Surgical operations assessing rules in Medicare 011-42060050

As part of the Government’s response to the MBS Review Taskforce (the Taskforce) changes were made to:

• general
• orthopaedic, and
• cardiac surgical services listed on the MBS on 1 July 2021

These changes:

• reflect contemporary practice
• encourage best clinical practice
• combine like procedures
• improve the quality of care provided, and
• simplify the arrangements for doctors and patients where they are unclear

For more information on each surgical category, see the link to the factsheets on the Resources page.

Surgical operations are in Category 3, Group T8 of the MBS.

Surgery means a procedure performed for structurally altering the human body by incision or destruction of tissues. It is part of the practice of medicine for the diagnostic or therapeutic treatment of conditions or disease.

Unless otherwise stated, the benefit payable for an operation includes:

• performance of the procedure
• repair or suturing of the wound
• aftercare provided to the patient

Surgical procedures determine the benefits for both the:

• associated anaesthesia
• assistant surgeon services

For processes in different claiming channels see:

• Medicare online claiming
• ECLIPSE claims for Simplified Billing in Medicare
• Electronic Data Interchange (EDI) claims for Simplified Billing in Medicare
• Patient claims processing in Medicare
• Bulk bill claims in Medicare

Medicare benefits are not payable for fees allocated to equipment costs or the cost of materials associated with operations, for example:

• staples
• orthopaedic plates or wires
• other consumables or tools

When more than one operative procedure is performed on the same patient on the same occasion by the same health professional, it is regarded as a 'multiple operation' and is treated as one service for payment purposes.

Multiple operations are also known as 'multiple procedures'.

Where 2 or more surgeons operate, and:

• each performs one or more operations, but
• one assists the other, or
• they assist each other, the surgeons are not considered to be operating independently

The multiple operation rule is applied to all the operations combined. The assessment of the assistant's fee is based on the fee for the combined operations.

The Resources page has examples of the Multiple Operation rule when 2 or more surgeons operate. This includes:

• example of one surgeon assists the other
• example of 2 surgeons assist the other

Payment of Medicare benefits for multiple operations is based on a total fee for the operations involved.

Where 2 or more operations (other than amputations), are performed on a patient on the one occasion, the fees are calculated according to the multiple operation rule (MOR), as follows:

• 100% of the fee for the item with the highest schedule fee
• 50% of the fee for the item with the next highest schedule fee, plus
• 25% of the schedule fee for all other surgical items

When the results of these calculations are added together, the total becomes the schedule fee for the multiple operation. This fee is used to calculate the Medicare benefit payable (75% or 85% depending on where the services are performed).

See Multiple operations assessing rules in Medicare for more information.

Spinal surgery items are in Category 3 Therapeutic Procedures, Group T8 Surgical Operations, Subgroup 17 Spinal Surgery.

Restrictions for spinal surgery:

• Spinal surgery items 51011 to 51171 cannot be performed with any other item in the surgical operations group outside of Subgroup 17 (items 30001 to 50952), when that surgical item is related to spinal surgery
• Spinal surgery items 51011 to 51171 can be performed with other spinal surgery items
• Spinal surgery for scoliosis and kyphosis in paediatric patients (Items 50600 to 50644) can be claimed in conjunction with items 51113 and 51114
• Combined anterior and posterior spinal surgery items 51061 to 51066 cannot be claimed with any item between 51020 and 51045
• Lumbar spinal fusion can only be claimed for chronic low back pain after diagnosis
• Other restrictions are located in the table on the Resources page

The Resources page has a link to MBS Online for more information about the procedures and billing of spinal surgery services (TN.8.141 and TN.8.142) and a table of the spinal items and restrictions.

Items 31530 and 31548 are 2 distinct medical procedures and restricted on the system:

• These items cannot be claimed for the same breast lesion/site
• Items 31530 and 31548 can be claimed together if performed on different sites

Where a claim is received for both or multiples of these items, the claim must state that the procedures are for different sites or times.

Health professionals use the times on a clock face to indicate the sites of breast lesions. If the claim includes text with the wording like '9 o’clock' or '3 o’clock', this refers to the site of the lesion.

The Resources page has examples of text notations for items 31530 and 31548.

TAVI Items 38495, 38514 and 38522 are:

• distinct medical procedures
• limited to one TAVI procedure per 5 years
• includes balloon valvuloplasty

The balloon valvuloplasty service performed under MBS item 38270:

• is inherent to TAVI procedure
• has a co-claiming restriction with the TAVI items for the same occasion of service

Claim text or notation indicating the following must be included if either or both:

• item 38270 service was not related
• services were performed on separate occasions

The Resources page has link to the MBS Online factsheets.

Where different health professionals perform 2 or more operations under the one anaesthetic, the surgeons are considered to be operating independently when neither:

• assists at or performs the other operations, or
• administers the anaesthetic

Where 2 health professionals operate independently and either performs more than one operation, the multiple operation rule applies to their own services.

