5.      Recommendations

The Committee reviewed 38 dermatology, allergy and immunology-related MBS items and made recommendations based on evidence and clinical expertise, in consultation with relevant stakeholders. The item-level recommendations can be found below. A brief summary item recommendation table can be found in Appendix A and the summary for consumers in Appendix B.

The Committee’s recommendations (prior to public consultation) are that seven items should be deleted (and their services no longer provided under the MBS); 28 items should be changed; and three items should remain unchanged. The changes focus on encouraging best practice, improving patient care and safety, and ensuring that MBS services provide value for the patient and the healthcare system. Some of this can be achieved by:

Δ Deleting items that are obsolete, or that provide questionable clinical value or low-value care;

Δ Consolidating or splitting items to address potential misuse;

Δ Modernising item descriptors to reflect best practice; and

Δ Providing clinical guidance for appropriate use through explanatory notes.

The recommendations are presented in item groups below, with higher priority groups presented first.

5.1        Phototherapy: Items 14050 and 14053

Table 3: Item introduction table for items 14050 and 14053

Item

Descriptor
[date last amended]

Schedule fee

Services FY2014/15

Benefits FY2014/15

Services 5-year annual avg. growth

14050

PUVA therapy or UVB therapy administered in whole body cabinet (not being a service associated with a service to which item 14053 applies) including associated consultations other than an initial consultation. [1991]

$52.75

564,939

$25,420,269

3.70%

14053

PUVA therapy or UVB therapy administered to localised body areas in a hand and foot cabinet (not being a service associated with a service to which item 14050 applies) including associated consultations other than an initial consultation. [1991]

$52.75

47,211

$2,120,443

8.50%

Recommendations

Δ Consolidate the two items into one item number that includes therapy administered in a whole body cabinet or hand and foot cabinet.

Δ Change the descriptor for this item to include a specified upper limit of 150 treatments per patient over a 12-month period, as well as a requirement that initiation and supervision of treatment involves a dermatologist. The proposed item descriptor is as follows:

 UVA or UVB phototherapy administered in a whole body cabinet or hand and foot cabinet including associated consultations other than the initial consultation. A maximum of 150 services in a 12 month period to be claimable per patient. Treatment to be initiated and supervised by an AMC recognised Dermatologist.

Δ Amend the explanatory notes for item 14050 to include appropriate use guidelines. The proposed explanatory notes are outlined below, and they should also include the National Institute of Health and Care Excellence (NICE) Guidelines’[4] online link for phototherapy treatment for psoriasis and palmoplantar pustulosis.

 Phototherapy should only be used when:

 Topical therapy has failed or is inappropriate.

 The severity of the condition as assessed by specialist opinion (including symptoms, extent of involvement and quality of life impairment) warrants its use.

 Narrow band UVB should be the preferred option for phototherapy unless there is documented evidence of superior efficacy of UVA phototherapy for the condition being treated.

 Phototherapy treatment for psoriasis and palmoplantar pustulosis should consider the National Institute of Health and Care Excellence’s (NICE) Guidelines [4]

 Involvement by an AMC recognised dermatologist at a minimum requires: a letter including the diagnosis, need for phototherapy, estimated time of treatment and review date.

Rationale

The recommendations focus on improving patient safety and are based on the following observations.

Δ The Committee agreed that there is no clinical requirement for two different item numbers, and that consolidating the items would have no cost impact on patients as both items have the same schedule fee.

Δ UV treatment may cause skin cancer, and there is currently insufficient evidence to determine maximum lifetime safe exposure levels with complete certainty.[4-6] However, these treatments are becoming more common, and it appears that some individuals are receiving a large number of treatments each year. Over the last five years, for example, service volume has grown by an annual average of 4 per cent[2] (compared to population growth of 1.3 per cent).[3] In FY 2014/15, there were 27 treatments per patient, on average.[2] Approximately 55 patients who received a treatment in 2014 had more than 150 treatments within a 12-month period.[7]

Δ Drawing on international guidelines and the clinical judgement of its members, the Committee agreed that limiting UV exposure by restricting use to a maximum of 150 treatments per patient over a 12-month period (with appropriate use guidelines included in the explanatory notes) would improve patient safety, particularly as there is currently no cap on a patient’s UV exposure under these items. This restriction aligns with the literature and a number of guidelines for treating different conditions, such as those outlined below.              

 The British Association of Dermatologists’ guidelines for the diagnosis and management of vitiligo state: “patients treated with PUVA or UVB should have their treatment closely supervised by a consultant dermatologist and the treatment regimen for patients with skin types I–III should not exceed 200 treatments for NB-UVB and 150 treatments for PUVA (lifetime).”[5]

 The NICE Guidelines [4] highlight a number of practices to avoid or consider for patients with plaque or guttate-pattern psoriasis or palmoplantar pustulosis, including the following:

 “Do not use PUVA when other appropriate treatments are available in: people with a personal history of skin cancer, people who have already received 150 PUVA treatments or children and young people.”

 “Do not routinely use phototherapy (narrowband UVB, broadband UVB or psoralen plus ultraviolet A [PUVA]) as maintenance therapy.”

 “Do not use PUVA in people with psoriasis of any type and a genetic predisposition to skin cancer, for example xeroderma pigmentosum or familial melanoma.”

 “Ensure that a permanent record of a person’s cumulative number of UV treatments is kept.”

 Olsen et al. (2016) state that certain rare patients, such as those seeking treatment for cutaneous T-cell lymphoma, may require treatment three times per week for an extended period of time,[8] which would result in approximately 150 treatments within a 12-month period.

Δ The Committee also noted that combination phototherapy treatment is likely to be ineffective in the long term. For example, an Australia study of 150 potential low-value care practices found that “combination treatment for Vitiligo using UVB to enhance re-pigmentation produces better results but no evidence of long term sustained benefit.”[9]

5.2        Treatment of benign and malignant neoplasms: Items 30195–7

Table 4: Item introduction table for items 30195–7

Item

Descriptor

[date last amended]

Schedule

fee

Services FY2014/15

Benefits FY2014/15

Services 5-year annual avg. growth

30195

Benign neoplasm of skin, other than viral verrucae (common warts) seborrheic keratoses, cysts and skin tags, treatment by electrosurgical destruction, simple curettage or shave excision, or laser photocoagulation, not being a service to which item 30196, 30197, 30202, 30203 or 30205 applies (1 or more lesions). (Anaes.) [2005]

$63.50

197,287

$10,877,938

3.20%

30196

Malignant neoplasm of skin or mucous membrane proven by histopathology or confirmed by specialist opinion, removal of, by serial curettage or carbon dioxide laser or erbium laser excision-ablation, including any associated cryotherapy or diathermy, not being a service to which item 30197 applies. (Anaes.) [2003]

$126.3

173,979

$14,770,498

6.00%

30197

Malignant neoplasm of skin or mucous membrane proven by histopathology or confirmed by specialist opinion, removal of, by serial curettage or carbon dioxide laser excision-ablation, including any associated cryotherapy or diathermy (10 or more lesions). [2003]

$440.05

3,352

$1,207,089

7.80%

5.2.1        Item 30195

Recommendation

Δ Delete this item from the MBS. Appropriate services should instead be claimed under biopsy item 30071 and sent to pathology for definitive diagnosis. In rare circumstances, appropriate services could be claimed under the proposed new item 3019X [Note: this item is to be created, please see recommendations for 30190] for less than 10 lesions.

