Surgical operations assessing rules in Medicare 011-42060050

Situation

Example of appropriate text

Separate sites

3 breast lesions:

Item 31548 - text states 'separate site 1 of 3 left 1 o'clock'

Item 31548 - text states 'separate site 2 of 3 left 2 o'clock'

Item 31548 - text states 'separate site 3 of 3 left 3 o’clock'

Separate sites

2 breast lesions:

Item 31548 - text states 'separate site left 2 o'clock'

Item 31530 - text states 'separate site left 3 o'clock'

Separate breasts

2 breast lesions:

Item 31548 - text states 'separate site 1 of 2 left 1 o'clock 2cm from nip'

Item 31548 - text states 'separate site 2 of 2 right 1 o'clock 4cm from nip'

Nip means nipple of the breast

Separate times

2 breast lesions:

Item 31548 - text states '9am'

Item 31548 - text states '3pm'

Item

Group (not MBS)

Item description

Number of motion segments

Restrictions for same operation

51011

A

Direct spinal decompression or exposure

One

Only one item number can be selected from this group

51012

A

Direct spinal decompression or exposure

2

Only one item number can be selected from this group

51013

A

Direct spinal decompression or exposure

3

Only one item number can be selected from this group

51014

A

Direct spinal decompression or exposure

4

Only one item number can be selected from this group

51015

A

Direct spinal decompression or exposure

More than 4

Only one item number can be selected from this group

51020

B

Simple fixation of part of one vertebra

Vertebra

Only one item number can be selected from this group

These items cannot be claimed with an item from group F

51021

B

Fixation of motion segment

One

Only one item number can be selected from this group

These items cannot be claimed with an item from group F

51022

B

Fixation of motion segment

2

Only one item number can be selected from this group

These items cannot be claimed with an item from group F

51023

B

Fixation of motion segment

3 or 4

Only one item number can be selected from this group

These items cannot be claimed with an item from group F

51024

B

Fixation of motion segment

5 or 6

Only one item number can be selected from this group

These items cannot be claimed with an item from group F

51025

B

Fixation of motion segment

7 to 12

Only one item number can be selected from this group

These items cannot be claimed with an item from group F

51026

B

Fixation of motion segment

More than 12

Only one item number can be selected from this group

These items cannot be claimed with an item from group F

51031

C

Spine, bone graft to

One

Only one item number can be selected from this group

These items cannot be claimed with an item from group F

51032

C

Spine, bone graft to

2

Only one item number can be selected from this group

These items cannot be claimed with an item from group F

51033

C

Spine, bone graft to

3

Only one item number can be selected from this group

These items cannot be claimed with an item from group F

51034

C

Spine, bone graft to

4 to 7

Only one item number can be selected from this group

These items cannot be claimed with an item from group F

51035

C

Spine, bone graft to

8 to 11

Only one item number can be selected from this group

These items cannot be claimed with an item from group F

51036

C

Spine, bone graft to

12 or more

Only one item number can be selected from this group

These items cannot be claimed with an item from group F

51041

D

Spinal fusion

One

Only one item number can be selected from this group

These items cannot be claimed with an item from group F

51042

D

Spinal fusion

2

Only one item number can be selected from this group

These items cannot be claimed with an item from group F

51043

D

Spinal fusion

3

Only one item number can be selected from this group

These items cannot be claimed with an item from group F

51044

D

Spinal fusion

4

Only one item number can be selected from this group

These items cannot be claimed with an item from group F

51045

D

Spinal fusion

5 or more

Only one item number can be selected from this group

These items cannot be claimed with an item from group F

51051

E

Pedicle Subtraction Osteotomy

One

Only one item number can be selected from this group

51052

E

Pedicle Subtraction Osteotomy

2

Only one item number can be selected from this group

51053

E

Vertebral Column Resection Osteotomy

One

Only one item number can be selected from this group

