Appendix B - Summary for consumers

This section includes tables which describe the medical service, the recommendation(s) of the clinical experts and why the recommendation(s) has been made.

Recommendation 1: Whole body cabinet phototherapy

Item

What it does

Committee recommendation

What would be different

Why

Replace and modify items 14050, 14053

New item – single item that includes therapy administered in a whole body cabinet or hand and foot cabinet, limited to 150 treatments per year with Dermatologist involvement

The new item will provide funding for the delivery of UVA or UVB phototherapy administered in a whole body cabinet or hand and foot cabinet, including associated consultations other than the initial consultation.

Treatments must be initiated and supervised by a Dermatologist, and limited to 150 treatments per patient per year. Narrow band UVB should be the preferred option except in specific conditions.

Introduce a new MBS item (see full report for detail)

There would be an annual treatment limit and the requirement of a Dermatologist’s involvement in the initiation and supervision of the phototherapy.

There would be no cost impact on patients since the original items received identical reimbursement values. The administration cap would prevent patients from receiving numbers of treatments that are not shown to be beneficial.

This change will improve patient safety by reducing the risk of over-exposure to UV treatment, which may cause skin cancer. There is also no requirement for two different item numbers.

 


Recommendation 2: Benign and malignant skin neoplasms

Item

What it does

Committee recommendation

What would be different

Why

Remove item 30195 — Treatment of a benign skin neoplasm (with exceptions) by destructive means.

 

Removing a lesion that is believed to be low-risk, by destroying it using electricity, cutting or laser treatment.

Remove this item from the MBS.

Use alternative MBS code 30071 that requires a biopsy to taken for pathology screening

This change will protect patient safety and reduce MBS misuse.

When removing a suspected benign neoplasm, a doctor would use a different MBS code and send the biopsy for pathology screening.

Doctors would be encouraged to consider whether a skin feature is being removed for safety reasons, or purely cosmetic reasons.

Simply destroying a skin feature (without checking it afterwards) can result in missing more serious skin problems such as melanoma, which require more in-depth treatment.

The very high usage and growth of this item suggests that it is being used for cosmetic procedures as well, which should not be claimed through MBS.

Change item 30196 – excision of malignant skin neoplasm. Consolidate with 30197 – excision of >10 malignant skin neoplasms

Removal of a suspected cancerous skin feature by excision

Change to require histopathological testing to be done, rather than being able to rely on specialist opinion alone.

Doctors will have to send samples for histopathological testing to confirm diagnosis, and will have to individually claim for each skin lesion removed

This change and consolidation will improve patient safety by confirming the diagnosis through pathology testing. It will also simplify MBS by consolidating an unnecessary extra item, and prevent misuse.


Recommendation 3: Allergy testing items

Item

What it does

Committee recommendation

What would be different

Why

Remove item 12003 – Skin sensitivity testing for >20 allergens

Skin testing for reactions to >20 allergens in one consultation

Remove this item from the MBS.

No impact on patients. Skin testing can still be done using the proposed MBS items 12000 A-D

Large numbers of these tests are performed even though there are very few situations in which there is clear benefit versus testing fewer, more specifically chosen allergens.

Split item 12000, and change item 21981 in to four MBS items

Skin testing for allergic reactions to a variety of allergens,

Create four MBS items (12000 A-D) that more accurately specify the allergens to be tested, and the reasons for doing so

Skin testing for allergens would be split between tests for environmental, food & latex, medication, and anaesthetic-related allergies.

These changes will protect patient safety by addressing the high number of false positive or clinically irrelevant test results obtained when testing for large numbers of allergens simultaneously. These can lead to unnecessary dietary restrictions and concern, as well as the unpleasantness associated with multiple tests (especially in children and infants).

Remove item 53600 – Skin sensitivity testing for allergens to anaesthetics and materials used in OMS surgery, using 1 to 20 allergens

Skin testing for reactions to anaesthetics and materials used in oral and maxillofacial surgery (OMS)

Remove this item from the MBS.

No impact on patients. Zero claims were made in 2014-15.

This item is obsolete and no longer reflects best practice.

 

Recommendation 4: Treating malignant lesions by liquid nitrogen cryotherapy

Item

What it does

Committee recommendation

What would be different

Why

Item 30202 – removal of malignant neoplasm of skin by liquid nitrogen cryotherapy

Removal of a skin lesion via repeated freeze-thaw cycles using liquid nitrogen

Change the wording of the item descriptor by replacing “specialist” with “AMC recognised dermatologist” and monitor high-volume doctors to ensure they are requesting the appropriate pathology tests

Increase patient safety: doctors will more often send the suspicious skin lesion for testing

Over the past year, only approximately 42% of lesions were sent for biopsy following removal

Item 30203 - removal of 10 or more malignant neoplasms of skin by liquid nitrogen cryotherapy

Removal of 10 or more skin lesions via repeated freeze-thaw cycles using liquid nitrogen

Consolidate this item into 30202 (above)