Rationale

The recommendation focuses on improving patient safety and value for the healthcare system. It is based on the following observations:

Δ Use of this item is unexpectedly high, with service growth exceeding population growth. In FY2014/15, for example, 197,000 services were provided, and services have been growing at an average of 3.2 per cent per year over the last five years [2] (compared to population growth of 1.3 per cent).[3] It is unclear what this item is being used for, as there are few instances in which treatment of benign lesions is not purely cosmetic (such as treating benign naevi and keratosis). Cosmetic services are not funded in the MBS, and cosmetic treatment should not be billed under item 30195. Instead, it should occur as part of a consultation or be billed privately. There is high variation in use across providers, which suggests that a small number of providers may be misusing the item. In FY2014/15, approximately 10 per cent of doctors who billed the item accounted for 80 per cent of services for item 30195. [10]

Δ There is a safety concern that malignant neoplasms are being missed or mis-diagnosed, as relatively few are being sent to pathology or confirmed by specialist opinion (as required under item numbers 30196 and 30197). In FY2014/15, histopathology or the biopsy item 30071 was used within the period 30 days before or after service delivery on only 45 per cent of occasions: General Practitioners (GPs) used it on 44 per cent of occasions, and specialists used it on 54 per cent of occasions.[11] GPs who billed the item accounted for 87 per cent of total services.[12] Furthermore, melanoma excisions were claimed within 30 days of item 30195 [13] on 1,205 occasions, potentially indicating that a number of melanomas may be missed due to use of item number 30195, where tissue is not sent for pathological examination.

Δ The Committee felt that it was reasonable to delete this item, given that item 30071 can be used if there is uncertainty about whether a lesion is benign or malignant. This recommendation will also ensure that lesions are sent to pathology.

Δ The Committee pointed out that a small number of severely disfiguring tumours—such as xanthelasma, pyogenic granuloma and epidermal naevi—were previously (and appropriately) treated under this item. The Committee recommended that these should now be billed under the proposed new item number 3019X [Note: this item is to be created, please see recommendations for 30190] for less than 10 lesions.

5.2.2        Item 30196

Recommendations

Δ Change the item descriptor to mandate histopathology by removing “confirmation of malignancy by specialist opinion” from the item descriptor.

Δ Advise the Department of Health (the Department) to monitor and conduct audits (where appropriate) of high-volume providers to ensure that providers are requesting the appropriate pathology tests. This item should also be reviewed after 12 months to assess the effect of deleting item 30197, and to determine whether providers are billing for many more than 10 lesions.

Δ The Committee calls on relevant colleges to encourage best-practice use of pathology post-treatment.

Rationale

The recommendations focus on increasing patient safety and encouraging best practice. They are based on the following observations.

Δ The position of the Committee is that item 30196 provides the most appropriate service for the treatment of malignant neoplasms within this group of items.

Δ However, it identified that some lesions are not being sent for histopathology, which represents a safety concern and does not reflect best practice. In FY2014/15, histopathology or the biopsy item 30071 was used in the period 30 days before or after service delivery on 89 per cent of occasions: GPs used it on 90 per cent of occasions, and specialists used it on 87 per cent of occasions.[11] GPs who billed this item accounted for 55 per cent of total services.[12] Within the same year, 844 melanoma excisions were claimed within 30 days of item 30196[13], potentially indicating that a number of melanomas may be missed due to use of item number 30196, where tissue is not sent for pathological examination.

Δ The Committee was also concerned to learn from the Department that certain GPs who specialise in skin are classifying themselves as specialists and are not performing histopathology.

Δ The Committee was also concerned to learn that certain GPs who specialise in skin lesions are classifying themselves as specialists and MBS data reflects that the data shows providers that are listed as GPs who are not performing histopathology.

Δ In light of the safety concerns and the proposed removal of item 30197 (a large number of lesions under this item were not sent for histopathology, and its services will now fall under item 30196), the Committee recommends: (i) mandating histopathology by removing confirmation “by specialist opinion”; (ii) encouraging colleges to promote best-practice use of histopathology amongst their members; (iii) monitoring high-volume users of the item (performed by the Department); and (iv) a further review in 12 months’ time of providers that bill multiple lesions in a single day under item 30196. The Committee does not anticipate this procedure volume to be high, as discussed in Section 5.2.3 (item 30197).

5.2.3        Item 30197

Recommendation

Δ Consolidate this item under item 30196.

Rationale

The recommendation focuses on improving patient care and addressing potential incentives for misuse. It is based on the following observations.

Δ The Committee felt that there are few circumstances in which the removal of 10 or more lesions is required. However, the item is becoming more commonly used. In FY2014/15, for example, 3,352 services were provided, and service volume has grown by 7.8 per cent per year over the last five years.[2] Furthermore, 527 patients (21 per cent) received two or more services under item 30197 in FY2014/15,[12] which is not commonly likely to be necessary. It is likely that a perverse incentive exists for claiming the higher schedule fee for item 30197, instead of using item 30196. This can be seen in an analysis of the frequency of claims for different numbers of lesions: 10 or more lesions are claimed three times as often as six to nine lesions, and marginally more often than four lesions (Figure 4).[14]

Δ There is also a safety concern that lesions are not consistently sent to pathology, and there is a limited audit trail because providers are not required to disclose treatment sites for this item. In FY2014/15, histopathology or the biopsy item 30071 was used in the period 30 days before or after service delivery on 65 per cent of occasions: GPs used it on 73 per cent of occasions, and specialists used it on 51 per cent of occasions.[11] GPs who billed this item accounted for 61 per cent of total services.[12]

Δ In light of the safety concerns and apparent miscoding, the Committee felt that deleting the item was an appropriate measure. Removal of multiple lesions can still be billed under item 30196. This would require each lesion to be individually sent for pathological examination and treatment areas to be specified, in line with best practice.

 

Figure 4: Count of patients by the number of lesions removed on the same day under items 30196-30197

 

 Figure 4 is a bar graph that shows the count of patients by the number of lesions removed on the same day under items 30196 and 30197 for the financial year 2014-15. The blue bar is item 30196 and the red bar is item 30197. The blue bars show declining trend as number of lesions increases, from 74,716 for one lesion down to 951 for five lesions. There are low numbers in 5-9 lesions with 477 patients for 6 lesions, 187 patients for 7 lesions, 96 patients for 8 lesions, and 39 patients for 9 lesions. The graph then increases again with the red bar claimed by 2,496 patients for 10 or more lesions.

5.3        Allergy: Items 12003, 12000, 21981 and 53600

Table 5: Item introduction table for items 12003, 12000, 21981 and 53600

Item

Descriptor

[date last amended]

Schedule

fee

Services FY2014/15

Benefits FY2014/15

Services 5- year annual avg. growth

12003

Skin sensitivity testing for allergens, using more than 20 allergens, not being a service associated with a service to which item 12012, 12015, 12018 or 12021 applies. [1995]

$58.85

50,241

$2,632,167

-0.90%

12000

Skin sensitivity testing for allergens, using 1 to 20 allergens, not being a service associated with a service to which item 12012, 12015, 12018 or 12021 applies. [1995]

$38.95

64,630

$2,275,306

4.40%

21981

Anaesthetic agent allergy testing, using skin sensitivity methods in a patient with a history of prior anaphylactic or anaphylactoid reaction or cardiovascular collapse associated with the management of anaesthesia agents (4 basic units). [2011]

$79.20

63

$9,500

14.50%

53600

Skin sensitivity testing for allergens to anaesthetics and materials used in OMS surgery, using 1 to 20 allergens. [2000]

$38.95

0

$0

N/A

5.3.1        Item 12003

Recommendation

Δ Remove the specific item for testing more than 20 allergens, and consolidate under item 12000 as part of the proposed changes to this item.

Rationale

The recommendation focuses on improving patient care and encouraging best practice. It is based on the following observations.