51054

E

Vertebral body, piece meal or subtotal excision

One vertebra

Only one item number can be selected from this group

51055

E

Vertebral body, piece meal or subtotal excision

2 vertebrae

Only one item number can be selected from this group

51056

E

Vertebral body, piece meal or subtotal excision

3 or more vertebrae

Only one item number can be selected from this group

51057

E

Vertebral body, en bloc excision of

One vertebra

Only one item number can be selected from this group

51058

E

Vertebral body, en bloc excision of

2 vertebrae

Only one item number can be selected from this group

51059

E

Vertebral body, en bloc excision of

3 or more vertebrae

Only one item number can be selected from this group

51061

F

Spine fusion

One

Only one item number can be selected from this group

These items cannot be claimed with an item from groups B, C or D

51062

F

Spine fusion

2

Only one item number can be selected from this group

These items cannot be claimed with an item from groups B, C or D

51063

F

Spine fusion

3

Only one item number can be selected from this group

These items cannot be claimed with an item from groups B, C or D

51064

F

Spine fusion

4 to 7

Only one item number can be selected from this group

These items cannot be claimed with an item from groups B, C or D

51065

F

Spine fusion

8 to 11

Only one item number can be selected from this group

These items cannot be claimed with an item from groups B, C or D

51066

F

Spine fusion

12 or more

Only one item number can be selected from this group

These items cannot be claimed with an item from groups B, C or D

51071

G

Removal of intradural lesion

N/A

Only one item number can be selected from this group

51072

G

Craniocervical junction lesion, transoral approach for

N/A

Only one item number can be selected from this group

51073

G

Removal of intramedullary tumour or arteriovenous malformation

N/A

Only one item number can be selected from this group

51102

H

Thoracoplasty

N/A

These items are for Miscellaneous Spinal Procedures for the cervical, thoracic and lumbar areas.

One or more item number(s) can be selected from this group

51103

H

Odontoid screw fixation

N/A

These items are for Miscellaneous Spinal Procedures for the cervical, thoracic and lumbar areas.

One or more item number(s) can be selected from this group

51110

H

Spine, treatment of fracture, dislocation or fracture-dislocation

N/A

These items are for Miscellaneous Spinal Procedures for the cervical, thoracic and lumbar areas.

One or more item number(s) can be selected from this group

51111

H

Skull calipers or halo, insertion of

N/A

These items are for Miscellaneous Spinal Procedures for the cervical, thoracic and lumbar areas.

One or more item number(s) can be selected from this group

51112

H

Plaster jacket, application of

N/A

These items are for Miscellaneous Spinal Procedures for the cervical, thoracic and lumbar areas.

One or more item number(s) can be selected from this group

51113

H

Halo, application of

N/A

These items are for Miscellaneous Spinal Procedures for the cervical, thoracic and lumbar areas.

One or more item number(s) can be selected from this group

51114

H

Halo-Thoracic Orthosis, application of

N/A

These items are for Miscellaneous Spinal Procedures for the cervical, thoracic and lumbar areas.

One or more item number(s) can be selected from this group

51115

H

Halo-Femoral traction

N/A

These items are for Miscellaneous Spinal Procedures for the cervical, thoracic and lumbar areas.

One or more item number(s) can be selected from this group

51120

H

Bone Graft, harvesting of

N/A

These items are for Miscellaneous Spinal Procedures for the cervical, thoracic and lumbar areas.

One or more item number(s) can be selected from this group

51130

H

Lumbar artificial intervertebral total disc replacement

One

These items are for Miscellaneous Spinal Procedures for the cervical, thoracic and lumbar areas.

One or more item number(s) can be selected from this group

51131

H

Cervical artificial intervertebral total disc replacement

One

These items are for Miscellaneous Spinal Procedures for the cervical, thoracic and lumbar areas.

One or more item number(s) can be selected from this group

51140

H

Previous Spinal Fusion, re-exploration for

Up to 3

These items are for Miscellaneous Spinal Procedures for the cervical, thoracic and lumbar areas.

