Appendix A Summary for consumers

This table describes the medical services for which changes have been recommended, the specific recommendation(s) of the clinical experts and the reasons for the recommendation(s). Additional information for consumers (written in plain English) is available in the consumer impacts summary in Section 3.4. The Committee has made extensive recommendations, many of which are highly specific and technical in nature or will have minimal impact on consumers. This table was prepared with the consumer representative and includes the major recommendations of the Committee.

Section 4: Cardiac imaging recommendations
Item #/ Item Group What it does Committee recommendation What would be different Why

Recommendations 1 and 1.2 Echocardiograms (echo) 55113; 55114; 55115

An echo is an ultrasound of the heart, used to identify congenital defects, damage or disease that affects the structure or function of the heart.

Restructure the existing echo items to make it clear when tests should be ordered.

Add all cardiac imaging items to the DHS MBS online checker tool.

Repeat tests will be more likely to be performed in line with best-practice guidelines. Specific items have been created for complex congenital heart disease, conditions that need frequent echos and other rare circumstances. These changes would ensure that all patients who have a clinically appropriate need for an echo receive one.

Doctors will be able to use the online checker tool to ensure patients are eligible for a Medicare benefit for the test before requesting or performing it.

To align the items with best-practice guidelines to ensure that patients have access to the most appropriate tests for their individual symptoms and condition.

Patients were sometimes receiving echo tests too frequently, potentially wasting the time and money of patients, and offering low value for the health system. Rules have been added because the Committee did not feel that there was any other way to reduce unnecessary, low- value use.

Recommendations 2 and 3 Exercise stress test 11712

This is usually a treadmill test, which helps doctors to see how the patient’s heart responds to stress. The patient exercises (usually for up to 15 minutes) to determine if exercise makes his/her chest pain worse. Sometimes medication is used in patients who cannot exercise.

Change the descriptor for 11712 and make exercise stress test the first test for patients who have ‘atypical’ chest pain and are at low risk of having a heart attack or another serious problem over the next five years. This means that patients will not receive a stress echo (ultrasound) or nuclear study of the heart as their first test.

If a doctor feels that a patient who has atypical pain and is at low risk of heart attack needs to have a test, the first test would be an exercise stress test, not an echo or nuclear test.

To align the items with best-practice guidelines to ensure that patients experiencing ‘atypical’ chest pain have access to the most appropriate tests for their individual symptoms and condition.

If a patient’s chest pain feels different from the way chest pain usually feels (‘atypical’), it means that his/her risk of blockages in the blood vessels of the heart is not high. Many patients do not need any tests because taking their medical history is the best way to work out if the pain is from the heart. If a doctor is still worried that it might be heart pain, many patients get an echo or nuclear test because they are assumed to be ‘better’ tests. In some patients an exercise stress test is just as useful as a stress echo and a nuclear test in low-risk patients. It also does not expose the patient to radiation (unlike a nuclear test), and it is a lot cheaper than a nuclear test or a stress echo. For this reason, an exercise stress test is the most appropriate test to start with in low-risk patients, followed by other tests if needed.

Recommendations 4, 5.1, 5.2, and 6.

Stress echo and nuclear tests (myocardial perfusion scans or MPS)

Stress echo 11712 with 55116; or 55117;

MPS 61302, 61303, 61306 and 61307

Stress echos and nuclear tests are similar to an exercise stress test, but they also provide images that can give extra information to help diagnose or rule out a heart problem.

For the majority of low-risk patients, both stress echo and nuclear tests give the same information about their heart disease. Nuclear tests involve some radiation, whereas stress echo is an ultrasound with no radiation.

Stress echo is more expensive than an exercise stress test, and a nuclear test is more expensive than a stress echo.

Restructure stress echo items into complete medical services that reflect a focussed stress echo study for each appropriate indication.

Changes made to encourage these tests to be used in patients who are likely to have heart disease or patients who are known to have heart disease with changing symptoms. Discouraging them from being used where there is no evidence of benefit, such as every year as part of a routine check-up, or for screening, or for patients without symptoms.

Nuclear tests are being restricted to situations where a stress echo is not available or not possible. Additionally, a note is being added to remind doctors to consider the cost of these tests and the radiation involved with nuclear tests, as well as patient factors, when deciding which test to use.

The Committee recommends that research should be undertaken focused on understanding the cost-effectiveness of cardiac investigations and intervention in Australia.

These tests would not be used as the first line test for patients who are unlikely to have heart disease.

Patients would only receive repeat tests when they need them, in line with best-practice guidelines.