Δ A relatively high number of tests are performed for 20 or more allergens. In FY2014/15, for example, tests for 20 or more allergens accounted for 44 per cent of total general allergy tests (12000 and 12003 services), and approximately 2,340 patients were tested for 20 or more allergens more than once. Two patients were tested more than seven times (at least 140 allergens tested each). The Committee noted that there are few circumstances in which a patient requires a test for 20 or more allergens, and even fewer circumstances in which this would be required more than once a year. This is true for both food and environmental allergens, at all ages:

 The clinical need for Immunoglobulin E (IgE) food allergy skin prick testing (SPT) generally focuses on a limited number of food allergens, as 98 per cent of IgE-mediated food allergies are due to nine food groups: eggs, milk, wheat, soy, fish, shellfish, peanuts, tree nuts and seeds.[15] This applies to both children and adults. Most egg, milk, wheat and soy allergens resolve with time, and most food allergies present in infancy and early childhood. Even then, it would be rare to require more than 20 food allergens to be tested at one time.[15]

 It is not necessary to test for more than 20 environmental (aeroallergens) allergens for allergic rhinitis (AR), asthma or atopic dermatitis (AD), as for these conditions, SPT is limited to common environmental allergens, such as house dust mites, furred animals (for example, cats, dogs), grass pollens, weed pollen and tree pollen.

 When testing for both food and environmental allergies it is also unlikely that testing for more than 20 allergies at one time would be necessary.

Δ Testing for many allergens is likely to lead to clinically irrelevant positives. Indeed, relevant literature from HealthNuts publications[16] highlights that SPTs have the potential to over-diagnose food allergies, especially when multiple tests are conducted at the same time. For instance, only 3 per cent of children have proven peanut allergies, despite an SPT positive rate of 8.9 per cent. Similarly, although 16.5 per cent of SPTs are positive for egg, only 8.9 per cent have challenge-proven raw egg allergy (dropping to 1.8 per cent for cooked eggs).

Δ Drawing on its clinical experience, the Committee also noted that testing for many allergens is unpleasant for patients, particularly small children. This can harm consumers’ experience of receiving healthcare services. In FY2014/15, 5,000 tests for more than 20 allergens were performed on infants aged 0–4 (10 per cent of total tests).

5.3.2        Item 12000 and 21981

Recommendations

Δ Split item 12000 and change item 21981 to four MBS items that:

 Accurately describe the allergens tested and the scope of practice required for each.

 Remove the specification of 1–20 tests, making it clear that all allergens tested under the relevant item number on the same day are included, thereby prohibiting co-claiming with itself. (These items cover billing for more than 20 allergens, on the rare occasions when this is necessary.)

 Shift MBS item 21981 to the allergy and immunology section of the MBS as 1200-D and amend the descriptor to bring in line with 1200-A to C.

 Prohibit billing of repeat testing in a 12-month period for item 1200-A.

 Prohibit co-claiming between items 1200-A, 1200-B and 1200-D.

Δ The proposed item descriptors are as follows:

 1200-A: Skin prick testing for aeroallergens, including all allergens tested on the same day, not being a service associated with a service to which item 1200-B, 1200-D, 12012, 12015, 12018 or 12021 applies. Item only claimable once per 12 month period.

 1200-B: Skin prick testing for food and latex allergens, including all allergens tested on the same day, not being a service associated with a service to which item 1200-A, 1200-D, 12012, 12015, 12018 or 12021 applies.

 1200-C: Skin testing for medication allergens (antibiotics, non-general anaesthetics agents) and venoms including prick testing and intradermal testing with a number of dilutions, including all allergens tested on the same day, not being a service associated with a service to which item 1200-D, 12012, 12015, 12018 or 12021 applies.

 1200-D: Skin testing for agents used in the perioperative period including prick testing and intradermal testing with a number of dilutions, to investigate anaphylaxis in a patient with a history of prior anaphylactic reaction or cardiovascular collapse associated with the administration of an anaesthetic. Including all allergens tested on the same day, not being a service associated with a service to which item 1200-A, 1200-B, 1200-C, 12012, 12015, 12018 or 12021 applies.

Δ Add explanatory notes for item 1200-B (testing for food allergens) to guide appropriate provider use. The proposed explanatory notes are as follows:

 Item 1200-B should only be used by appropriately trained doctors such as allergist immunologists or equivalently trained medical practitioners. An alternative to Skin Prick Testing (SPT) is serum specific IgE food allergen testing. Serum specific IgE (ssIgE) allergy blood testing to food panels is not recommended.

Δ Add explanatory notes for items 1200-C and 1200-D to guide appropriate provider use. The proposed explanatory notes are as follows:

 Item 1200-C should only be used by appropriately trained doctors such as allergist immunologists or equivalently trained medical practitioners.

 Item 1200-D should only be used by appropriately trained doctors such as allergist immunologists, anaesthetists or equivalently trained medical practitioners.

Δ The Committee advises that utilisation of these items should be monitored and reviewed again in 12 months to check whether the restructured items are being used appropriately.

Δ The Committee suggests revising the schedule fee for these items to reflect the complexity and expense of testing, which scale from 1200-A (least complex) to 1200-D (most complex).

Δ The Committee calls on the Australasian Society of Clinical Immunology and Allergy (ASCIA) to create a scope-of-practice document.

Rationale

The recommendations focus on improving patient care and encouraging best practice. They are based on the following observations.

Δ The Committee noted that inappropriate testing patterns could be contributing to relatively high service volumes. For instance, item 12000 was used 64,630 times in FY2014/15, and service volume has been growing by an average of 4.4 per cent per year over the last five years[2] (compared to population growth of 1.3 per cent)[3]. This can also be attributed to increased servicing of the population (services per 100,000 has grown by 3.1 per cent)[2] and the increasing prevalence of food allergy and atopic disease.

Δ The Committee expressed concern about the high volume of use and noted that the current allergy items do not capture the true scope of practice required to test for different allergies. There was particular concern that food allergy may be over-tested leading to over-diagnosis, which potentially leads to clinically irrelevant positives, unnecessary dietary restriction and patient concern.

Δ The Committee reviewed the clinically accepted allergy groups, the scope of practice and complexity required to test for different allergies and recommended splitting the items accordingly (as seen above).

Δ The restructuring of the allergy items is intended to encourage best-practice use and provide a means of monitoring the types of providers testing for food allergies in particular, as well as latex and medication (antibiotics and non-general anaesthetics) and venom allergies. Food and latex were grouped together because they have a similar scope of practice and level of complexity in testing, and because the volume for latex allergy testing will most likely be too small to justify a specific item number. Similarly medication (antibiotics and non-general anaesthetics) and venom were grouped together, and in this case venom allergy testing is unlikely to have a large enough volume to justify a specific item number.

Δ The Committee considered placing a provider restriction in the item descriptor for items 1200-B, C and D. However, it ultimately decided against this due to (i) the challenges associated with appropriately restricting providers, (ii) the lack of appropriate restriction mechanisms that acknowledge the skills of non-allergist immunologists, and (iii) the potential impact of an immediate restriction on patient access. Nonetheless, the Committee agreed that data showing which providers are performing allergen testing should be gathered over a 12-month period, after which a further review should be conducted to determine whether a restriction is necessary. The Committee also recommended including appropriate provider guidelines in the explanatory notes to encourage appropriate provider use of the items.