Patient would be at less risk of unnecessary removal of harmless skin growths

There are few reasons why a patient would need more than 10 lesions removed by cryotherapy, and it causes significant pain and damage to the skin. Item 30202 will still allow for this procedure if needed, but doctors will now have less financial incentive to remove a large number of skin growths unnecessarily

Item 30205 - removal of malignant neoplasms of skin by liquid nitrogen cryotherapy where the neoplasm extends into cartilage

Removal of a skin lesion which extends into cartilage via repeated freeze-thaw cycles using liquid nitrogen

Delete this item from the MBS

Patients will have these lesions removed using a best-practice treatment such as surgical excision

Freezing cartilage is not best-practice as it results in longer recovery times and may not fix the problem in 100% of cases; better alternatives like surgical excision are available

 

Recommendation 5: Definitive removal of palmar or plantar warts

Item

What it does

Committee recommendation

What would be different

Why

Item 30185 – removal of 10 or more warts on hands and feet

 

Item 30186 – removal of less than 10 warts on hands and feet

Removal of warts on hands and feet by surgical excision

Delete these items from the MBS

Warts on hands and feet will be removed by cryotherapy

Over the past year, only approximately 42% of lesions were sent for biopsy following removal


Recommendation 6: Laser photocoagulation

Item

What it does

Committee recommendation

What would be different

Why

Items 14100-14124

Laser treatment of lesion or other skin disorders (e.g. port-wine stains, café-au-lait macules, moles)

Require all laser equipment to be listed by the TGA and include IPL

 

Require photo evidence to be captured during treatment

 

Change maximum number of sessions from six to four within 12-month period

 

Reword to ‘vascular abnormalities’ as this is more accurate and up-to-date language

Patients will be at lower risk of being exposed to unsafe equipment and to unnecessary treatments

Inferior low-cost lasers are increasingly available, leading to worse health outcomes

 

Photographic evidence is easy to capture and will help ensure doctors are using this item appropriately

 

Experts agreed that three sessions with modern lasers are sufficient to achieve maximum reasonable benefit; plus one more optional maintenance session

 

Recommendation 7: Micrographically controlled serial excision (Mohs)

Item

What it does

Committee recommendation

What would be different

Why

Items 31000-31002

High-precision surgery for removal of skin tumours

Split each item into two parts: A for Head, neck, genitalia, hand, digits, leg (below knee) and foot, and B for all other parts of the body

 

State in an explanatory note that each doctor’s procedures on this item should be >90% Type A items, and monitor accordingly

 

Require all providers to be certified by the Australasian College of Dermatologists

 

Change the descriptor to include the phrase “mohs surgery”

Patients will receive a more appropriate set of procedures, thanks to better oversight of doctors’ activity by body part operated upon

 

Patients will have lower risk of poor surgical outcomes thanks to tighter restrictions on qualifications of doctors

Clinical guidelines and experience indicate that the majority of Mohs surgery (approximately 90 per cent) should be conducted on Area A.

 

An increasing number of short and insufficient training courses are available, and although certified doctors currently provide the majority of services (99 per cent of providers are dermatologists), this may change in the near future.

 

The phrase “Mohs surgery” removes any misinterpretation of which procedures are included.


Recommendation 8: Teliangectases or starburst vessels

Item

What it does

Committee recommendation

What would be different

Why

Items 30213-30214

Injections to treat starburst vessels on the head and/or neck

Delete these items from the MBS

Patients will receive a more effective and up-to-date treatment

These items are obsolete and do not reflect best practice. Necessary treatment can be provided under laser item 14100.

 

 

Recommendation 9: Treatment of pre-malignant skin lesions

Item

What it does

Committee recommendation

What would be different

Why

Item 30192: Premalignant skin lesions (including solar keratoses), treatment of, by ablative technique (10 or more lesions

Treatment of 10 or more pre-malignant skin lesions by ablation

Leave this item unchanged

-

This item is still required and there are no major issues that need to be fixed.

 

 

Recommendation 10: Skin lesions, multiple injections of hydrocortisone or similar preparations

Item

What it does

Committee recommendation

What would be different

Why

Item 30207: Injections of hydrocortisone

 

Item 30210: Injection of hyodrocortisone similar preparations for exensive skin lesions and/or keloids, in the operating theatre of a hospital

Hydrocortisone or similar medications are anti-inflammatory drugs administered before removing skin lesions or keloids

Prevent item 30210 from being claimed for patients aged 16 and over

 

Use the term “glucocorticoid” to avoid ambiguity in which medications are included

Adults and older teenagers would not receive this treatment in an operating theatre

 

Patients are at less risk of receiving inappropriate medications for this procedure

While children may need general anaesthetic (and hence an operating theatre) for this painful procedure, it is not necessary for adults and older teenagers

 

 

 


Recommendation 11: Superficial radiotherapy

Item

What it does

Committee recommendation

What would be different

Why

Item 15000: Superficial radiotherapy, including treatment with xrays, radium rays or other radioactive substances

