GP Guide to Medicare

55808 – Shoulder Ultrasound

• Evaluation of injury to tendon, muscle or muscle / tendon junction.
• Rotator cuff tear / calcification / tendinosis (biceps, subscapular, suspraspinatus, infraspinatus)
• Biceps subluxation; or
• Capsulitis and bursitis
• Evaluation of mass including ganglion
• Occult fracture
• Acromioclavicular joint pathology

55828 – Knee Ultrasound

• Abnormality of tendons or bursae about the knee
• Meniscal cyst, popliteal fossa cyst, mass or pseudomass
• Nerve entrapment, nerve or nerve sheath tumour
  Injury of collateral ligaments

Benefits are not payable when referred for non-specific knee pain alone or other knee conditions including:

• Meniscal and cruciate ligament tears
• Assessment of chondral surfaces

56553 – for exclusion or diagnosis of colorectal neoplasia in a symptomatic or high risk patient if:

1. one [or more] of the following applies:
   
   • the patient has had an incomplete colonoscopy in the 3 months before the scan;
   • there is a high-grade colonic obstruction;
   • the patient is referred by a specialist or consultant physician who performs colonoscopies [in the practice
     of his or her speciality]; and
2. the service is not a service to which item 56301, 56307, 56401, 56407, 56409, 56412, 56501, 56507, 56801,56807 or 57001 applies; and
3. the service has not been performed on the patient in the 36 months before the scan

CT Coronary Arteries
57360 – performed on a minimum of a 64 slice (or equivalent) scanner, where the request is made by a specialist or consultant physician and

1. the patient has stable symptoms consistent with coronary ischaemia, is at low to intermediate risk of coronary artery disease and would have been considered for coronary angiography; or
2. the patient requires exclusion of coronary artery anomaly or fistula; or
3. the patient will be undergoing non-coronary cardiac surgery

CT Spiral Angiography
57350 – (1 in 12 months)

The service is performed for the exclusion of arterial stenosis, occlusion, aneurysm or embolism; and the service is not a study performed to image the coronary arteries

57351 – (1 in 12 months)

The service is performed for the exclusion of acute or recurrent pulmonary embolism; acute symptomatic arterial occlusion; post operative complication of arterial surgery; acute ruptured aneurysm; or acute dissection of the aorta, carotid or vertebral artery; and the service is not a study performed to image the coronary arteries, and the services to which item 57350 apply have been performed on the same patient within the previous 12 months

Adults (16 years or over)

BRAIN

• Unexplained seizure(s) (63551)
• Unexplained chronic headache with suspected intracranial pathology (63551)

CERVICAL SPINE

• Suspected trauma (63557)
• Suspected radiculopathy (63554)

KNEE (16-49 years of age)

• following acute trauma
• inability to extend knee suggesting acute meniscal tear
• clinical findings suggesting suspected acute anterior cruciate ligament tear.

Children (under 16 years of age)

BRAIN

• Unexplained seizure(s)
• unexplained headaches, significant pathology suspected
• paranasal sinus disease not responding to treatment.

SPINE*

• Significant trauma
• unexplained neck/back pain with associated neurological symptoms
• unexplained back pain, significant pathology suspected

ELBOW*

• Significant fractures +/- avulsion injury suspected

WRIST*

• Suspected scaphoid fractures

HIP*

• Suspected septic arthritis
• suspected slipped capital femoral epiphysis
• suspected perthes disease

KNEE

• Internal joint derangement

* to be eligible for a Medicare rebate the patient must have a x-ray first *

61523 – Lung – Solitary Pulmonary Nodule

Whole body FDG PET study, performed for evaluation of a solitary pulmonary nodule where the lesion is considered unsuitable for transthoracic fine needle aspiration biopsy, or for which an attempt at pathological characterisation has failed.

61524 – Breast Cancer – Staging of locally advanced (Stage III) disease

Whole body FDG PET study, performed for the staging of locally advanced (Stage III) breast cancer, for a patient who is considered suitable for active therapy

61525 – Breast Cancer – Suspected metastasis or local/regional recurrence

Whole body FDG PET study, performed for the evaluation of suspected metastatic or suspected locally or regionally recurrent breast carcinoma, for a patient who is considered suitable for active therapy

61529 – Non Small Cell Lung Carcinoma

Whole body FDG PET study, performed for the staging of proven non-small cell lung cancer, where curative surgery or radiotherapy is planned.