Δ The provider guidelines in the proposed explanatory notes align with the clinical literature, which indicates that SPT is appropriate for evaluating the following conditions:

 IgE food allergy:

 The performance and interpretation of SPT to food allergens requires specialised training and should be restricted to specialists or equivalently trained medical practitioners.[17-18]

 Although rare, SPT for food allergies can lead to immediate allergic reactions, including anaphylaxis. Practitioners performing SPT must be able to identify and manage allergic reactions and anaphylaxis.[17]

 Using SPT to screen for food allergy is not recommended and should be discouraged. Allergy testing for foods is indicated to confirm suspected food allergy where there has been a clinical reaction following known exposure. It is not an appropriate tool for screening for possible food allergies as there can be high rates of clinically irrelevant low-level SPT positivity.[16] Screening SPTs can lead to over-diagnosis of food allergy and unnecessary dietary restriction/delayed introduction of allergenic foods,[15],[18] which recent evidence suggests may be contributing to rising rates of food allergies.[19]

 Allergy to aeroallergens associated with AR, asthma and AD:

 This is generally confined to common environmental allergens. It is not unreasonable for a non-specialist to perform aeroallergens allergy tests, but performance and interpretation of SPT does require training.[18]

 Latex allergy:

 Performance and interpretation of SPT requires specialised training and should be restricted to specialists or equivalently trained medical practitioners.[18]

 Medication allergy:

 Performance and interpretation of SPT requires specialised training and should be restricted to specialists or equivalently trained medical practitioners.[18]

Δ The Committee proposed a new item for medication allergy testing (antibiotics, non-general anaesthetics) and venom allergy testing, which have previously not had a specific item number on the MBS. This item was added to reflect the true scope of practice required to adequately test patients. (On the limited occasions when tests for these allergies were conducted in the past, it is likely that they were performed under items 12000 and 12003.) Conducting these tests will help patients to better understand what they are allergic to, and could lead to more rational medication allergy labelling for patients. The Committee acknowledged that medication allergy testing is time-consuming, reagents are expensive and test interpretation is complex. It therefore anticipates that this item will be rarely used, and only by appropriately trained specialists or medical practitioners.

Δ Testing for anaesthetics under item 21981 is currently listed in a different section of the MBS due to its item number. The Committee’s proposed change is designed to simplify the MBS and encourage the appropriate use of items by grouping the four types of allergen testing together. The proposed wording adjustment to the descriptor is intended to improve quality of testing by allowing for agents used in the perioperative period that sometimes go beyond anaesthetics.

Δ The Committee decided to restrict co-claiming between item numbers 1200-A, B and D to prevent the proposed changes resulting in higher costs for the patient. (Under the previous item numbers, these were billed together.) These tests can still be performed together, but a patient will not be billed for all of the tests, and the fees should be adjusted to reflect this. The Committee decided not to restrict co-claiming with item 1200-C as this will be required on certain occasions, and the associated schedule fee is unlikely to reimburse the costs involved.

Δ The Committee also agreed that testing for aeroallergens more than once in a 12 month period would be unnecessary and billing for this should not be permitted.

5.3.3        Item 53600

Recommendation

Δ Delete this item from the MBS.

Rationale

The recommendation focuses on encouraging best practice and modernising the MBS. It is based on the following observations.

Δ The Committee concluded that this item is obsolete and no longer reflects best practice. MBS data indicates that the item has only been billed twice in the last decade.[2]

Δ There are already large restrictions placed on this item, which prohibit use. The term “OMS surgery” in the item descriptor restricts the use of this item to dental practitioners who were approved by the then Minister for Health prior to 1 November 2004 for the provision of oral and maxillofacial surgery services and relevant attendances.

5.4        Treating malignant lesions by liquid nitrogen cryotherapy using repeat freeze-thaw cycles: Items 30202, 30203 and 30205

Table 6: Item introduction table for items 30202–3 and 30205

Item

Descriptor

[date last amended]

Schedule

fee

Services FY2014/15

Benefits FY2014/15

Services 5-year annual avg. growth

30202

Malignant neoplasm of skin or mucous membrane proven by histopathology or confirmed by specialist opinion, removal of, by liquid nitrogen cryotherapy using repeat freeze-thaw cycles, not being a service to which item 30203 applies. [2003]

$48.35

61,776

$2,004,167

3.40%

30203

Malignant neoplasm of skin or mucous membrane proven by histopathology or confirmed by specialist opinion, removal of, by liquid nitrogen cryotherapy using repeat freeze-thaw cycles (10 or more lesions). [2003]

$170.25

12,383

$1,751,331

5.50%

30205

Malignant neoplasm of skin proven by histopathology, removal of, by liquid nitrogen cryotherapy using repeat freeze-thaw cycles where the malignant neoplasm extends into cartilage. (Anaes.) [2003]

$126.30

180

$15,608

-0.90%

5.4.1        Item 30202

Recommendations

Δ Change the wording of the item descriptor by replacing “specialist” with “AMC recognised dermatologist.”

Δ Advise the Department to monitor high-volume providers to ensure that providers are requesting the appropriate pathology tests. This item should also be reviewed after 12 months to assess the effect of deleting item 30197, and to determine whether providers are billing for many more than 10 lesions.

Δ The Committee calls on relevant colleges to encourage best-practice use of pathology post-treatment.

Rationale

The recommendations focus on increasing patient safety and encouraging best practice. They are based on the following observations.

Δ The position of the Committee is that item 30202 provides the most appropriate service for the treatment of malignant neoplasms within this group of items.

Δ However, the surprisingly low number of lesions sent to pathology represents a large safety concern and does not reflect best practice. In FY2014/15, for example, histopathology or the biopsy item 30071 was used in the period 30 days before or after service delivery on only 42 per cent of occasions: GPs used it on 55 per cent of occasions, and specialists used it on 25 per cent of occasions.[11] GPs who billed this item accounted for 58 per cent of total services.[12] Auditing provider practice and encouraging best practice (via the relevant colleges) may contribute to improving practice patterns.

Δ As mentioned above, the Committee was also concerned to learn that certain GPs who specialise in skin lesions are classifying themselves as specialists and MBS data reflects that the data shows providers that are listed as GPs who are not performing histopathology.

Δ In light of safety concerns and the consolidation of item 30203 under item 30202, the Committee recommends: (i) changing the word “specialist” to “AMC recognised dermatologist”; (ii) encouraging colleges to promote best-practice use of histopathology amongst their members; (iii) monitoring high-volume users of the item (conducted by the Department); and (iv) conducting a further review in 12 months’ time of providers that bill multiple lesions in a single day under item 30202. The Committee does not anticipate this procedure volume to be high, as discussed in Section 5.4.2 (item 30203). The Committee notes that the recommendation regarding the word “specialist” in the item descriptor is slightly different from the wording change recommended for item 30196. This decision was made because the procedure under 30202 is different, and dermatologists often try to avoid removing tissue where possible to avoid scarring.

5.4.2        Item 30203

Recommendation

Δ Consolidate this item under item 30202.

Rationale

The recommendation focuses on improving patient care and addressing incentives for misuse. It is based on the following observations.

Δ The Committee’s position is that there are few circumstances in which the removal of 10 or more malignant lesions by liquid nitrogen cryotherapy with repeat freeze-thaw cycles is appropriate, particularly as it causes significant pain and damage to the skin. Despite this, 12,383 services were provided in FY2014/15, and services have been growing at an average of 5.5 per cent year per over the last five years [2] (compared to population growth of 1.3 per cent) [3]. Furthermore, a substantial number of patients undergo over 20 lesion removals in a year: in FY2014/15, for example, 26 per cent of patients received two or more services under item 30203.[10] This may be because the higher schedule fee for item 30203 has created a perverse incentive to bill this item, rather than billing multiple times under item 30202 (Figure 5)[14]. The Committee noted with surprise that the number of patients undergoing at least 10 lesion removals is double the number of patients undergoing two lesion removals on the same day.

Δ There is a safety concern that lesions are not consistently sent to pathology, and there is a limited audit trail because providers are not required to disclose treatment sites for this item. In FY2014/15, histopathology or the biopsy item 30071 was used in the period 30 days before or after service delivery on only 43 per cent of occasions: GPs used it on 47 per cent of occasions, and specialists used it on 29 per cent of occasions.[11] GPs who billed this item accounted for 78 per cent of total services.[12]

Δ In light of the safety concerns and apparent mis-coding, the Committee felt that deleting the item was a reasonable action. Under item 30202, each lesion would need to be individually sent for pathological examination and treatment areas would need to be specified, in line with best practice.