Radiation therapy of the skin

Consolidate these items together with the orthovoltage radiotherapy items (items 15100-15115) if the Oncology Clinical Committee agrees

Billing would be simplified for providers; patients would see little if any change in treatment

The Committee believes this is still a clinically relevant treatment, and sees no concerns with consolidating the items to simplify the MBS. There is no expected impact on cost or access for patients

 

Recommendation 12: Administration of immunomodulating agent

Item

What it does

Committee recommendation

What would be different

Why

Item 14245: IV administration of immune-modulating agent for at least 2 hours

Intravenous delivery of a medication for immune-modulation

Leave this item unchanged

-

The Committee is of the view that this is still a clinically relevant treatment

 

Recommendation 13: Bone or cartilage excision

Item

What it does

Committee recommendation

What would be different

Why

Item 31340: excision of one or more bone or cartilage specimens

Removal of bone or cartilage, performed together with skin lesion removal

Leave this item unchanged

-

The Committee is of the view that this is still a clinically relevant treatment


Recommendation 14: Laser excision of face or neck tumours

Item

What it does

Committee recommendation

What would be different

Why

Item 30190: laser removal of 10 or more tumours such as angiofibromas and trichoepitheliomas

Removal by carbon dioxide laser or erbium laser of 10 or more severely disfiguring tumours such as angiofibromas

Exclude common lesions that are not severely disfiguring, such as melanocytic naevi

 

Add an item number for removing less than 10 tumours, including lesions which were previously billed under item 30195 (which is recommended for deletion)

 

Change the wording “confirmed by specialist opinion” to “confirmed by AMC recognised dermatologist opinion.”

 

Committee advises that treatment under the new item would have a similar scope of practice as item 14100, and that these lesions were most likely treated under item 30195 in the past; so both of these schedule fees may be used as reference to determine the price

Patients

Prevent doctors from inappropriately billing 30190 instead of 30195 (if deleted)

 

Create new item to protect access to this service for patients with rare conditions (e.g., epidermal naevi)

 

There is concern that certain GPs who specialise in skin are classifying themselves as specialists. The Committee decided to address this issue by changing this wording to “AMC recognised dermatologist.”

 

 

Recommendation 15: Laser resurfacing for face or neck

Item

What it does

Committee recommendation

What would be different

Why

Items 45025 and 45026: Laser resurfacing of face or neck for severely disfiguring scarring, excluding fractional laser therapy

Facial treatment by laser for severe scarring from trauma, burns, or acne

Add the use of fractional ablative lasers (Erbium and CO2) to the item

 

Exclude non-ablative fractional laser therapy

Patients would have access to fractionated laser therapy

Evidence shows that fractionated laser therapy can have equivalent results to non-fractionated lasers

 

Recommendation 16: Laser vermilionectomy

Item

What it does

Committee recommendation

What would be different

Why

Item 45669: Vermilionectomy, using carbon dioxide laser or erbium laser excision-ablation. (Anaes.)

Surgical removal of the ‘vermilion border’ on the upper lip

Require biopsy proof in the item descriptor

 

Consumers would be at lower risk of this item being misused in a low-value way, since doctors would have to provide proof that it was treating an appropriate condition

Helps ensure appropriate use of the item

 

Recommendation 17: Laser treatment of rhinophyma

Item

What it does

Committee recommendation

What would be different

Why

Item 45652:Carbon dioxide laser or erbium laser excision-ablation of rhinophyma

Laser treatment of rhinophyma (a condition causing a large, bulbous ruddy nose)

Add the phrase “Rhinophyma of a moderate or severe degree” to the descriptor, and require photographic evidence

 

Consumers will continue to have access to this item where needed, i.e. the condition is appropriately severe

Specifying moderate or severe rhinophyma will ensure that this item is used to treat the appropriate thickening associated with rhinophyma

 

Recommendation 18: Full-face chemical peel

Item

What it does

Committee recommendation

What would be different

Why

Item 45019: Full face chemical peel for severely sun-damaged skin where the damage affects 75% of the facial skin surface area

Treatment of severe sun-caused damage to the face (e.g., yellowing and leathering of the skin, solar keratosis) where at least medium-depth peeling agents are used

Add full resurfacing lasers Erbium CO2 and Fractional Thulium 1927 to the item descriptor.

 

Specify “Solar Keratoses not responsive to medical therapies, where the solar Keratosis Load exceeds 30 individual lesions.”

 

Change the word “specialist” to “AMC recognised dermatologist and plastic surgeon.”

 

Consumers are at lower risk of being treated by an inadequately skilled doctor, and are more likely to receive the appropriate treatment (e.g., can now use full resurfacing lasers)

The recommendations modernise the MBS to reflect current best-practice standards of care in treating multiple areas of facial dysplasia

 

There is concern that certain GPs who specialise in skin are classifying themselves as specialists. The Committee decided to address this issue by changing this wording to “AMC recognised dermatologist.”