61538 – Malignant Brain Tumour

FDG PET study of the brain for evaluation of suspected residual or recurrent malignant brain tumour based on anatomical imaging findings, after definitive therapy (or during ongoing chemotherapy) in patients who are considered suitable for further active therapy.

61541 – Colorectal Carcinoma – Restaging

Whole body FDG PET study, following initial therapy, for the evaluation of suspected residual, metastatic or recurrent colorectal carcinoma in patients considered suitable for active therapy.

61553 – Melanoma

Whole body FDG PET study, following initial therapy, performed for the evaluation of suspected metastatic or recurrent malignant melanoma in patients considered suitable for active therapy.

61559 – Epilepsy

FDG PET study of the brain, performed for the evaluation of refractory epilepsy which is being evaluated for surgery.

61565 – Ovarian Carcinoma – Restaging

Whole body FDG PET study, following initial therapy, performed for the evaluation of suspected residual, metastatic or recurrent ovarian carcinoma in patients considered suitable for active therapy.

61571 – Carcinoma Uterine Cervix – Staging

Whole body FDG PET study, for the further primary staging of patients with histologically proven carcinoma of the uterine cervix, at FIGO stage IB2 or greater by conventional staging, prior to planned radical radiation therapy or combined modality therapy with curative intent.

61575 – Carcinoma Uterine Cervix – Restaging

Whole body FDG PET study, for the further staging of patients with confirmed local recurrence of carcinoma of the uterine cervix considered suitable for salvage pelvic chemoradiotherapy or pelvic exenteration with curative intent.

61598 – Head and Neck Cancer – Staging

Whole body FDG PET study performed for the staging of biopsy-proven newly diagnosed or recurrent head and neck cancer.

61604 – Head and Neck Cancer (Residual) – Restaging

Whole body FDG PET study performed for the evaluation of patients with suspected residual head and neck cancer after definitive treatment, and who are suitable for active therapy.

61610 – Metastatic SCC Cervical Lymph Nodes – Unknown Primary

Whole body FDG PET study performed for the evaluation of metastatic squamous cell carcinoma of unknown primary site involving cervical nodes.

61620 – Lymphoma – Initial Staging

Whole body FDG PET study for the initial staging of newly diagnosed or previously untreated Hodgkin’s or non-Hodgkin’s lymphoma.

61622 – Lymphoma – Therapy Response

Whole body FDG PET study to assess response to first line therapy either during treatment or within three months of completing definitive first line treatment for Hodgkin’s or non-Hodgkin’s lymphoma.

61628 – Lymphoma – Restaging

Whole body FDG PET study for restaging following confirmation of recurrence of Hodgkin’s or non-Hodgkin’s lymphoma.

61632 – Lymphoma – Post Second Line Chemotherapy

Whole body FDG PET study to assess response to second-line chemotherapy when stem cell transplantation is being considered for Hodgkin’s or non-Hodgkin’s lymphoma.

61640 – Bone or Soft Tissue Sarcoma – Staging

Whole body FDG PET study for initial staging of patients with biopsy-proven bone or soft tissue sarcoma (excluding gastrointestinal stromal tumour) considered by conventional staging to be potentially curable.

61646 – Residual or Recurrent Sarcoma – Restaging

Whole body FDG PET study for the evaluation of patients with suspected residual or recurrent sarcoma (excluding gastrointestinal stromal tumour) after the initial course of definitive therapy to determine suitability for subsequent therapy with curative intent.

59303 – Single breast only
Where there is reason to suspect the presence of malignancy because of:

1. the past occurrence of breast malignancy in the patient or members of the patient’s family; or
2. symptoms or indications of malignancy found on an examination of the patient by a medical practitioner.