 

Figure 5: Count of patients by the number of lesions removed on the same day under items 30202-30203

 Figure 5 is a bar graph that shows the count of patients by the number of lesions removed on the same day under items 30202 and 30203. The blue bar is item 30202, while the red bar is item 30203. The trend is similar to Figure 4 which shows a declining frequency from left to right and then a spike at 10 or more. The majority of patients have a single lesion removed (blue) and in this figure the second highest value is the red bar with 8,077 claims for 10 or more lesions on the same day. The remaining blue bars show 4,183 with 2 lesions, 1,566  with 3 lesions, 613 with 4 lesions, 322 with 5 lesions, 188 with 6 lesions, 153 with 7 lesions, 154 with 8 lesions, 9 with 9 lesions, and 6 patients who had 10 or more lesions claimed using item 30202 instead of 30203 which is for 10 or more lesions removed.

5.4.3        Item 30205 

Recommendation

Δ Delete this item from the MBS, and instead use item 30202.

Rationale

The recommendation focuses on encouraging best practice and patient safety. It is based on the following observations.

Δ The position of the Committee is that this treatment no longer reflects best practice, given that freezing cartilage results in longer recovery times for patients, definitive treatment cannot be assured, and there are better alternative treatments available such as surgical excision. MBS data also suggests a general trend away from using the item. In FY2014/15, for example, the item was only used 180 times, and use has been decreasing by an average of 0.9 per cent per year over the last five years[2] (compared to population growth of 1.3 per cent)[3].

Δ The Committee agreed that deleting this item would not cause any access issues for patients as item 30202 is provided far more often and has a lower schedule fee.

5.5        Definitive removal of palmar or plantar warts: Items 30185 and 30186

Table 7: Item introduction table for items 30185–6

Item

Descriptor

[date last amended]

Schedule

fee

Services FY2014/15

Benefits FY2014/15

Services 5-year annual avg. growth

30185

Palmar or plantar warts (10 or more), definitive removal of, excluding ablative methods alone, not being a service to which item 30186 or 30187 applies. (Anaes.) [2003]

$182.50

1,068

$163,974

0.30%

30186

Palmar or plantar warts (less than 10), definitive removal of, excluding ablative methods alone, not being a service to which item 30185 or 30187 applies. (Anaes.) [2003]

$47.45

35,149

$1,378,442

-0.40%

Recommendation

Δ Delete both items from the MBS. Treatment should be provided using other therapies (such as cryotherapy) within a normal consultation.

Rationale

The recommendation focuses on improving patient care and promoting best practice. It is based on the following observations.

Δ The Committee identified these items as obsolete, noting that they no longer reflect best practice. Item 30185 is cause for particular concern, given that it covers treatment of more than 10 warts. MBS data also suggests a general trend away from using these items. Over the last five years, for example, the service volumes for these items have fallen by an average of 0.4 per cent per year[2] (compared to population growth of 1.3 per cent)[3].

 The Committee’s clinical judgment is that treatment modalities such as cryotherapy reflect best practice, as outlined in international consensus clinical guidelines. For instance, Lipke (2006) notes: “Surgical excision and cautery of warts is not recommended as a standard therapy because it can be painful and cause scars that are difficult to treat. Like any destructive therapy, there is no assurance that the wart will not recur. Recurrence rates can be as high as 30%.”[20] The British Association of Dermatology’s recommendations for treating plantar warts[21] identify cryotherapy and other treatments as the best forms of treatment, including: “Salicylic acid (15–40%) topical paints or ointments.” 

 “Cryotherapy, fortnightly for 3–4 months.”

 “Salicylic acid and/or cryotherapy used with more aggressive regimens is probably more effective than standard regimens, but care is needed with worse side-effects. Combination treatments can be undertaken.”

 “Other treatments: dithranol, 5-FU, formaldehyde, glutaraldehyde, hyperthermia, laser, PDT, podophyllotoxin, topical immunotherapy.”

 The recommendations also note: “Cure rates are lower at this site probably due to a thicker cornified layer and subsequent poorer penetration of treatments to the lower epidermis. Paring, if used to remove excess skin from warts before treatment, should avoid damaging surrounding skin because of the risk of spreading infection.”

Δ Furthermore, a 2012 Cochrane Review found that “surgical excision and curettage with cautery have certainly been recognised treatments for common warts in the past, but fewer dermatologists advocate these treatments now due to the morbidity of the procedure, particularly scarring, and the anecdotal experience of high rates of recurrence. We did not identify any controlled trials or RCTs [randomised controlled trials] that evaluated these treatments.”[22]

Δ The Committee agreed that other treatment options are available to patients (such as cryotherapy), and these should be conducted as part of a normal consultation.

Δ The Committee agreed that deleting this item would create greater value for patients as it would encourage best-practice treatment and allow funds to be re-allocated to higher value care for patients.

5.6        Laser photocoagulation: Items 14100, 14106, 14109, 14112, 14115, 14118 and 14124

Table 8: Item introduction table for items 14100, 14106, 14109, 14112, 14115, 14118 and 14124

Item

Descriptor

[date last amended]

Schedule

fee

Services FY2014/15

Benefits FY2014/15

Services 5-year annual avg. growth

14100

Laser photocoagulation using laser light within the wave length of 510–1064nm in the treatment of vascular lesions of the head or neck where abnormality is visible from 3 metres, including any associated consultation, up to a maximum of 6 sessions (including any sessions to which items 14100 to 14118 and 30213 apply) in any 12 month period. (Anaes.) [2004]

$152.5

23,881

$3,507,367

6.00%

14106

Laser photocoagulation using laser light within the wave length of 510–1064nm in the treatment of port wine stains, haemangiomas of infancy, cafe-au-lait macules and naevi of Ota, other than melanocytic naevi (common moles), where the abnormality is visible from 3 metres, including any associated consultation, up to a maximum of 6 sessions (including any sessions to which items 14100 to 14118 and 30213 apply) in any 12 month period – area of treatment up to 50cm2. (Anaes.) [2005]

$152.50

2,991

$470,789

-1.20%

14109

“area of treatment more than 50cm 2 and up to 100cm 2” [2004]

$187.35

331

$74,485

-7.00%

14112

“area of treatment more than 100cm 2 and up to 150cm 2” [2004]

$221.75

146

$38,195

-6.20%

14115

“area of treatment more than 150cm 2 and up to 250cm 2” [2004]

$256.50

148

$48,166

-14.10%

14118

“area of treatment more than 250cm 2” [2004]

$325.75

148

$67,543

-1.20%

14124

Laser photocoagulation using laser light within the wave length of 510–1064nm in the treatment of haemangiomas of infancy, including any associated consultation – where a 7th or subsequent session (including any sessions to which items 14100 to 14118 and 30213 apply) is indicated in a 12 month period. [2014]

$152.50

54

$7,345

-2.10%

Some descriptors have been shortened; see Appendix A for complete descriptors.

5.6.1        Item 14100

Recommendations

Δ Change the item descriptor wording for item 14100, replacing “vascular lesion” with “vascular abnormalities.”

Δ Change the maximum number of sessions from six to four within a 12-month period.

Δ Include a requirement for all laser equipment to be listed by the Therapeutic Goods Administration (TGA).

Δ Include use of IPL within the item descriptor, recognising that this recommendation may need to be evaluated by the MSAC.

Δ Include a requirement for photo evidence to be captured during treatment to assist providers with documenting compliance with the item descriptor.

Rationale

The recommendations focus on encouraging best practice and optimal patient care. They are based on the following observations.

Δ “Vascular abnormalities” is a clearer description of the required indications for this item. For example, “vascular abnormality” better reflects the fact that rosacea produces telangiectasia and erythema.

