Health
textual image stating 'Department of Health, Victoria, Australia'

Hospital Circular 20/1998

Date Issued: 10 December, 1998
Publication: 20/1998
Contact: Regional Office
Distribution: Public Hospitals
Subject: MRI funding arrangements - update

1. Update

Circular 14/98 noted arrangements for the listing of MRI on the MBS effective 1 September, pending Commonwealth clarification of some funding issues. The Commonwealth:

2. Background

New MRI funding arrangements were developed in response to the recommendations of the Australian Health Technology Advisory Committee’s (AHTACs) "Review of Magnetic Resonance Imaging".

Under the previous Health Program Grant a limited number of public hospital MRI sites received some Commonwealth/State funding. This arrangement (including a one month transitional arrangement period) ceased effective 1 October 1998.

3. New MRI Funding Arrangements

New MBS arrangements for funding of MRI came into effect from 1 September 1998, at which time Medicare Benefits were introduced for a range of nominated MRI services. The new arrangements apply to MRI services requested by a specialist or consultant physician or oral and maxillofacial surgeon on or after 1 September 1997.

The new MRI/MBS arrangements apply to private admitted patients and public and private non-admitted patients (eligibility conditions apply). States remain responsible for ensuring that, where MRI services are provided to public admitted patients, these services are provided free of charge. The State will continue to fund MRI services to public inpatients via casepayments. It is recognised that a small number of recent and emerging clinical uses of MRI may not yet be adequately reimbursed in case payments. Providers in public hospitals can apply for funding for these scans though the annual New Technologies / Clinical Practices funding program. The contact person is Mr Andrew Crettenden, Service Development, Acute Health, Victorian Department of Human Services, 16 Floor, 555 Collins St, Melbourne, Victoria 3000, or Phone (03) 9616 7615, or Fax (03) 9616 8980 or E-Mail andrew.crettenden@dhs.vic.gov.au

Additionally, the conditions associated with the new MBS/MRI arrangement apply equally to both the public and private sectors.

Queries about the MBS funding arrangements can be directed to Ms Siepie Larkin, Diagnostic Imaging Section, Diagnostic and Technology Branch, Commonwealth Department of Health and Aged Care, Phone (02) 6289 7143, or Mr Andrew Crettenden, Service Development, Acute Health, Victorian Department of Human Services on Ph: (03) 9616 7615.

4. Requirements associated with new MRI arrangements

There are a range of specific requirements associated with the new MRI arrangements including referrals; and eligibility requirements in relation to providers, equipment and services. These and related matters are detailed in the Medicare Benefits Schedule book 1 November 1998 (as may be amended from time to time). Hospitals are required to note the attached important excerpt from the MBS book; and to refer to the book for other important details including Category 5 - Diagnostic Imaging Services - Outline of Arrangements, and schedule of MRI services eligible for MBS payment.

The Commonwealth advises that a Statutory Declaration to the HIC is required from providers wishing to be listed as eligible for the purposes of providing MRI services under the MBS. For assistance of eligible providers, a sample Statutory Declaration form is attached. The HIC may also request additional documents and further information to support statements made in the Statutory Declaration.

If a provider renders MRI services at more than one location, a separate declaration must be submitted in respect of each MRI machine. The Statutory Declaration may be submitted in advance of an anticipated date of installation. However a copy of the contract and written confirmation of installation will be required prior to commencement of payment of Medicare benefits for services rendered on that machine. Providers who might have indicated an intention to apply for Medicare benefits for MRI but do not feel they meet the above eligibility requirements are not under any obligation to proceed with an application.

Providers should be aware that a false Statutory Declaration can attract penalties of up to four years imprisonment. Additionally, there are penalties under the Health Insurance Act for making false statements in relation to Medicare benefits. Provider eligibility Statutory Declarations should be returned to Provider Liaison Section, Health Insurance Commission, PO Box 9822, MELBOURNE. Phone: 132150 for enquiries. The Statutory Declaration can be faxed to the HIC but will need to be followed up with the original. The fax number is (03) 9284 3727. For installed equipment, the required Statutory Declaration should have been returned no later than 1 October 1998 to enable benefits to be claimed for services rendered from 1 September 1998.

The MBS Book 1 November 1998 is available in book or disk format. Copies are available for purchase by non-medical and commercial users, from the Government Information Shop, 190 Queens St, Melbourne, 3000, Ph 96704224, fax: 96704115. A copy of the book or disk is $24.95 each, or $40.00 for both the book and disk. To be placed on a standing order to be notified of updates, you can place a request in writing to AusInfo (previously the Australian Government Publishing Service) fax (02) 62954888, or mail GPO Box 84, CANBERRA, ACT 2601.For further information ring AusInfo on Ph:132447.