One or more item number(s) can be selected from this group

51141

H

Previous Spinal Fusion, re-exploration for

More than 3

These items are for Miscellaneous Spinal Procedures for the cervical, thoracic and lumbar areas.

One or more item number(s) can be selected from this group

51145

H

Wound debridement or excision following spinal surgery

N/A

These items are for Miscellaneous Spinal Procedures for the cervical, thoracic and lumbar areas.

One or more item number(s) can be selected from this group

51150

H

Coccyx, excision of

N/A

These items are for Miscellaneous Spinal Procedures for the cervical, thoracic and lumbar areas.

One or more item number(s) can be selected from this group

51160

H

Anterior exposure of thoracic or lumbar spine

One

These items are for Miscellaneous Spinal Procedures for the cervical, thoracic and lumbar areas.

One or more item number(s) can be selected from this group

Scenario

Description

Example A

Two surgeons act in both roles (principal and conjoint surgeon), e.g. Surgeon A is performing item 45564 on the right breast and item 45565 on the left breast, and Surgeon B is performing 45565 on the right breast and 45564 on the left breast.

Question: Can a surgeon be both a principal and conjoint surgeon on the same occasion with respect to different sites?

Answer: Yes. As this claim applies to the bi-lateral reconstruction of the breast, the surgeons can claim the principal surgeon item (45564) on one side and the conjoint surgeon item (45565) on the other. The 2 surgeons are working predominantly on one side and assisting each other.

Question: Can a single surgeon claim both the principal surgeon item (45564) and the conjoint surgeon item (45565) for the same operation/site?

Answer: No, a single surgeon cannot claim both the principal surgeon item (45564) and the conjoint surgeon item (45565) for the same operation/site.

Scenario

Description

Example A

The surgeon is claiming item 51021x2 and 51041x2. They have stated different approaches, for example, right and left approach when performing the fixation of motion segment with vertebral body screw.

Question: Can the surgeon claim items 51021x2 and 51041x2, by providing text/notation stating that a different approach was used. For example, right and left approach when performing the fixation of motion segment?

Answer: No. Items 51021 and 51041 should not be claimed more than once for a single operation. The surgeon should bill the most clinically relevant item, determined by the number of motion segments operated on, and the method of exposure, for example open, microscopic, minimally invasive, lateral or bilateral.

Example B

The surgeon requests the following procedures be assessed as 2 separate operations performed under the one anaesthetic.

The claims have been sent to Medicare for assessment via 2 different claiming channels.

Stage One, first admission to theatre 7am, claim received via the ECLIPSE channel.

• Item 51023
• Item 51043
• Item 51165
• Item 51303 claimed by assistant
• Anaesthetist

Stage 2, second admission to theatre 2pm, while under the same anaesthetic, the claim was received as a patient claim.

• Item 51024
• Item 51012
• Item 51034
• Item 51303 claimed by assistant

Question: Would this procedure be considered as one operation because the patient was continually anaesthetised?

Answer: Yes, as one anaesthetic procedure was performed it is considered to be a single operation.

Question: Would 2 assistant surgeons attract a Medicare benefit in this situation?

Answer: No, only one assistant’s fee would attract a Medicare benefit.

Question: Items 51023 and 51024 are restrictive; can these items be claimed together?

Answer: No. Items 51023 and 51024 are for the same procedure fixation of motion segment. The surgeon can claim the item number corresponding to the total number of motion segments operated on.

Item

Group T8 - Surgical Operations, Subgroup 5 - Urological

Operations on urethra, penis or scrotum

37345

Urethroplasty - 2 stage operation - first stage (Anaes.) (Assist.)

37348

Urethroplasty - 2 stage operation - second stage (Anaes.) (Assist.)

Item

Schedule fee

Calculation of benefit

Abated (reduced) fee

44370

$742.70

100% of this schedule fee equals.

Total schedule fee (for amputation item).

Multiple operation rule applies below.