Symptoms or indications of malignancy include: localised mass, localised lumps, localised pain, localised tenderness. For previous history of malignancy in patient or family member please provide relevant history. The following criteria will NOT attract a Medicare rebate: screening, cyst, generalised tenderness or pain, previous benign lump, lumpy breasts, non-specific follow up, or no clinical indication. It is helpful to include any relevant clinical information such as past history of breast surgery, breast reduction or augmentation and specific information relating to the area of interest, including the side, size and location within the breast.

59300 – Unless otherwise stated both breasts
Where there is a reason to suspect the presence of malignancy because of:

1. the past occurrence of breast malignancy in the patient or members of the patient’s family (blood relative); or
2. symptoms or indications of malignancy found on an examination of the patient by a medical practitioner

Symptoms or indications of malignancy include: localised mass, localised lumps, localised pain, localised tenderness. For previous history of malignancy in patient or family member please provide relevant history. The following criteria will NOT attract a Medicare rebate: screening, cyst, generalised tenderness or pain, previous benign lump, lumpy breasts, non-specific follow up, or no clinical indication. It is helpful to include any relevant clinical information such as past history of breast surgery, breast reduction or augmentation and specific information relating to the area of interest, including the side, size and location within the breast.

59305 – Mammogram + Tomosynthesis unilateral

Three dimensional tomosynthesis of one breast, if there is reason to suspect the presence of malignancy because of:

a)      the past occurrence of breast malignancy in the patient; or

b)      significant history of breast or ovarian malignancy in the patient’s family; or

c)      symptoms or indications of breast disease found on examination of the patient by a medical practitioner

Not being a service to which item 59303 applies (R)

59302 – Mammogram + Tomosynthesis Bilateral

Three dimensional tomosynthesis of both breasts, if there is reason to suspect the presence of malignancy because of:

a)      the past occurrence of breast malignancy in the patient; or

b)      significant history of breast or ovarian malignancy in the patient’s family; or

c)      symptoms or indications of breast disease found on examination of the patient by a medical practitioner

Not being a service to which item 59300 applies (R)

31536 – Hook wire – Unilateral

Radiographic examination of excised breast tissue to confirm satisfactory excision of one or more lesions in one breast or both following pre-operative localisation in conjunction with a service under item (R)

31536 – Hook wire – Bilateral

Breast, preoperative localisation of lesion of, by hookwire or similar device, using interventional imaging techniques, but not including imaging (Anaes.)

31548 – Biopsy – unilateral

Breast, biopsy of solid tumour or tissue of, using mechanical biopsy device, for histological examination, other than a service associated with a service to which item 31530 applies (Anaes.)

31548 – Biopsy – Unilateral

Breast, biopsy of solid tumour or tissue of, using mechanical biopsy device, for histological examination, other than a service associated with a service to which item 31530 applies (Anaes.)

Medicare guidelines around Bone Densitometry (DEXA scans) are quite strict and must meet the relevant criteria to obtain a rebate. This also includes timeframe of examinations. 

12306 – (1 service only in a period of 24 consecutive months)

The confirmation of a presumptive diagnosis of low bone mineral density made on the basis of;
1 or more fractures occurring after minimal trauma; or
for the monitoring of low bone mineral density proven by bone densitometry at least 12 months previously

12312 – (1 service only in a period of 12 consecutive months)

• prolonged glucocorticoid therapy;
• conditions associated with excess glucocorticoid secretion;
• male hypogonadism; or
• female hypogonadism lasting more than 6 months before the age of 45.

12315 – (1 service only in a period of 24 consecutive months)

For the diagnosis and monitoring of bone loss associated with 1 or more of the following conditions

• primary hyperparathyroidism;
• chronic liver disease;
• chronic renal disease;
• proven malabsorptive disorders;
• rheumatoid arthritis; or
• conditions associated with thyroxine excess.

12320 – (1 service only in a 5 year period)

For the measurement of bone mineral density, if:

• the patient is 70 years of age or over; and
• either:
  (i) the patient has not previously had bone densitometry; or
  (ii) the t score for the patient’s bone mineral density is -1.5 or more

12321 – (1 service only in a period of 12 consecutive months)

For the measurement of bone density 12 months following a significant change in therapy (change in class of drugs not just dose changes) for

• established low bone mineral density; or
• the confirmation of a presumptive diagnosis of low bone mineral density made on the basis of 1 or more fractures occurring after minimal trauma.

