was not completed should be co-claimed with item 30001

Out-of-hospital service, notional charge and multiple T8 items

Out-of-hospital patient claims require individual charges assigned to each item being claimed. This will ensure the patient’s Extended Medicare Safety Net (EMSN) can be applied correctly.

In-hospital service, notional charge and multiple T8 items

Patient claims for in-hospital services that have a notional charge, should be apportioned (split) over all the services being claimed, excluding item(s) 30001.

The Resources page contains examples of how claims for discontinued or abandoned surgery should be itemised.

Long-acting reversible contraception (LARC), includes:

• hormonal and copper-bearing intrauterine devices (IUDs), and
• the contraceptive implant

Item 82206 is in:

• Category 8 - Miscellaneous Services
• Group M14 - Nurse Practitioners
• Subgroup 4 - Nurse Practitioner Procedures

Item 82206 applies when the insertion or removal of a LARC (item 82201 or 82202) has commenced but is discontinued for:

• clinical reasons, or
• other reasons that are beyond the nurse practitioner’s control

Item 82206 must be co-claimed with an item from Subgroup 4, it is a derived fee item that applies 50% of the schedule fee for the co-claimed item.

For more information on LARC services, see Surgical operations assessing rules in Medicare.

Claims for abandoned surgery submitted via an electronic claiming channel require an individual charge for each item, including item 30001 or 82206. The minimum charge amount that is accepted is $1.00. The system automatically rolls the charge for item 30001 or 82206 into the charge for the item directly above it.

Electronic claims require item 30001 or 82206 immediately beneath any abandoned surgical item.

Note: for further information on processing, see the QITI Assessing Ruling for item 30001 or 82206 plus the page for the relevant claiming channel:

• Patient claims processing in Medicare
• Simplified Billing claims in Medicare
• ECLIPSE claims for Simplified Billing in Medicare
• Bulk bill claims in Medicare

Item 21990 are in:

• Category 3 - Therapeutic Procedures
• Group T10 - Relative Value Guide for Anaesthesia
• Subgroup 18 - Miscellaneous

Item 21990 is claimed for initiation of management of anaesthesia where no procedure ensues. It should only be claimed where the procedure is abandoned before surgery commences. If the procedure is abandoned after surgery has commenced, the anaesthetist should claim the relevant anatomical initiation item.

Item 21990 is only payable where an anaesthetist provides the service in connection with an eligible surgical procedure, that is an MBS item that includes “(Anaes)” in the item description. Item 21990 must be claimed in conjunction with a time based item (23010 to 24136).

Modifier items (25000 to 25020) can also apply with 21990.

Item 21990 can also be paid with Subgroup 19 therapeutic and diagnostic imaging service (22002 – 22075).

Items for assistance at operations are in:

• Category 3 - Therapeutic Procedures
• Group T9 - Assistance at Operations

Where a T8 procedure, or combination of procedures, is discontinued Medicare benefits are payable for the assistance. The assistant still needs to meet the full requirements set out in the item description and the MBS explanatory notes.

The item number and schedule fee for assistance at operations is determined by the fee for the T8 surgical item or series of surgical items. When calculating the fee for the surgical operation, or aggregate fee for a series of operations, the T8 surgical item/s that were discontinued should be reduced by 50% to reflect the derived fee applied to the discontinued procedure. The reduced fees are then used (within the multiple operation rule) to calculate the correct assistant item number and, if applicable, the fee for the assistant.