$742.70

47393

$563.05

100% of this schedule fee equals

$563.05

31245

$380.50

50% of this schedule fee equals

$190.25

30087

$30.35

25% of this schedule fee equals

$7.60

Total schedule fee

$1503.60

Situation

Apply multiple operation rule

Calculate assistant fee

Compare the total schedule fee

Dr X and Dr Y each perform a series of operations on a patient on the same occasion. Dr Y also assists Dr X. Each of Dr X's services is eligible for an assistant fee.

Dr X (primary surgeon)

Operation A (Assist.) - Schedule fee $500

Operation B (Assist) - Schedule fee $400

Operation C (Assist) - Schedule fee $300

Operation D (Assist) - Schedule fee $200

Assisted by Dr Y

Dr Y (assistant surgeon)

Operation 1 - Schedule fee $450

Operation 2 - Schedule fee $100

Assisting Dr X

Operation A - Schedule fee $500 x 100%

Operation 1 - Schedule fee $450 x 50%

Operation B - Schedule fee $400 x 25%

Operation C - Schedule fee $300 x 25%

Operation D - Schedule fee $200 x 25%

Operation 2 - Schedule fee $100 x 25%

Calculate the fee for the assistant, reapply the multiple operation rule only to those services that are eligible for an assistant fee, and at which assistance is rendered.

Dr X assisted by Dr Y

Operation A (Assist) - Schedule fee $500 x 100% = $500

Operation B (Assist) - Schedule fee $400 x 50% = $200

Operation C (Assist) - Schedule fee $300 x 25% = $75

Operation D (Assist) - Schedule fee $200 x 25% = $50

Total schedule fee = $825

Compare the total schedule fee with items 51300 and 51303 descriptions to check which assistant item applies.

Dr Y assisting Dr X

Item 51303 applies to the assistant services as the total schedule fee for the operations exceeds the threshold in QITI.

Note: the division of the surgeon fee is a matter for the surgeons involved.

Situation

Apply multiple operation rule

Calculate assistant fee

Compare the total schedule fee

Dr X and Dr Y each perform a series of operations on a patient on the same occasion. Both surgeons assist each other.

Dr X

Operation A - Schedule fee $400

Operation B (Assist) - Schedule fee $240

Operation C (Assist) - Schedule fee $200

Dr Y

Operation 1 (Assist) - Schedule fee $210

Operation 2 - Schedule fee $180

Operation A - Schedule fee $400 x 100%

Operation B - Schedule fee $240 x 50%

Operation 1 - Schedule fee $210 x 25%

Operation C - Schedule fee $200 x 25%

Operation 2 - Schedule fee $180 x 25%

Calculate the fee for the assistant, reapply the multiple operation rule only to the services that are eligible for an assistant fee, and at which assistance is rendered.

Operation B (Assist) - Schedule fee $240 x 100% = $240

Operation 1 (Assist) - Schedule fee $210 x 50% = $105

Operation C (Assist) - Schedule fee $200 x 25 % = $50

Total schedule fee = $395

Compare the total schedule fee to items 51300 and 51303 descriptions to determine which assistant item applies.

Item 51300 applies because the total schedule fee for the operations does not exceed the threshold in QITI.

Note: if each surgeon assists the other, the divisions of the surgeon and assistant fees are a matter for the surgeons involved.

Item

Group T8 - Surgical Operations, Subgroup 5 - Urological

General

36506

Renal transplant performed by vascular surgeon and urologist operating together vascular anastomosis including after-care (H) (Anaes.) (Assist.)

36509

Renal transplant, performed by vascular surgeon and urologist operating together - ureterovesical anastomosis including after-care (H) (Assist.)

Item

Group T8 - Surgical Operations, Subgroup 8 - Ear, nose and throat

41575

Cerebello pontine angle tumour, removal of by 2 surgeons operating conjointly, by transmastoid, translabyrinthine or retromastoid approach - transmastoid, translabyrinthine or retromastoid procedure (including after-care) (H) (Anaes.) (Assist.)