Δ Drawing on the clinical judgement of its members, the Committee determined that no more than three sessions with modern lasers are required to achieve maximum reasonable improvement. Allowing four sessions provides patients with an opportunity to receive a maintenance session within the same 12-month period.

Δ All laser equipment should be TGA-listed. Inferior low-cost lasers are increasingly available, which may lead to poor patient outcomes.

Δ The Committee agreed that IPL should be included in the item descriptor, based on clinical judgement and the relevant literature, which confirms that it provides equivalent patient care [23-25]

Δ The Department informed the Committee that providers must produce evidence that they are compliant with the item descriptor, and that it is unlikely that this is occurring at the moment. The Committee recommended a simple solution: require providers to capture photographic evidence, as cameras are available and are used by most providers (especially to highlight to patients the impact of their treatment).

5.6.2        Items 14106, 14109, 14112, 14115 and 14118

Recommendations

Δ Change the item descriptor wording for all items to include International Society for the Study of Vascular Anomalies (ISSVA) terminology. Specifically, use the term “vascular malformations,” which in ISSVA terminology encompasses:

 Capillary malformation (CM; previously “port wine stain”).

 Venous malformation (VM; previously “cavernous haemangioma”).

 Arterio-venous malformation (AVM).

Δ Change the item descriptor wording, replacing “haemangiomas of infancy” with “infantile haemangiomas,” and replacing “laser light within wave length of 510–1064nm” with “laser radiation.”

Δ Consolidate item numbers into three items:

 Area of treatment less than 150 cm2.

 Area of treatment 150 to 300 cm2.

 Area of treatment greater than 300 cm2.

Δ Include a requirement for all laser equipment to be TGA-listed.

Δ Include a requirement for photo evidence to be captured during treatment to assist providers with documenting compliance with the item descriptor.

Rationale

The recommendations focus on modernising and simplifying the MBS and are based on the following observations.

Δ The wording of the item descriptors should be changed to reflect modern medical terminology.

Δ Consolidating item numbers and making areas of treatment more intuitive (150 cm2 is the approximate average area of a hand) will increase ease of use for providers. It will also decrease unintentional mis-coding of more complex procedures and encourage appropriate billing of patients.

Δ Removing the wavelength requirement will allow CO2 lasers to be used, which are important for effectively treating a small number of conditions. The Committee felt that this change would not open the item number to intended or un-intended misuse.

Δ The Department informed the Committee that providers must produce evidence that they are compliant with the item descriptor, and that it is unlikely that this is occurring at the moment. The Committee recommended a simple solution: require providers to capture photographic evidence, as cameras are available and used by most providers (especially to highlight to patients the impact of their treatment).

5.6.3        Item 14124

Recommendations

Δ Change the wording in the item descriptor, replacing “haemangiomas of infancy” with “infantile haemangiomas.”

Δ Monitor non-specialist providers to ensure that the item is being used properly.

Δ Include a requirement for all laser equipment to be TGA-listed.

Δ Include a requirement for photo evidence to be captured during treatment to assist providers with documenting compliance with the item descriptor.

Rationale

The recommendations focus on patient care and modernising the MBS. They are based on the following observations.

Δ The wording of the item descriptors should be changed to reflect modern medical terminology.

Δ The Committee noted that paediatric dermatologists should be the primary users of this item, but that GPs who bill this item currently account for 69 per cent of usage volumes.[12]

Δ The Department informed the Committee that providers must produce evidence that they are compliant with the item descriptor, and that it is unlikely that this is occurring at the moment. The Committee recommended a simple solution: require providers to capture photographic evidence, as cameras are available and used by most providers (especially to highlight to patients the impact of their treatment).

5.7        Mohs: Items 31000–31002

Table 9: Item introduction table for items 31000–2

Item

Descriptor

[date last amended]

Schedule

fee

Services FY2014/15

Benefits FY2014/15

Services 5-year annual avg. growth

31000

Micrographically controlled serial excision of skin tumour utilising horizontal frozen sections with mapping of all excised tissue, and histological examination of all excised tissue by the specialist performing the procedure – 6 or fewer sections. [1995]

580.90

9,076

$3,872,553

8.00%

31001

7 to 12 sections (inclusive). [1995]

726.05

3,110

$1,716,609

8.90%

31002

13 or more sections. [1995]

871.30

452

$306,793

5.20%

Some descriptors have been shortened; see Appendix A for complete descriptors.

Recommendations

Δ Change the item descriptor to recognise the term “Mohs surgery.” This term would replace “Micrographically controlled serial excision” and would appear at the beginning of the item descriptor.

Δ Change the item descriptor to include provider restrictions. Providers must be certified under the Australasian College of Dermatologists (ACD) or have an equivalent qualification accepted by the college.

Δ Split each Mohs item into two separate items:

 Area A: Head, neck, genitalia, hand, digits, leg (below knee) and foot.

 Area B: All other areas (e.g., areas not included in Area A).

Δ Add the following explanatory notes: “Services under Area A items should make up at least 90% of a Mohs surgeon’s caseload of category A and B items annually.” (Explanatory notes are not currently provided for these items.)

Δ Monitor providers who bill a relatively high number of services within Area B.

Rationale

The recommendations focus on ensuring patient safety and appropriate use of the items. They are based on the following observations.

Δ Mohs surgery is complex, and providers require a sufficient level of training and certification to ensure patient safety and procedural quality. However, there is no current requirement for this in the MBS. Furthermore, 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 ACD has a register of certified Mohs surgeons who have undergone specific ACD-approved training, or whose skills have been recognised by the ACD. A process to certify doctors currently performing or intending to perform Mohs could be used as a means to assure service quality. It is recognised that equivalently qualified doctors from overseas should also be allowed to perform Mohs. Equivalent qualifications could be assessed and recognised by the ACD.

Δ Clinical experience and guidelines[36] indicate that the majority of Mohs surgery (approximately 90 per cent) should be conducted on Area A. Creating two separate item numbers will encourage more appropriate use of these items and facilitate monitoring and potential auditing of providers who bill relatively high amounts of services under Area B.

Δ The term “Mohs surgery” reflects the most up-to-date medical terminology and removes any potential misinterpretation of what procedure is included under these items.

5.8        Telangiectases or starburst vessels: Items 30213 and 30214

Table 10: Item introduction table for items 30213–4

Item

Descriptor

[date last amended]

Schedule

fee

Services FY2014/15

Benefits FY2014/15

Services 5-year annual avg. growth

30213

Telangiectases or starburst vessels on the head or neck where lesions are visible from 4 metres, diathermy or sclerosant injection of, including associated consultation – limited to a maximum of 6 sessions (including any sessions to which items 14100 to 14118 and 30213 apply) in any 12 month period – for a session of at least 20 minutes duration. [1996]

$109.80

3,888

$517,478

-3.60%

30214

Telangiectases or starburst vessels on the head or neck where lesions are visible from 4 metres, diathermy or sclerosant injection of, including associated consultation – session of at least 20 minutes duration – where it can be demonstrated that a 7th or subsequent session (including any sessions to which items 14100 to 14118 and 30213 apply) is indicated in a 12 month period. [1997]

$109.8

0

$0

N/A

Recommendation

Δ Delete both items from the MBS.

Rationale

The recommendation focuses on encouraging best practice and optimal patient care. It is based on the following observations.