Patients who are clinically suitable for a stress echo or nuclear test and who have access to and can afford the stress echo, will have this instead of a nuclear test.

To align the items with best-practice guidelines to ensure that patients have access to the most appropriate tests for their individual symptoms and condition.

These tests are most likely being done too often, and when they are used inappropriately they provide low-value care. These changes will help to prevent some of this low-value use.

For certain patients, a nuclear test is a better test, and they should have this test instead of a stress echo. For many patients, stress echo and nuclear tests provide the same information. This means that doctors can choose the test that avoids radiation exposure and is less expensive, but still receive equivalent information about their patient.

However, in some regional areas, wait times are much shorter for nuclear tests, and they are more likely to be bulk billed, which means that the doctor might decide that the nuclear test is preferred for these reasons.

These changes will encourage use of stress echo, with no radiation, where it is appropriate, and include exceptions to ensure that specific patient groups who might have difficulty getting a stress echo can still choose, with their GP, to have an MPS instead.

Section 5: General recommendations
Item #/ Item Group What it does Committee recommendation What would be different Why

Recommendation 7: Implement a process of ongoing review of the MBS to ensure it remains in line with contemporary clinical practice.

Ongoing review of the MBS will ensure patients have access to contemporary services and MBS item descriptors support this.

Implement a review process, and more specifically, review recommendations 1 to 5 to ensure intended outcomes are achieved and whether further revision is necessary.

MBS items for cardiac services would remain aligned with contemporary practice over time.

Clinical guidelines and research are continually changing. There is currently no ongoing review process for the MBS. As clinical practice changes, the MBS items become out of date.

Recommendation 8: Create structured request forms for cardiac investigations.

The patient’s doctor writes a referral for a patient to give to a specialist for investigation/s of heart problems. The referral will be in a specific format and require relevant information to be included so the best investigations are performed.

Create structured request forms for cardiac investigation referrals.

Doctors will complete structured request forms to refer their patients for cardiac investigations.

Doctors receiving referrals will have sufficient information to determine the most appropriate investigations for their patient, reducing low value tests and saving patients and the system time and resources.

Structured request forms for cardiac tests will encourage best-practice care as the requesting doctor will consider and provide sufficient information for the service provider to determine the correct investigation/study.

Test providers, not referrers are required to comply with MBS item descriptors and will require sufficient information from the referring provider in order to determine if the patient is eligible for an MBS rebate.

Recommendation 9: Restrict co-claiming of consultations with cardiac imaging and procedural services.

A Medicare benefit is payable for a consultation between a doctor and patient where it is necessary for the ongoing care of the patient. Imaging and procedural items include relevant consultations before, during and immediately after the service. The exception to this is where the decision to perform a test or procedure is made by the clinician during a consultation and was not previously determined to be necessary.

Add instructions for cardiac imaging and procedural services to reinforce that an extra consultation should not be claimed, unless necessary for planning the ongoing care of the patient.

Patients will only be billed for a consultation when the doctor performing the cardiac investigation or study is also planning or providing their ongoing care beyond what would reasonably be expected of another provider performing the same service.

Discussion between the patient and service provider on performance or results of the requested investigation or procedure forms part of provision of the service and does not constitute the billing of a separate consultation. That is unless the service provider will be providing ongoing care of the patient and the consultation covers care planning which another provider would not reasonably have provided as part of the investigation or procedure service. (i.e. explaining results of a procedure would not constitute a consultation.)

Recommendation 10: Heart Team case conference

A Heart Team case conference brings together an interventional cardiologist (one who does procedures on the heart), a cardiac surgeon, and a non-interventional cardiologist to discuss the best treatment for a patient. The conference can include the patient and the patient’s GP (but it does not have to), and a letter must be given to the patient’s GP outlining the discussion and treatment recommendations.

Create new items to fund Heart Team conferences and allow this conference to be held for some procedures.

Specialists would be able—and sometimes required—to have a Heart Team conference before deciding the best treatment for a patient.

To align the items with best-practice guidelines to ensure that patients have access to the most appropriate treatment (medication, surgery or stenting) for their individual symptoms and condition.

For some patients, surgery may be better than a stent, and in other patients the opposite might be true. Evidence shows that patients who only get one opinion are more likely to get a treatment that is not necessarily the best treatment for them. Some patients are also asked to give consent during a procedure or when they have taken medications that make them drowsy, which prevents them from giving proper informed consent.