12322 – (1 service only in a 2 year period)

For the measurement of bone mineral density, if:

• the patient is 70 years of age or over; and
• the t score for the patient’s bone mineral density is less than -1.5 but more than -2.5

DEXA – for screening bone mineral density, which is not eligible for a Medicare rebate.

61485 – Adrenal Study

Repeat planar and single photon emission tomography imaging, or repeat planar imaging or single photon emission tomography imaging on an occasion subsequent to the performance of item 61364, 61426, 61429, 61430, 61442, 61450, 61453, 61469 or 61485, if there is no additional administration of radiopharmaceutical and if the previous radionuclide scan was abnormal or equivocal (R)

61446 – Bone Scan – Localised

Regional scintigraphic study, using an approved bone scanning agent, including when undertaken, blood flow imaging, blood pool imaging and repeat imaging on a separate occasion (R)

61449 – Bone San Localised + Spect

Regional scintigraphic study, using an approved bone scanning agent and single photon emission tomography, including when undertaken, blood flow imaging, blood pool imaging and repeat imaging on a separate occasion (R)

61450 – Localised + Gallium

Localised study using gallium (R)

61453 – Localised + Gallium + SPECT

Localised study using gallium, with single photon emission tomography (R)

61421 – Whole Body Bone Scan

Bone study—whole body, with, when undertaken, blood flow, blood pool and delayed imaging on a separate occasion (R)

61425 – Whole Body Bone Scan + Spect

Bone study—whole body and single photon emission tomography, with, when undertaken, blood flow, blood pool and delayed imaging on a separate occasion (R)

61429 – Whole Body + Gallium

Whole body study using gallium (R)

61430 – Whole Body + Gallium + Spect

Whole body study using gallium, with single photon emission tomography (R)

61402 – Cerebral Perfusion Study

Cerebral perfusion study, with single photon emission tomography and with planar imaging when performed (R)

61387 – DSMA

Renal cortical study, with single photon emission tomography and planar quantification (R)

61381 – Gastric Emptying Study

Gastric emptying study, using single tracer (R)

61361 – HIDA

Hepatobiliary study with formal quantification following baseline imaging, using a cholagogue (R)

61353 – Liver and Spleen Study

Liver and spleen study (colloid) (R)

61328 – Lung Perfusion

Lung perfusion study (R)

61469 –Lymphoscintogram

Lymphoscintigraphy (R)

61329 – Myocardial Perfusion Scan GP Referred

Note: the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: IR.4.1

Combined stress and rest, stress and re‑injection or rest and redistribution myocardial perfusion study, including delayed imaging or re‑injection protocol on a subsequent occasion, with single photon emission tomography, with or without planar imaging, if:

(a) the patient has symptoms of cardiac ischaemia; and

(b) at least one of the following applies:

(i) the patient has body habitus or other physical conditions (including heart rhythm disturbance) to the extent that a stress echocardiography would not provide adequate information;

(ii) the patient is unable to exercise to the extent required for a stress echocardiography to provide adequate information;

(iii) the patient has had a failed stress echocardiography provided in a service to which item 55141, 55143, 55145 or 55146 applies; and

(c) the service includes resting electrocardiograph, continuous electrocardiograph monitoring during exercise (with recording), blood pressure monitoring and the recording of other parameters (including heart rate); and

(d) the service is requested by a medical practitioner (other than a specialist or consultant physician); and

(e) the service is not associated with a service to which item 11704, 11705, 11707, 11714, 11729, 11730, 61321, 61324, 61325, 61345, 61357, 61394, 61398, 61406 or 61414 applies

Note: this item applies to a service provided to a patient who is 17 years or older not more than once each 24 months. (R)

61345 – Myocardial Perfusion Scan Spec Referred

Note: the service only applies if the patient meets the requirements of the descriptor and the requirements of Note: IR.4.1

Combined stress and rest, stress and re‑injection or rest and redistribution myocardial perfusion study, including delayed imaging or re‑injection protocol on a subsequent occasion, with single photon emission tomography, with or without planar imaging, if:

(a) the patient has symptoms of cardiac ischaemia; and

(b) at least one of the following applies:

(i) the patient has body habitus or other physical conditions (including heart rhythm disturbance) to the extent that a stress echocardiography would not provide adequate information;

(ii) the patient is unable to exercise to the extent required for a stress echocardiography to provide adequate information;

(iii) the patient has had a failed stress echocardiography provided in a service to which item 55141, 55143, 55145 or 55146 applies; and

(c) the service includes resting electrocardiograph, continuous electrocardiograph monitoring during exercise (with recording), blood pressure monitoring and the recording of other parameters (including heart rate); and

(d) the service is requested by a specialist or consultant physician; and

(e) the service is not associated with a service to which item 11704, 11705, 11707, 11714, 11729, 11730, 61321, 61324, 61325, 61329, 61357, 61394, 61398, 61406 or 61414 applies

Note: this item applies to a service provided to a patient who is 17 years or older not more than once each 24 months. (R)

61480 – Parathyroid

Parathyroid study (R)

61389 – Renogram + Captopril

Single renal study with pre-procedural administration of a diuretic or angiotensin converting enzyme (ACE) inhibitor (R)

61390 – Renogram + Lasix

Renal study with diuretic administration after a baseline study (R)

61473 – Thyroid

Thyroid study (R)

61348 – VQ

Lung perfusion study and lung ventilation study using aerosol, technegas or xenon gas (R)

59751 – Arthogram
Arthrography, each joint, excluding the facet (zygapophyseal) joints of the spine, single or double contrast study, with or without preliminary plain films and with preparation and contrast injection (R)

55700 – Dating Scan (Pregnancy < 12 weeks only)

Pelvis or abdomen, pregnancy related or pregnancy complication, ultrasound scan of, by any or all approaches, for determining the gestation, location, viability or number of foetuses, if the dating of the pregnancy (as confirmed by ultrasound) is less than 12 weeks of gestation 55707 – Nuchal translucency scan (Crown rump length of 45 to 84 mm) Pelvis or abdomen, pregnancy related or pregnancy complication, foetal development and anatomy, ultrasound scan of, by any or all approaches, if: (a) the pregnancy (as confirmed by ultrasound) is dated by a foetal crown rump length of 45 to 84 mm; and (b) nuchal translucency measurement is performed to assess the risk of foetal abnormality; and (c) the service is not performed with item 55700, 55703, 55704 or 55705 on the same patient within 24 hours

55704 – Early anatomy scan (Pregnancy  12 – 16 weeks only)

Pelvis or abdomen, pregnancy related or pregnancy complication, foetal development and anatomy, ultrasound scan of, by any or all approaches, for determining the structure, gestation, location, viability or number of foetuses, if the dating of the pregnancy (as confirmed by ultrasound) is 12 to 16 weeks of gestation

55706 – Anatomy scan (Pregnancy 17-22 weeks only. Item can only be claimed once per pregnancy.)

Pelvis or abdomen, pregnancy related or pregnancy complication, foetal development and anatomy, ultrasound scan of, by any or all approaches, with measurement of all parameters for dating purposes, if: (a) the dating for the pregnancy (as confirmed by ultrasound) is 17 to 22 weeks of gestation; and (b) the service is not performed in the same pregnancy as item 55709

55718 – (Pregnancy >22 weeks only)

Pelvis or abdomen, pregnancy related or pregnancy complication, foetal development and anatomy, ultrasound scan of, by any or all approaches, if:
(a) the dating of the pregnancy (as confirmed by ultrasound) is after 22 weeks of gestation; and
(b) the service is not performed in the same pregnancy as item 55723

55759 – Anatomy scan for multiple pregnancy (Pregnancy 17-22 weeks only)

Pelvis or abdomen, pregnancy related or pregnancy complication, foetal development and anatomy, ultrasound scan of, by any or all approaches, with measurement of all parameters for dating purposes, if:
(a) ultrasound of the same pregnancy confirms a multiple pregnancy; and
(b) the dating of the pregnancy (as confirmed by ultrasound) is 17 to 22 weeks gestation; and
(c) the service mentioned in item 55706, 55709, 55712, 55715 or 55762 is not performed in conjunction with the scan during the same pregnancy