Δ The position of the Committee is that these items are obsolete, do not reflect best practice and should be removed from the MBS. Necessary treatment can be provided under laser item 14100. MBS data demonstrates that services are not being provided under item 30214, which has only ever been billed once.[2]

Δ The Committee’s only reservation about deleting item 30213 was the potential impact on patient access. However, MBS data revealed that there are limited rural access concerns: less than six services were provided in remote and very remote areas of Australia in FY2014/15, and laser treatment is sufficiently available as an alternative for rural patients.[12]

5.9        Treatment of pre-malignant skin lesions: Item 30192

Table 11: Item introduction table for item 30192

Item

Descriptor

[date last amended]

Schedule

fee

Services FY2014/15

Benefits FY2014/15

Services 5-year annual avg. growth

30192

Premalignant skin lesions (including solar keratoses), treatment of, by ablative technique (10 or more lesions). [2003]

$39.55

690,879

$21,388,250

3.20%

Recommendation

Δ Leave this item unchanged.

Rationale

Δ The position of the Committee is that this treatment is still required, and that the significant service volume is likely to be appropriate given the incidence of skin cancer in Australia.[37]

Δ The Committee considered recommending topical and field therapies in the explanatory notes as they are increasingly becoming available and often provide better treatment. [38]However they noted that such therapies are not currently listed on the PBS and require a submission that is approved through the Pharmaceutical Benefits Advisory Committee (PBAC) process. Furthermore a large education campaign would be required to inform doctors of these new treatments. Therefore they decided not to include such explanatory notes.

5.10    Skin lesions, multiple injections of hydrocortisone or similar preparations: Items 30207 and 30210

Table 12: Item introduction table for items 30207 and 30210

Item

Descriptor

[date last amended]

Schedule

fee

Services FY2014/15

Benefits FY2014/15

Services 5-year annual avg. growth

30207

Skin lesions, multiple injections with hydrocortisone or similar preparations. [1991]

$44.60

36,620

$1,602,971

6.00%

30210

Keloid and other skin lesions, extensive, multiple injections of hydrocortisone or similar preparations where undertaken in the operating theatre of a hospital. (Anaes.) [1991]

$162.95

740

$70,127

-3.30%

Recommendations

Δ Change the item descriptor for item 30210 to restrict use to patients of less than 16 years of age. Older patients can be treated using item 30207.

Δ Change the wording in both item descriptors, replacing “hydrocortisone or similar preparations” with “glucocorticoid preparations.”

Rationale

The recommendations focus on ensuring optimal patient care and are based on the following observations.

Δ Although these are painful procedures, the Committee believes that it is not necessary to conduct these injections on adults or older teenagers in an operating theatre, as per item 30210. There are circumstances in which patients under the age of 16 may find the injections into keloids too painful to be conducted without general anaesthetic delivered in an operating theatre, but MBS data indicates that the majority of patients who receive these injections in an operating theatre are adults or older teenagers. In FY2014/15, for example, 91 per cent of patients treated under item 30210 were aged 15 or over.[10] It therefore seems reasonable to restrict use of item 30210 to patients for whom it is most appropriate. All other patients should be treated under item 30207.

Δ The wording in the item descriptors should be changed to remove any ambiguity regarding similar preparations for hydrocortisone injections and ensure appropriate use of the item. Hydrocortisone will now be captured in the term “glucocorticoid.”

5.11    Superficial radiotherapy: Item 15000

While reviewing this item number, the Committee was contacted by the Radiation Oncology Working Group of the Oncology Clinical Committee to discuss whether it would be appropriate to consolidate the orthovoltage radiotherapy items (items 15100–15115) into the superficial radiotherapy items (items 15000–15009). Comments regarding this are presented in the recommendation below.

Table 13: Item introduction table for item 15000

Item

Descriptor

[date last amended]

Schedule

fee

Services FY2014/15

Benefits FY2014/15

Services 5-year annual avg. growth

15000

(Benefits for administration of general anaesthetic for radiotherapy are payable under Group T10) Radiotherapy, superficial (including treatment with xrays, radium rays or other radioactive substances), not being a service to which another item in this Group applies each attendance at which fractionated treatment is given – 1 field. [1991]

$42.55

22,738

$892,102

9.80%

Recommendation

Δ Consolidate orthovoltage radiotherapy items (items 15100–15115) into the superficial radiotherapy items (items 15000–15009), as recommended by the Radiation Oncology Working Group. This recommendation is not yet final, and the complete recommendation will be finalised and presented for consultation by the Oncology Clinical Committee.

Rationale

Δ The position of the Committee is that this is still a required and clinically relevant treatment. However, in principle, the Committee has no issues with consolidating the items to simplify the MBS. The Committee assumes that this change will be cost neutral for consumers, ensuring no adverse impact on patient access.

5.12    Administration of immunomodulating agent: Item 14245

Table 14: Item introduction table for item 14245

Item

Descriptor

[date last amended]

Schedule

fee

Services FY2014/15

Benefits FY2014/15

Services 5-year annual avg. growth

14245

Immunomodulating agent, administration of, by intravenous infusion for at least 2 hours duration – payable once only on the same day and where the agent is provided under section 100 of the Pharmaceutical Benefits Scheme. [2007]

$97.95

17,397

$1,389,263

19.90%

Recommendation

Δ Leave this item unchanged.

Rationale

Δ The position of the Committee is that this is a required and clinically relevant treatment and no change is necessary.

Δ The Committee initially identified two potential issues of concern: high growth in use (approximately 20 per cent per year, on average, over the last five years)[2]; and inter-state variation in use (for example, Tasmania provided 300 more services per capita (per 100,000) than the average).[12] However, it ultimately agreed that these are not substantial issues and do not warrant any change, particularly as they are likely to be driven by recent changes to the PBS (this item is largely driven by PBS utilisation) and different billing practices across states.

5.13    Bone or cartilage excision: Item 31340

Table 15: Item introduction table for item 31340

Item

Descriptor

[date last amended]

Schedule

fee

Services FY2014/15

Benefits FY2014/15

Services 5-year annual avg. growth

31340

Note: Multiple Operation and Multiple Anaesthetic rules apply to this item.

 

Muscle, bone or cartilage, excision of one or more of, where clinically indicated, where the specimen excised is sent for histological confirmation, performed in association with excision of malignant tumour of skin covered by item 31255, 31256, 31257, 31258, 31260, 31261, 31262, 31263, 31265, 31266, 31267, 31268, 31270, 31271, 31272, 31273, 31275, 31276, 31277, 31278, 31280, 31281, 31282, 31283, 31285, 31286, 31287, 31288, 31290, 31291, 31292, 31293, 31295, 31300, 31305, 31310, 31315, 31320, 31325, 31330 or 31335. (Anaes.) [2005]

75% of fee for excision of malignant tumour

8,511

$541,837

6.30%

Recommendation

Δ Leave this item unchanged.

 

Rationale

Δ The position of the Committee is that this is a required and clinically relevant treatment. No further changes need to be made beyond those already planned, which are outside the scope of the Committee.

5.14    Laser excision of face or neck tumours: Item 30190

Table 16: Item introduction table for item 30190

Item

Descriptor

[date last amended]

Schedule

fee

Services FY2014/15

Benefits FY2014/15

Services 5-year annual avg. growth

30190

Angiofibromas, trichoepitheliomas or other severely disfiguring tumours suitable for laser excision as confirmed by specialist opinion, of the face or neck, removal of, by carbon dioxide laser or erbium laser excision-ablation including associated resurfacing (10 or more tumours). [2001]

$397.75

617

$237,181

-5.30%

Recommendation

Δ Change the item descriptor to exclude common lesions that are not severely disfiguring tumours, including melanocytic naevi, sebaceous hyperplasia, dermatosis papulosa nigra, Campbell De Morgan angiomas and seborrheic or viral warts. The proposed item descriptor is as follows:

 Angiofibromas, trichoepitheliomas or other severely disfiguring tumours excluding melanocytic naevi, sebaceous hyperplasia, dermatosis papulosa nigra, Campbell De Morgan angiomas and seborrheic or viral warts, suitable for laser ablation as confirmed by AMC recognised dermatologist opinion, of the face or neck, removal of, by carbon dioxide laser or erbium laser ablation including associated resurfacing (10 or more tumours).