This Heart Team case conference item ensures that doctors are paid when they have Heart Team conferences for their patients. Making it a requirement of some items also ensures that patients understand all their options and are able to give fully informed consent when deciding the most appropriate treatment.

Recommendation 11: Reports with results of cardiac procedures/investigations that have specific indications should outline how the requirements in the item description were met.

The report on the outcome of a patient’s cardiac procedure/investigation for a specific indication/s will outline how the requirements listed in the MBS item were met.

Reports for cardiac procedures/investigations with specific indications, will require documentation in a written report outlining how the requirements in the descriptor (and explanatory notes, where relevant) were met.

Audits will be able to be used to ensure that the requirements of MBS items are being met.

To ensure patients have access to the most appropriate interventions or procedures and that the MBS is supporting high value care.

Section 6: CAD-related recommendations
Item #/ Item Group What it does Committee recommendation What would be different Why

Recommendation 12
Invasive coronary angiogram (ICA)

Items 38200 to 38206, 38215 to 38246

A catheter (tube) is inserted into a blood vessel in the groin or wrist and goes up to the heart. X-ray pictures of the heart are taken while X-ray dye is injected through the catheter into the blood vessels supplying oxygen to the heart. Doctors look at the X-rays as they are taken to see if there are any blockages.

This procedure should only be performed: (i) when a patient is having a heart attack, (ii) when there is evidence that the patient has significant heart disease, or (iii) before cardiac surgery.

Patients should be more likely to receive this procedure in line with best-practice guidelines. At present, some patients may undergo this procedure when it is not necessary.

To align the items with best-practice guidelines to ensure that patients have access to the most appropriate tests for their individual symptoms and condition.

This procedure has a small chance of serious complications and involves radiation. It is also quite expensive. Patients should not receive this procedure if they do not need it. These changes encourage this procedure to only be done in line with best-practice guidelines. This should improve patient safety and reduce unnecessary procedures.

Recommendation 13
Percutaneous coronary intervention (PCI) also known as ‘stenting’ or ‘angioplasty’

Items 59903 to 59973.

This procedure is done if a patient has a heart problem caused by a full or partial blockage in a coronary artery, which is a blood vessel that feeds oxygen to the heart. PCI opens the blockage and restores normal blood flow to the heart. A catheter (tube) with a balloon at the end is inserted into a blood vessel in the groin or wrist. The tube goes into the blocked artery and is inflated, stretching the artery back open (angioplasty). A metal tube or coil is usually put in the artery to help keep it open (stent).

This procedure should only be performed: (i) when a patient is having a heart attack, or (ii) when a patient has ongoing symptoms, despite a long trial of heart medications.

When the procedure is performed, it is only claimable for the arteries where there is evidence that the heart is not getting enough blood or oxygen (ischaemia) due to a narrowing in that artery.

PCI will be paid for each blood vessel treated, not for each stent inserted.

Patients should be more likely to only receive this procedure if there is evidence that a blood vessel is causing symptoms or heart problems, in line with best-practice guidelines. This change would mean that patients receive fewer unnecessary stents.

The changes also mean that if a doctor chooses one long stent for their patient instead of two short stents, the MBS rebate doesn’t change. Ensuring they can decide what is best for their patient.

To align the items with best-practice guidelines to ensure that PCI is only performed on patients where stenting is their best treatment option based on their individual symptoms and condition.

Some patients were receiving stents that they did not need, which may not have led to better outcomes. Stents have some risks and should not be put in when they are not needed. These changes encourage best-practice of only treating vessels where there is evidence that there is a blockage which is affecting blood flow to the heart.

There were financial implications for the number of stents used to treat a vessel and this is not a helpful incentive so these changes remove that incentive by making the same fee for whatever number and length of stents are used to treat each vessel.

Recommendation 14
CT coronary angiogram (CTCA) MBS items 57360 and 57361

This is a CT scan of the heart after an injection of X-ray dye, which shows the blood vessels supplying oxygen to the heart. The X-ray pictures show any blockages in these blood vessels.

At present, this test can only be ordered by specialists. The Committee has recommended that GPs and other doctors should be able to order this test for patients with atypical symptoms (see exercise stress test – recommendations 2 & 3) and risk factors that mean that the risk of heart attack or another serious problem in the next five years is greater than 10 per cent.

Patients who meet the requirements would not have to see a specialist to have this test.

To align the items with best-practice guidelines to ensure that patients have access to the most appropriate tests for their individual symptoms and condition.

For patients with atypical symptoms but risk factors that make them higher risk of having a heart attack within 5 years, this test could be used instead of an exercise stress test.