55768 – Multiple Pregnancy (Pregnancy >22 weeks only)

Pelvis or abdomen, pregnancy related or pregnancy complication, foetal development and anatomy, ultrasound scan of, by any or all approaches, if:
(a) dating of the pregnancy (as confirmed by ultrasound) is after 22 weeks of gestation; and
(b) the ultrasound confirms a multiple pregnancy; and
(c) the service is not performed in the same pregnancy as item 55770; and
(d) the service mentioned in item 55718, 55721, 55723 or 55725 is not performed in conjunction with the scan during the same pregnancy

55712 – Anatomy Scan Specialist referral only (Pregnancy 17-22 weeks only)

Pelvis or abdomen, pregnancy related or pregnancy complication, foetal development and anatomy, ultrasound scan of, by any or all approaches, with measurement of all parameters for dating purposes, if:
(a) the service is requested by a medical practitioner who:
(i) is a Member or Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists; or
(ii) has a Diploma of Obstetrics; or
(iii) has a qualification recognised by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists as equivalent to a Diploma of Obstetrics; or
(iv) has obstetric privileges at a non-metropolitan hospital; and
(b) the dating of the pregnancy (as confirmed by ultrasound) is 17 to 22 weeks of gestation; and
(c) further examination is clinically indicated after performance, in the same pregnancy, of a scan mentioned in item 55706 or 55709

55721 – Specialist referral only (Pregnancy >22 weeks only)

Pelvis or abdomen, pregnancy related or pregnancy complication, foetal development and anatomy, ultrasound scan of, by any or all approaches, if:
(a) the service is requested by a medical practitioner who:
(i) is a Member or Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists; or
(ii) has a Diploma of Obstetrics; or
(iii) has a qualification recognised by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists as equivalent to a Diploma of Obstetrics; or
(iv) has obstetric privileges at a non-metropolitan hospital; and
(b) the dating of the pregnancy (as confirmed by ultrasound) is after 22 weeks of gestation; and
(d) further examination is clinically indicated in the same pregnancy to which item 55718 or 55723 applies (R)

55764 – Anatomy scan for multiple pregnancy Specialist referral only (Pregnancy 17-22 weeks only)

Pelvis or abdomen, pregnancy related or pregnancy complication, foetal development and anatomy, ultrasound scan of, by any or all approaches, with measurement of all parameters for dating purposes, if:
(a) the service is requested by a medical practitioner who:
(i) is a Member or Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists; or
(ii) has a Diploma of Obstetrics; or
(iii) has a qualification recognised by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists as equivalent to a Diploma of Obstetrics; or
(iv) has obstetric privileges at a non-metropolitan hospital; and
(b) ultrasound of the same pregnancy confirms a multiple pregnancy; and
(c) the dating of the pregnancy (as confirmed by ultrasound) is 17 to 22 weeks gestation; and
(d) further examination is clinically indicated in the same pregnancy in which item 55759 or 55762 has been performed; and
(e) the service mentioned in item 55706, 55709, 55712 or 55715 is not performed in conjunction with the scan during the same pregnancy (R)

55772 – Specialist referral only (Pregnancy >22 weeks only)

Pelvis or abdomen, pregnancy related or pregnancy complication, foetal development and anatomy, ultrasound scan of, by any or all approaches, if:
(a) dating of the pregnancy as confirmed by ultrasound is after 22 weeks of gestation; and
(b) the service is requested by a medical practitioner who:
(i) is a Member or Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists; or
(ii) has a Diploma of Obstetrics; or
(iii) has a qualification recognised by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists as equivalent to a Diploma of Obstetrics; or
(iv) has obstetric privileges at a non-metropolitan hospital; and
(c) further examination is clinically indicated in the same pregnancy to which item 55768 or 55770 has been performed; and
(d) the pregnancy as confirmed by ultrasound is a multiple pregnancy; and
(e) the service mentioned in item 55718, 55721, 55723 or 55725 is not performed in conjunction with the scan during the same pregnancy