5. Fees

The Commonwealth has advised that under the new Medicare benefits arrangements the schedule fee for an MRI is $475 (as may be amended from time to time). The schedule fee applies to services provided by both public and private MRI units. It contains a component towards capital costs.

6. Research funding applications

The Commonwealth advises that over the past year, a general program has been operating for research into Diagnostic Imaging and related issued. Under this program, some funding will be provided for more targeted research that will focus on the clinical role and value of MRI. The contact is Ms Siepie Larkin, Diagnostic Imaging Section, Diagnostic and Technology Branch, Commonwealth Department of Health and Aged Care, Phone (02) 6289 7143.

7. New Clinical Application of MRI for MBS listing

New clinical application of MRI beyond those currently rebateable under the MBS will require assessment of the evidence under the Commonwealth’s new Medical Services Advisory Committee (MSAC) arrangements prior to any consideration of listing on the MBS. To contact the MSAC, write to the Secretary, Medicare Services Advisory Committee, MDP 107, GPO Box 9848, Canberra ACT 2601, or Phone (02) 6289 4488 or Fax 61-2-62898 799 or Email msac.secretariat@health.gov.au

8. Monitoring and Review

The new MBS MRI arrangements will be reviewed within 18 months from 1 September 1998. During this time, data will be collected on MRI clinical use and delivery and some support will be provided for research into the clinical role and value of MRI and other diagnostic imaging modalities.

9. Adjustments and Relocation

As part of the new arrangements, an Adjustment and Relocation Scheme is being developed to assist sectoral adjustments to the new arrangements, encourage relocation to underserviced regions, and promote private and public sector collaboration. The Commonwealth advises that consultations will be taking place with the States and Territories regarding the operation of the scheme. Comments you would like to make in the mean time can be submitted to Mr Andrew Crettenden, Service Development, Acute Health, Victorian Department of Human Services, 16 Floor, 555 Collins St, Melbourne, Victoria 3000, or Phone (03) 9616 7615, or Fax (03) 9616 8980 or E-Mail andrew.crettenden@dhs.vic.gov.au

10. MRI and Day Only Arrangements - Type C (exclusion) listing

Day only arrangements were designed by the Commonwealth in 1989 to encourage greater use of day only treatment as an efficient, safe and cost-effective alternative to overnight hospital care. At that time the Commonwealth identified three categories of professional attention. Basically, these types are:

Day Only Arrangements focus on Type B and Type C procedures.

Under the day only arrangements, there is no requirement that a day only patient must "occupy a bed" in order to qualify for a day facility benefit. It was recognised that the removal of this requirement to 'occupy a bed' could open up the potential for facilities to claim same day benefits for procedures traditionally undertaken on non-admitted (out-patient or accident-emergency) basis eg.: diagnostic/investigatory procedures.

In an effort to clarify what usually constitutes such services the Commonwealth developed an 'exclusion list' of procedures. Known as the Type C exclusion list it is a list of services for which hospital default benefits will not normally be paid.

10.3 MRI Admission Criteria

The MRI items listed in he MBS book are also listed in the attached Day Only Arrangements Type C (exclusion) list. However, there will be occasions when admission for a service on the Type C exclusion list is warranted. In such an event the reason for admission must be documented in accordance with the Department of Human Service’s Acute Health Circular 15/1998 (as may be amended or replaced).

Note: If a Type C procedure such as an MRI service on the exclusion list is performed in conjunction with a Type A or Type B procedure then certification for hospital admission will not be necessary. (Ref: Circular 15/1998)

Attachments:

If you require further information about the type c list, please telephone (02) 62898786 24 hour answering service - Health Insurance Section, Commonwealth Department of Health and Aged Care, OR E-MAIL the enquiry to his@health.gov.au

CHRIS BROOK
DIRECTOR
ACUTE HEALTH

ATTACHMENT I

Source: Medicare Benefits Schedule book 1 November 1998 pages 353 to 355

EXPLANATORY NOTES

DIL. MAGNETIC RESONANCE IMAGING

DIL.1 General

New arrangements for the payment of Medicare benefits for Magnetic Resonance Imaging (MRI) came into effect from 1 September 1998. These changes are in response to recommendations made by the Australian Health Technology Advisory Committee (AHTAC) 'Review of magnetic resonance imaging'. The new arrangements include a detailed itemisation and a number of eligibility criteria relating to MRI provision.

