Discontinued and abandoned surgery assessing rules in Medicare 011-42060030

Example

Outcome

Example A

Dr Z commenced a surgical operation covered by a single Group T8 (item A). This procedure was discontinued on medical grounds part way through. The items must be claimed and keyed in the following order:

• Item A (claimed with text or note ‘abandoned’)
• Item 30001

Example B

Dr Y commenced a surgical operation made up of 3 Group T8 items:

• item B with a schedule fee of $300
• Item C with a schedule fee of $100
• Item D with a schedule fee of $500

The operation was abandoned due to equipment failure. The patient had been positioned on the operation table, anaesthetised and draped, however none of the operations had started. This meets the requirements that the procedure had commenced.

The items should be claimed and keyed in the following order:

• Item D (claimed with text or note ‘abandoned’) - because the procedure is abandoned before an item number is commenced only the item with the highest schedule fee applies
• Item 30001

Example C

Dr X commenced a surgical operation made up of 4 Group T8 items:

• the first 2 procedures (item E and item F) were completed in full
• the third (item G) was discontinued on medical grounds, and
• the fourth (item H) was therefore abandoned

The items should be claimed and keyed in the following order with appropriate text stating completed or abandoned:

• Surgical item E (claimed with text or note ‘completed’)
• Surgical item F (claimed with text or note ‘completed’)
• Surgical item G (claimed with text or note ‘abandoned’)
• Item 30001
• Surgical item H (claimed with text or note ‘abandoned’)
• Item 30001

Example D

A manual inpatient claim has been received with a notional charge and multiple surgical items:

• Total charge $5,000.00
• Surgical item I - claimed with text or note “completed”
• Surgical item J - claimed with text or note “completed”
• Surgical item K - claimed with text or note “abandoned”
• Item 30001
• Surgical item L - claimed with text or note “abandoned”
• Item 30001

If the claim is keyed with $5,000.00 as charge for the first item on the claims (item I) and $0.00 as the charge for the other items - the system returns the message 5-REQ CHG.

Over-key the control line with supervisor access control line. The schedule fee for each surgical (group T8) item will display in the claim.

By over-keying the charge amount for each item (excluding items 30001), with their applicable schedule fee, the notional charge can be apportioned (split) across the relevant items.

Note: for the benefit to pay correctly, the charge must never be keyed as less than the schedule fee.

• Key 0 against the 30001 item(s). The system will automatically add reason code 158 to any item 30001
• Add the schedule fees then take that total from the $5,000.00 notional charge and add the balance to the item with the highest schedule fee
• After following other return messages, the mainframe system then shows the total charge up the top right of the screen as $5,000.00
• Claim can be paid with P to Pay [Enter]

Note: for outpatient services, manual patient claims require an invoice/account from the practice displaying the individual charges raised against each item. This ensures the patient’s Extended Medicare Safety Net (EMSN) can be applied correctly.

Example

Description

Example A

Dr W assisted at a surgical operation made up of 2 Group T8 MBS items:

• item M (Assist) with a schedule fee of $300
• item N with a schedule fee of $50

The procedure was discontinued on medical grounds. The assistant fee is calculated below:

• Item M (Assist) - $300 @50% = $150
• Item N – because (Assist) is not in the item description = $0

Item selected is 51300 as the fee is below the threshold specified in the item descriptor.

Example B

Dr V assisted at a surgical operation made up of 4 Group T8 items.

The first 2 procedures (item O and item P) were completed in full. The third procedure (item Q) was discontinued on medical grounds, and the fourth procedure (item R) was therefore abandoned. All item descriptions for procedures O, Q and R include ‘(Assist)’.

The assistant fee is calculated below:

• Item O (Assist) - $300 @100% (completed) and @100% (multi op) = $300
• Item P - (Assist) is not in the item description, therefore = $0
• Item Q (Assist) - $200 @ 50% (abandoned) and @50% (multi op) = $50
• Item R (Assist) - $150 @50% (abandoned) and @25% (multi op) = $18.75
• Total fee = $368.75

Item selected is 51300 as the aggregate fee calculated is below the threshold specified in the item descriptor.

Example C

Dr T assisted at a surgical operation made up of 2 Group T8 items:

• item S (Assist) with a schedule fee of $2,000
• item R (Assist) with a schedule fee of $100

The operation was abandoned due to equipment failure. The patient had been positioned on the operation table, anaesthetised and draped however none of the procedures had started.

The assistant fee is calculated below:

• Item S (Assist) - $2,000 @50% = $1,000
• Item T (Assist) – because the procedure is abandoned before an item number was commenced only the item with the highest schedule fee applies = $0

Item selected is 51303 as the fee is above the threshold specified in the item descriptor. The schedule fee for item 51303 is 20% of the fee of the surgical item and is therefore calculated at $200.