This test is very expensive and is only available in very specific situations. It is a good test for ruling out disease, and the Committee recommends it for patients who are unlikely to have pain caused by heart disease. To prevent this expensive test (which involves radiation) being used inappropriately in lots of patients, the Committee recommends that it should only be allowed to be ordered by GPs for patients who have a lot of risk factors for having a heart attack such as smoking or high cholesterol. As more evidence is published for this test, as technology improves and as it becomes more cost- effective, it may be appropriate to allow it to be used for more patients.

Recommendation 15.1
Amend MBS item 38274 Closure of ventricular septal defect

This procedure closes the hole in the wall that separates the two lower chambers of the heart.

The Committee recommends that the item be amended so that the imaging component can be billed separately by the imaging provider.

The schedule fee would be reviewed to remove the imaging component and the patient will be billed by both the proceduralist and the imaging provider for their separate services. A new imaging item would also be required.

The Committee noted that a second provider is required to perform the imaging part of this service.

Recommendation 15.2
Amend MBS item 38274 Closure of atrial septal defect

This procedure closes the hole in the wall that separates the two upper chambers of the heart.

The Committee recommends that only patients with evidence of significant symptoms or complications undergo this procedure.

Asymptomatic patients would not be eligible for the operation as there is no supporting evidence for this practice. Doctors performing the operation for eligible patients will be required to keep documented evidence of their condition.

To align the items with best-practice guidelines to ensure that patients have access to the most appropriate tests for their individual symptoms and condition.

Section 7: Electrocardiography (ECG) recommendations
Item #/ Item Group What it does Committee recommendation What would be different Why

Recommendation 16 11700 – ECG trace and report

Sticky dots are put on the chest to take an electrical picture of the heart. This item includes putting the dots on and printing the result (trace), as well as interpreting and reporting the trace (report).

This item should be a referred service.

A copy of the trace and report needs to be kept by the service provider and also provided to the referring practitioner.

A copy can be made available to another practitioner with the patient’s consent.

Almost all of the 2.75 million ECGs done each year are claimed as this item. Most of them do not have a formal report provided.

The patient would be referred to a specialist for an ECG trace and report where necessary. Alternatively, the GP might perform the ECG trace and send it to a specialist for a formal report if needed (see recommendation 17 below).

To ensure that patients have access to the most appropriate tests for their individual symptoms and condition, and that a written report of the test is available to guide the patient’s diagnosis and treatment.

Most of these ECGs are done by doctors in their rooms. Some are looked at and put in the patient’s file, and others are done only as a ‘baseline’ test with no indication or review. Many of these tests are of low value and some may be inappropriate. The Committee agreed that the doctor should get paid for taking the trace (normally done by a nurse), but it felt that looking at that trace was a standard part of a consultation and was not the same as providing a formal report.

The Committee thought about removing this item completely, particularly because new ECG machines make it much easier to do an ECG. However, the Committee felt that it was important for providers, particularly GPs and providers in rural and remote areas, to be able to refer for an expert second opinion where necessary.

Recommendations 17 and 20
11701 – ECG report only

This item allows providers to send an ECG trace to be reported by an expert. It is particularly intended for providers in rural and remote areas where access to formal ECG services may be limited.

Clarify the requirements of a formal report and ensure that it is available to other providers, with patient consent.

Add a restriction to only allow benefits to be paid for a maximum of two services on the same day.

This would ensure that all reports include interpretation of the trace, as well as comment on how significant the findings are for the specific patient.

Patients will not be able to have Medicare pay for more than 2 ECGs in a day.

Some reports are written without the expert receiving any clinical information about the patient or the reason for the ECG being done. This lack of information means that the expert is less able to assess whether any findings are significant for that patient and can’t comment on this in the report. By requiring this interpretation to be in the report, it will encourage giving clinical information to the expert reporting the trace and should mean that GPs and requesting doctors get more detailed and useful reports back.

The Committee felt that some patients may be getting more ECGs than is clinically required.

Recommendation 18
11702 – ECG trace only

This item covers taking an ECG (as described above), but only if the trace is not formally reported by an expert.

Retain this item without referral because it can be a clinically valuable service.

Require the provider to review the trace for patient safety reasons.

Most providers review all their ECG traces already but this change will encourage all providers to do this.

Despite new technology making ECG traces much easier to do, The Committee recommends that this item should be kept because ECGs can be clinically valuable tests when done for the right reasons.

The Committee recommends that all ECGs should be reviewed by the provider for patient safety because even when an ECG is done for a low-risk reason, it might detect a potentially life threatening condition which is important not to miss.