Δ Add an item number (e.g., 3019-X) for removing less than 10 tumours, including lesions that were previously (and appropriately) billed under item 30195, which is recommended for deletion. These include: epidermal naevi, xanthelasma, pyogenic granuloma, genital angiokeratomas, hereditary haemorrhagic telangiectasia and other severely disfiguring or recurrently bleeding tumours. Change the treatment methodology, adding: “other appropriate laser (or curettage and fine point diathermy for pyogenic granuloma only).” The proposed item descriptor for item 3019-X is as follows:

 Angiofibromas, trichoepithelioma, epidermal naevi, xanthelasma, pyogenic granuloma, genital angiokeratomas, hereditary haemorrhagic telangiectasia and other severely disfiguring or recurrently bleeding tumours, excluding melanocytic naevi, sebaceous hyperplasia, dermatosis papulosa nigra, Campbell De Morgan angiomas and seborrheic or viral warts. Confirmed by AMC recognised dermatologist opinion and treated with carbon dioxide/erbium, other appropriate laser (or curettage and fine point diathermy for pyogenic granuloma only). One or more lesions.

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

Δ Although pricing was not within the scope of the Committee, it advises that treatment under item 3019-X would have a similar scope of practice as item 14100, yet also acknowledges that these lesions were most likely treated under item 30195 in the past, and both of these schedule fees could be used as reference to determine the price.

Rationale

The recommendations focus on ensuring adequate patient access to treatment for rare conditions, as well as safeguarding against inappropriate leakage from the recommended deletion of other item numbers. They are based on the following observations.

Δ Although the volume of services has been declining by an average of 5.3 per cent per year for the last five years,[3] the Committee agreed that this is still a required and clinically relevant treatment. It is likely that the reduction in volume is explained by the introduction of new topical drugs, which the Committee agreed are not appropriate for a small group of patients.

Δ The Committee acknowledged that the recommended deletion of item 30195 could shift inappropriate billing of common lesions to item 30190. Although the Committee does not believe that there will be a large volume shift to item 30190, it amended the item descriptor to address this risk, specifically excluding melanocytic naevi, sebaceous hyperplasia, dermatosis papulosa nigra, Campbell De Morgan angiomas and seborrheic or viral warts.

Δ The recommended deletion of item 30195 could result in access problems for patients who require the removal of a small number of rare conditions. These conditions were previously (and appropriately) billed under item 30195 and include: epidermal naevi, xanthelasma, pyogenic granuloma, genital angiokeratomas, hereditary haemorrhagic telangiectasia and other severely disfiguring or recurrently bleeding tumours. The Committee felt that the best course of action was to create a new item (e.g., 3019-X) that will allow for appropriate treatment of these conditions. Again, the Committee does not anticipate a large volume shift to this item, but it applied the exclusions listed for item 30190 to safeguard against this. This item will also permit several additional treatment methods to reflect modern treatment of these conditions.

Δ The Committee was also concerned to learn that certain GPs who specialise in skin lesions are classifying themselves as specialists. The Committee decided to address this issue by changing this wording to “AMC recognised dermatologist.”

5.15    Laser resurfacing for face or neck: Items 45025 and 45026

Table 17: Item introduction table for items 45025–6

Item

Descriptor

[date last amended]

Schedule

fee

Services FY2014/15

Benefits FY2014/15

Services 5-year annual avg. growth

45025

Carbon dioxide laser or erbium laser (not including fractional laser therapy) resurfacing of the face or neck for severely disfiguring scarring resulting from trauma, burns or acne – limited to 1 aesthetic area. (Anaes.) [2007]

$177.35

1,242

$197,064

29.0%

45026

Carbon dioxide laser or erbium laser (not including fractional laser therapy) resurfacing of the face or neck for severely disfiguring scarring resulting from trauma, burns or acne – more than 1 aesthetic area. (Anaes.) [2007]

$398.55

1,656

$655,439

16.0%

Recommendations

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

Δ Add the words “non-ablative” to the bracketed part of the item descriptor. For example, (“excluding non-ablative fractional laser therapy”).

Rationale

The recommendations focus on improving patient care and safety. They are based on the following observation.

Δ Evidence indicates that equivalent results can be obtained using fractionated lasers, and that using fractionated laser systems may improve the safety of this procedure.[39-40]

5.16    Vermilionectomy using laser: Item 45669

Table 18: Item introduction table for item 45669

Item

Descriptor

[date last amended]

Schedule

fee

Services FY2014/15

Benefits FY2014/15

Services 5-year annual avg. growth

45669

Vermilionectomy, using carbon dioxide laser or erbium laser excision-ablation. (Anaes.) [2001]

$326.05

508

$144,386

4.3%

Recommendation

Δ Require biopsy proof in the item descriptor. The proposed descriptor is as follows: “Vermilionectomy for biopsy confirmed cellular atypia, using carbon dioxide laser or erbium laser excision-ablation. (Anaes.)”

Rationale

The recommendation focuses on encouraging best practice and is based on the following observation.

Δ Adding the biopsy confirmation requirement ensures best-practice use of the item and avoids potential misuse of this procedure in the future.

5.17    Treatment of rhinophyma using laser: Item 45652

Table 19: Item introduction table for item 45652

Item

Descriptor

[date last amended]

Schedule

fee

Services FY2014/15

Benefits FY2014/15

Services 5-year annual avg. growth

45652

Rhinophyma, carbon dioxide laser or erbium laser excision-ablation of. (Anaes.) [2001]

$356.35

259

$87,293

15.5%

Recommendation

Δ Add the phrase “Rhinophyma of a moderate or severe degree” to the descriptor.

Δ Include a requirement for photo evidence to be captured during treatment to assist providers with documenting compliance with the item descriptor.

Rationale

The recommendation focuses on encouraging best practice and is based on the following observations.

Δ Amending the descriptor to specify moderate or severe rhinophyma will ensure that this item is used to treat the appropriate thickening associated with rhinophyma.

Δ The Department informed the Committee that providers must produce evidence that they are compliant with the item descriptor, and that it is unlikely that this is occurring at the moment. The Committee recommended a simple solution: require providers to capture photographic evidence, as cameras are available and used by most providers (especially to highlight to patients the impact of their treatment).

5.18    Full-face chemical peel: Item 45019

Table 20: Item introduction table for item 45019

Item

Descriptor

[date last amended]

Schedule

fee

Services FY2014/15

Benefits FY2014/15

Services 5-year annual avg. growth

45019

Full face chemical peel for severely sun-damaged skin, where it can be demonstrated that the damage affects 75% of the facial skin surface area involving photodamage (dermatoheliosis) typically consisting of solar keratoses, solar lentigines, freckling, yellowing and leathering of the skin, where at least medium depth peeling agents are used, performed in the operating theatre of a hospital by a specialist in the practice of his or her specialty – 1 session only in a 12 month period. (Anaes.) [1997]

$396.70

14

$4,166

-7.8%

Recommendation

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

Δ Change the indication in the item descriptor to read: “Solar Keratoses not responsive to medical therapies, where the solar Keratosis Load exceeds 30 individual lesions.”

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

Rationale

This recommendation focuses on modernising the MBS to reflect current best-practice standards of care.

Δ The recommendations modernise the MBS to reflect current best-practice standards of care in treating multiple areas of facial dysplasia (solar keratoses) that have resisted previous therapies. This change will also modify the indication for this procedure to treat cellular dysplasia/precancerous changes.[41]

Δ The Committee was concerned to learn that certain GPs who specialise in skin are classifying themselves as specialists and data suggests they were utilising the MBS in this manner. The Committee decided to address this issue by changing the word “specialist” to “AMC recognised dermatologist and plastic surgeon.”