This type of surgery involves 2 surgeons working concurrently (sometimes from different specialities) to perform certain types of procedures:

• a principal surgeon leading the procedure, and
• a co-surgeon working in their speciality

There are specific MBS items for conjoint surgery. The Resources page contains a table with examples.

Where 2 or more health professionals operate and each performs one or more operations plus one assists the other:

• the multiple operation rule applies to all operations
• the assistant fee is based on all procedures at which the assistance was rendered and that have the word '(Assist)' in the item descriptor

The Resources page has examples of this rule and how to calculate benefits.

Where 2 or more health professionals operate and each performs one or more operations plus each assists the other:

• the multiple operation rule applies to all the operations (as though they had been performed by one surgeon)
• the assistant fee is based on all the procedures (if they attract an assistant fee) after being reduced by the multiple operation rule

The division of the surgeon and assistant fees is a matter for the health professionals involved.

The Resources page has examples of this rule and how to calculate benefits.

A staged procedure is any operation undertaken in 2 or more separate parts, with a break between the stages to facilitate tissue healing or clearance of infection.

The Resources page contains tables with examples of different stage operations.

When a re-operation is required for vascular surgery, item 35202 would be used in combination with vascular items and the multiple operation rule would apply.

This item is payable more than once on the same day if a number of incisions were performed on different parts of the body as per the item description.

Amputation items are located in Subgroup 12 of Group T8 Surgical Operations in the MBS.

The multiple operation rules does not apply to amputations. Where more than one amputation is performed each service attracts 100% of the schedule fee.

Where an amputation is performed in association with one or more operative procedures, the amputation will be paid at 100% schedule fee and all other services will be subject to the multiple operation rule.

See Multiple operations assessing rules in Medicare for more information.

The Resources page contains a table with an example showing the calculation for an amputation performed with other procedures subject to the multiple operation rule.

Services performed for cosmetic reasons such as face lifts, eyelid reductions, and hair transplants (except in certain circumstances) do not attract Medicare benefits.

Where a claim for surgery does not attract a benefit, then benefit is not payable for the following:

• assistance rendered at the operation
• administration of the anaesthetic (including pre-operative examination)

See Cosmetic and plastic surgery assessing rules in Medicare for more information.

Excision of burnt tissues or definitive burn wound closure item 46100 is a derived fee item co-claimed with items 46101 to 46135 (other than 46112 or 46124).

When assessing, item 46100 and its associated base item must be treated as one service for the purposes of:

• multiple operation rule
• assistant surgical fee calculation
• abandoned surgery fee calculation
• diagnostic multiple services rule (DIMSR)
• greatest permissible gap

Apply the derived fee calculation before applying any other calculation.

See Skin services in the Medicare Benefits Schedule (MBS) for more information.

Orthopaedic items for fracture treatment are in Category 3, Group T8 Surgical Operations, Subgroup 15 Orthopaedic of the MBS.

Where the treatment of a fracture:

• is not specifically covered by an item, health professionals can claim an appropriate attendance item from Category 1. For example, the treatment of a fractured metacarpal that requires no reduction, could be billed as an attendance item
• requires reduction on multiple occasions to achieve adequate alignment, benefits are payable for each separate occasion at which reduction is performed under the relevant item covering the fracture treatment

Closed reduction means treatment of a dislocation or fracture by non-operative reduction, and includes the use of percutaneous fixation or external splintage by cast or splints.

Open reduction means treatment of a dislocation or fracture by either:

• operative exposure including the use of any internal or external fixation
• non-operative (closed reduction) where intra-medullary or external fixation is used. This includes the use of surgical hardware to stabilise a fracture from the outside of the skin

The multiple operation rule does not apply to obstetric items (Group T4).

See Multiple operations assessing rules in Medicare for more information.

Assistant surgeon fees are calculated based on the total fees for the surgery performed by the principal surgeon.

Benefits for assistant surgeons will only be paid if the procedural items have the word '(Assist)' in the descriptor.

See Assistance at operations assessing rules in Medicare for more information.

The Human Rights and Equal Opportunity Commissioner has provided guidelines on sterilisation procedure conducted on minors.

The Resources page has a link to:

• legal requirements for items 35637, 35688, 35691 and 37623 (MBS Note TN.8.46)
• the AskMBS email advice service

Benefits are payable for gender confirmation surgery if:

• the service rendered is covered by an existing item in the MBS, and
• the service is clinically relevant

See General assessing information for Medicare for more information about clinically relevant services.

The Resources page contains a link to the health direct website for more information on gender confirmation surgery.

There are a number of items within the MBS that relate specifically to neonates (newborn infants), for example items 43801-43882.

These items are located in Category 3, Group T8, Surgical Operations Subgroup 11, Paediatric.