Recommendation 19
Items 11701, 11702

As above

Items 11700 and 11702 will not be claimable for patients admitted to hospital.

Item 11701 (for the report only) will still be available for patients admitted to hospital if a provider requests a second opinion on a non-routine trace.

Hospitals would no longer be able to bill the MBS for ECG traces. This should not affect patients receiving clinically appropriate ECGs, and expert reports will be available where clinically necessary.

Reviewing an ECG trace when necessary is a core part of caring for an admitted patient and should be a standard part of a doctor reviewing their patient.

The ECG trace is taken by a nurse and for admitted patients; nurse and consumable costs are not covered by the MBS. There is no medical cost that the MBS would cover for taking an ECG trace.

Some hospitals may not have a doctor on site that is confident in interpreting ECG traces. If the doctor caring for the patient reviews a trace and wants an expert second opinion, they can request that the trace be sent for a formal report under item 11701.

Section 8: AECG and electrophysiology recommendations
Item #/ Item Group What it does Committee recommendation What would be different Why

Recommendations 22 and 23 and 25
Ambulatory ECG
Items 11709 and 11710

These items are for monitoring the electrical activity of the heart short term (less than 24hrs, longer term monitoring up to many months can be done with implanted devices, item 11722) to detect unusual heart rhythms that are not there all the time. Short term monitors involve sticky dots and a monitor that is carried which stores data to be downloaded. The data is reviewed to look for unusual rhythms, beats or ‘events.’

Restructure these items with specific indications that encourage the most appropriate test for the patient. For example, if a patient has symptoms once every few weeks, monitoring for 7 to 30 days may be the most appropriate option, given that a 24-hour monitor may not be worn on a day when the patient has symptoms.

Changes will encourage patients to receive the most appropriate monitor for their situation. This reduces inconvenience for patients having multiple tests and means they should get the most appropriate test.

To align the items with best-practice guidelines to ensure that patients have access to the most appropriate tests for their individual symptoms and condition.

Many tests are negative because the wrong test is ordered for the patient, and some patients have multiple repeat tests instead of the more appropriate longer term test.

Recommendation 26
Implanted ECG loop recorders
Items 11722, 38285 and 38286

These items are for an implanted cardiac resynchronisation device which resynchronises the contractions of the heart's ventricles by sending tiny electrical impulses to the heart muscle, to help the heart pump blood throughout the body more efficiently.

Allow implanted monitors (implanted loop recorders, item 11722) to be inserted in consulting rooms, not just in hospitals (and item 38285 if an exception to the Prostheses List is granted). Restrict benefit for item 11722 to once per month. Allow implanted monitor removal item 38286 to be performed without admission to hospital.
As for recommendations 22 and 23, these changes will encourage the most appropriate test for the patient.

Patients would no longer need to be admitted to hospital to receive an implanted monitor or have it removed. This would save the patient an admission gap payment and reduce private health insurer admission costs.
As for recommendations 22 and 23, these changes will encourage patients to receive the most appropriate monitor for their situation. This reduces inconvenience for patients having multiple tests and means they should get the most appropriate test.

Inserting an implanted monitor used to require surgery because the device was inserted under the chest muscles. New technology means this can now be safely and quickly injected or removed in a consulting room. This means that an admission is a low-value use of resources.

As for recommendations 22 and 23, these changes align the items with best-practice guidelines to ensure that patients have access to the most appropriate tests for their individual symptoms and condition.

Many tests are negative because the wrong test is ordered for the patient, and some patients have multiple repeat tests instead of the more appropriate longer term test.

Recommendation 27.
Removal of implantable ECG loop recorder
Item 38286

This item is for the removal of a small cardiac monitor that is implanted just under the skin of the chest to record the heart's electrical activity.

Remove the requirement that the device can only be removed when the patient is admitted into hospital.

Adult patients with new devices will have the choice to have their implanted device removed as an outpatient.

New devices are implanted just under the skin which can be removed safely out of hospital, avoiding significant additional costs and inefficiencies. Inpatient removal continues to be best practice for older devices which are implanted deeper in the chest muscle.

Recommendations 28.1 and 28.2
Cardiac resynchronisation device
Items 38365 and 38368

These items are for an implanted cardiac resynchronisation device which resynchronises the contractions of the heart’s ventricles by sending tiny electrical impulses to the heart muscle, to help the heart pump blood throughout the body more efficiently.

Update the item descriptions to align them with international guidelines.

Create a benefit for an assistant surgeon at these operations.

The item descriptions would be modernised to align with international guidelines.

Although the items specifically list sinus rhythm amongst other patient criteria, removal of this wording would not prevent the items being claimed.

Recommendation 28.3
Cardiac resynchronisation device
Item 38371

This item is for the insertion, removal or replacement of implanted cardiac resynchronisation device which resynchronises the contractions of the heart’s ventricles by sending tiny electrical impulses to the heart muscle, to help the heart pump blood throughout the body more efficiently.

Remove item 38371 from the MBS as the changes made to items 38365 and 38365 make the item redundant.

The insertion, removal or replacement of implanted cardiac resynchronisation devices would now be claimed under a different number.

Implanted cardiac resynchronisation device is more appropriately claimed under the new revised items.

Recommendation 29.2
Electrophysiological studies
Items 38212 and 38213

A cardiac electrophysiology study (EP test or EP study) is a minimally invasive procedure that tests the electrical conduction system of the heart to assess the electrical activity and conduction pathways of the heart.

Amend items 38212 to remove defibrillator testing. Amend item 38213 to specifically include defibrillator testing.

Defibrillator testing would now be claimed using a different item number.

Defibrillator testing is more appropriately claimed using item 38213 given the requirements of the procedure.

Recommendations 30.1, 30.2 and 30.3
Implanted defibrillators and pacemakers
Items 38384, 38390, 38387, 38393 and 11727.

These items are for inserting different devices that monitor the heart, some of which deliver a shock when a dangerous rhythm is detected.

Update the indications for these items in line with best-practice clinical guidelines.

Some patients who could not receive these devices easily would now be eligible. Some other patients would no longer be eligible.

To align the items with best-practice guidelines to ensure that patients have access to the most appropriate implanted defibrillators and pacemakers for their individual symptoms and condition.

New evidence has been published about when devices are safe and effective. There is also new evidence that they may cause more harm than good in certain patients.

Recommendation 32.3
Item 11721

This item is for testing an implanted pacemaker and is performed on behalf of the doctor by a technician.

The item be amended so it can only be claimed when the doctor is immediately available to attend the patient where clinically indicated.

Patients would receive a better service.

Changes will ensure a doctor will be available to influence the patient’s outcome if the result of the test indicated an urgent review was required.

Recommendation 33
Item 38358

This item is for complex, minimally invasive removal of implanted pacemaker or defibrillator leads that have been in place for longer than six months.

The Committee recommends the item be split into two. One for the provider who performs the procedure, and the other item to be billed by a cardiac surgeon providing support if a cardiologist is performing the procedure. The second item is for the surgeon to be present and ready to immediately surgically open the chest wall if required.
The changes also provide greater clarity on the requirements for performing the procedure safely, in line with contemporary clinical practice.

There should be no discernible difference for the patient. Providers will have greater clarity on the expected safety requirements for performing this procedure. The vast majority of procedures are already believed to be performed in line with best practice.

The Committee recommends that new arrangements would more accurately reflect how the procedure is performed.

Surgical standby and performance of the procedure in a setting capable of immediate emergency surgery is already the expected standard of clinical practice however the current MBS item was not clear on what level of support was required.

Recommendation 34
Item 13400

Restores normal heart rhythm by delivering an electrical shock to the heart.

This item should only be claimed in a hospital or an equivalent setting.

The service would be performed in a safe environment.

Patient safety will be increased.

Section 9: Cardiac surgery recommendations
Item #/ Item Group What it does Committee recommendation What would be different Why

Recommendation 38
All Cardiac Surgery procedures

This group of items in the MBS are for patients having cardiac surgery.

Apply a general rule to the cardiac surgery section of the MBS specifying that the items contained therein are intended to be complete medical services.

The new items would not be able to be claimed with services outside the cardiac surgery section of the MBS.

Cardiothoracic surgical procedures are regularly claimed with other items from other areas of the MBS, particularly the vascular and plastics sections. Items were already intended to be complete medical services and should generally not have been co-claimed in this way. This can also mean that patients having the same procedures can be eligible for different MBS rebates.

Recommendation 39

Coronary artery bypass grafting (also known as bypass surgery, CAGS or CABG)

Items 38496, 38497, 38498, 38500, 38501, 38503 and 38504.

This procedure uses grafts (pieces of other blood vessels) to provide a path for blood to go around blockages in the blood vessels of the heart.

Restructure items as complete medical services.

Currently, doctors claim very different combinations of MBS items for the same procedure. These changes would mean that all patients who have the procedure would have the same MBS items claimed and would therefore receive the same rebate.

Simplifies the MBS items to align with best practice guidelines Previous MBS items were often added together in different ways because of how the schedule was designed, with providers claiming more items for a procedure to get higher MBS rebates. The new structure is clearer and simpler, with a single item for bypass surgery, and some add-on items for specific things that make the surgery longer or more difficult but might be needed in some patients.

Recommendation 42.1

All Cardiac Surgery procedures

This group of items in the MBS are for patients having cardiac surgery.

Restructure all cardiac surgery items as complete medical services.

Currently, doctors claim very different combinations of MBS items for the same procedure. These changes would mean that all patients who have the procedure would have the same MBS items claimed and would therefore receive the same rebate.

Simplifies the MBS items to align with best practice guidelines Previous MBS items were often added together in different ways because of how the schedule was designed, with providers claiming more items for a procedure to get higher MBS rebates. The new structure is clearer and simpler, with a single item for bypass surgery, and some add-on items for specific things that make the surgery longer or more difficult but which may be clinically needed in some patients.

Recommendation 42.2, 42.3 and 42.4 Primary valve replacement items.

These procedures involve repairing or replacing any of the primary valves in the heart.

Restructure the existing items into three new items to make them stand alone or complete medical services.

The changes would ensure patients receive the same rebate for equivalent procedures.

The changes are designed to reduce variation in rebates for similar procedures.

Recommendation 43
Valve repair and replacement items: Items 38550, 38553, 38556 and 38572

These procedures involve repairing or replacing any of the valves in the heart.

Restructure items as complete medical services and add new items for valve replacement, including removing (explanting) a previous valve prosthesis.

The changes would ensure patients receive the same rebate for equivalent procedures.

Surgeons would have an item that reflects the additional time and complexity of repeat valve replacements.

The changes are designed to reduce variation in claims (as above), and to ensure that longer and more complex repeat valve surgeries are fairly rebated for the extra time or expertise required for the surgery.

Recommendation
44.2
Cardiac surgery
items 38568, 38571

These procedures involve repairing or replacing the aorta – a major artery of the heart.

Not allow the claiming of other item numbers for services which are already part of the procedure being performed.

Patients undergoing similar procedures would be eligible for the same rebate.

The changes are designed to reduce variation in rebates for similar procedures.

Recommendation 44.3

All cardiac valvular surgery items

This group of items in the MBS are for patients having cardiac surgery.

The Vascular Clinical Committee will be asked to review the cardiac valvular surgical items to construct complete medical services.

Another Clinical Committee of the Taskforce will be asked to review the items to ensure that they are standalone items.

Creating standalone items or complete medical services for each item will reduce the variability of benefits paid to patients for the same service.

Recommendation 45
Cardiac surgery items on the aortic arch.
tems 38559, 38562, 38565.

These procedures involve repairing or replacing the aortic arch – a part of a major artery of the heart.

Consolidate items 38565, 38559 and 38562 into two items- one for simple and another for complex procedures.

There would only be two items instead of three for this procedure.

This change will simplify and modernise the MBS.

Recommendations 46.2
Cardiac surgery items -congenital heart disease.
Items 38706, 38709, 38712.

These procedures involve repairing of the aorta for on young patients with congenital heart disease.

Delete 38712 from the MBS and replace with a new item.

The new item will includes more detail on the process and indications for this complex procedure.

Paediatric cardiac surgery items on the MBS have not been revised for some time and the changes reflect contemporary clinical practice.

Recommendation 47.1
Other cardiac surgical items.
Items 38640, 38643, 37647 and 38656

These three items involve cutting adhesions around the heart. Adhesions are abnormal scar-like bands that form between two surfaces inside the body. In this case, the surgery is performed to allow normal movement of the heart or to allow access to the heart to perform other surgical procedures.

The Committee recommends consolidating the three items into one item.

There would be only one MBS item instead of three items for this procedure. The current items are differentiated by the amount of time taken to divide the adhesions.

This change is designed as a cost-neutral change. The time tiered items were originally designed to reflect the effort involved but this creates an incentive for longer procedures which may not be better for patients. By creating a single average item, there is no reward for operating slowly.

Recommendations 48.1, 48.2 and 48.3. Other surgical items – circulatory support Items 38577, 38588, 38600, 38603, 38609, 38612, 38613, 38627

Cardiopulmonary bypass items is a procedure that temporarily takes over the function of the heart and lungs during sur gery, maintaining the circulation of blood and the oxygen content of the patient's body.

Delete item 38577 and incorporate into the aortic arch procedures.
Review 38588 for potential deletion 12 months after implementation of the recommendations in this report.
Amend item descriptor for 30603.

Cardiopulmonary bypass services will be included as part of the items for cardiac surgical procedures so only one item number has to be claimed.

These bypass items should be used as part of other surgical procedures so merging them simplifies the MBS. People who need bypass without cardiac surgery can still use other MBS items intended for those situations.

Recommendation 48.5
Intra-aortic balloon pump
Item 38613

The Intra-aortic balloon pump is a small balloon that increases blood flow to the coronary arteries and is often used to transition patients after cardio pulmonary bypass.

Delete item 38613 as item 38612 renders it redundant.

There will an alternative item to claim for intra-aortic balloon pump procedures.

The proposed changes will simplify and modernise the MBS.

Recommendation 49.1 and 49.2 Transoesophageal echocardiogram (TOE).
Items 55118, 55130, 55135.

A transoesophageal echocardiogram is an ultrasound of the heart using a special probe that scans the heart from inside the oesophagus.

The Committee recommends the removal of the word ‘video tape” from items 55118, 55130, 55135.

Update the co-claiming restrictions for item 55135 to reflect the new valve item structure.

There will not be any noticeable differences because of these recommendations.

Video tape is a historical reference and is no longer relevant to current practice, recordings should be digital.

A claiming restriction is currently in place for TOE services with 55130. This restriction will continue to be reflected in the new items.

Recommendation 52
Pacemaker insertion Items 38470, 38473, 38654

For the insertion, removal and or replacement of an artificial pacemaker. A pacemaker is a medical device which uses electrical impulses, delivered by electrodes contracting the heart muscles, to regulate or resynchronise the beating of the heart.

The Committee recommends consolidating items 38473, 38654, and 38470 into one item.

There will be one item to claim for pacemaker services.

This change will simplify the MBS and consolidate to include all approaches.

Recommendations 54.1, 54.2 and 55 Congenital heart disease (hole in the heart disease) Items 38727 and 38730; items 38739 and 38742.

These procedures mend the hole between the heart chambers for children with born with a heart condition.

The Committee recommends revising the current items for repair of the heart with and without cardiopulmonary bypass. In addition the Committee recommends creating a new item for the repair of pulmonary arteries in addition to item 38727 and 38730. The committee also recommends reviewing items 38727 and 38730 at a later date to see if they remain a contemporary service.

A new item will be available for a specific complex paediatric surgery which is currently not well described by existing items.

Some items that were being claimed inappropriately as part of other procedures will now only be used when they are the primary procedure.

Repair or replacement of pulmonary arteries are important paediatric procedures and the current schedule and claim patterns do not reflect contemporary clinical practice.

Recommendation 61

Ventricular surgery Items 38506-08

Surgery on the left ventricular repair is sometimes used to treat heart failure.

The Committee recommends consolidating items 38506-08 into a single item for left ventricular aneurysm repair.

There will be one item to claim for left ventricular repair.

This change will simplify the MBS and consolidate to include all approaches.

Recommendation 65.1
Other ungrouped surgical items Item 38650

This item relates to a surgical procedure where there's an obstruction of blood leaving the heart.

The Committee recommends consolidating item 38650 into item 38763.

There will only be one item to claim for myomectomy.

This change focuses on modernising and simplifying the item number to reflect best clinical practice for patients.

No change: Items where the Committee recommended no changes as the items remained current or were recent additions to the MBS

Recommendation Item numbers

15.3

38270, 38273, 38275, 38359, & 38362

29.1

38209.

30.4

11725 and 11726

31

38287, 38290 & 38293

32.1

11719, 11720, 38256, 38350, 38353 & 38356.

36

11724

40

38687

41

38505

44.1

38568 & 38571

46.1

38706 & 38709.

47.2

38656.

48.4

38600, 38609, 38612 & 38627

50

38512, 38515 & 38518

51

38670, 38673, 38677, 38680

53

38615, 38618, 38621, 38624.

55

38739

56

38748 & 38751

57

38745 & 38754

58

38700 & 38703

59

38715 & 38718

60

38721 & 38724

62

38509

63

38733 & 38736

64

38757 & 38760

65.2

38653 & 38766.

Obsolete: Items which no longer reflect contemporary practice and will be removed from the MBS

Recommendation Item numbers

13.2

38300, 38306, 38312, 38315 & 38318

21

11708

24

11711

32.2

11718

35

11713

37

11715



|

_________________________________________