DIL.2 Itemisation

A series of items, Group I5, has been introduced for clinical applications of MRI, where AHTAC found evidence that MRI has a proven clinical role and is superior or complementary to other imaging modalities.

MRI items 63000 to 63946 are divided into subgroups defined according to the area of the body to be scanned, (ie head, spine, musculoskeletal system, cardiovascular system or body) and whether the scan is for the exclusion, further investigation or monitoring of a clinical condition. Subgroups are then divided into individual items, with each item being for a specific clinical indication.

Requests

MRI services can only be requested by a specialist or consultant physician. A referral must be in writing and identify the clinical indications for the service. Oral and maxillofacial surgeons may request Items 63621, 63671 and 63712, for scanning of the temporomandibular joint.

A MRI or Magnetic Resonance Angiography (MRA) service may be claimed for one of the three following purposes:

* Exclusion of a condition - where MRI or MRA (if performed) is used as the initial imaging modality for diagnosis;

* Further investigation of a condition - where MRI or MRA (if performed) is used as the secondary imaging modality when the diagnosis is uncertain or to assess the extent or severity of the condition;

* Monitoring of a condition - where MRI or MRA (if performed) is used following confirmed diagnosis to assess progress of a condition following treatment.

For the 'further investigation of' or 'monitoring of' purposes the initial imaging modality could have been MRI or any other diagnostic imaging modality.

DIL.3 Number of eligible services

Items have been placed in subgroups with limits on the number of services eligible for a Medicare benefit as follows:

* Subgroups 1, 2, 3, 4, 9, 10, 11, 12, 13, 14, 17, 18, 19, 22, 25, 27, 28 and 29, only one service for each subgroup can be claimed in a 12 month period;

* Subgroups 5, 6, 21, 23 and 24 only two services for each subgroup can be claimed in a 12 month period; and

* Subgroups 7, 8, 15, 16, 20, 26 and 30 which do not have a restriction on the number of eligible services.

DIL.4 Eligible services

Group I5 items, apply only to an MRI or MRA service performed:

(a) on referral by a recognised specialist or consultant physician, where the request for the scan specifically identifies in writing the clinical indication for the scan;

(b) under the professional supervision of an eligible provider; and

(c) with eligible equipment.

DIL.5 Specialist or consultant physician

Specialist or consultant physician means a medical practitioner recognised for the purposes of the Health Insurance Act 1973 as a specialist or consultant physician in a particular specialty.

DIL.6 Professional supervision

Group I5 items must be performed as follows:

(a) under the professional supervision of an eligible provider who is available to monitor and influence the conduct and diagnostic quality of the examination, including, if necessary, by personal attendance on the patient; or

(b) if the above paragraph is not complied with

- in an emergency; or

- because of medical necessity - in a remote or rural location.

DIL.7 Eligible providers

In Group I5, an eligible provider is a specialist in diagnostic radiology who satisfies the Health Insurance Commission (HIC) that:

(a) he or she is a participant in the Royal Australasian College of Radiologists' Quality and Accreditation Program; and

(b) the equipment he or she proposes to use for providing services of the kind mentioned in Group I5 is eligible equipment.

 

DIL.8 Eligible equipment

An eligible service must be provided within a medical practice, or the radiology department of a hospital, that offers a comprehensive range of alternative diagnostic imaging procedures. A minimum of diagnostic x-ray, ultrasound and computerised tomography (CT) is needed to meet this requirement.

The equipment must:

(a) have been installed in a medical practice or hospital before 7.30pm EST on Tuesday 12 May 1998; or

(b) although uninstalled, have been purchased or leased before that time on that day under a contract, in writing, that did not contain an option to cancel the contract; or

(c) be replacement equipment for equipment mentioned in the two dot points above.

Once equipment mentioned in paragraph (a) or (b) above is replaced, the original equipment ceases to be eligible equipment.

DIL.9 Eligible Provider Declaration

The specialist must give the HIC a statutory declaration:

(a) stating that he or she is enrolled in the RACR Quality and Accreditation Program;

(b) specifying the location of the MRI equipment;

(c) specifying the kinds of diagnostic imaging procedures offered at that location;

(d) stating the date of installation of the equipment; and

(e) if the equipment had not been installed before 7.30 pm on 12 May 1998, the specialist must also give the HIC a copy of the contract for the purchase or lease of the equipment.

In addition, the HIC may request further supporting documentation.

DIL.10 Adjustment and Relocation Scheme

An Adjustment and Relocation Scheme is being developed to assist sectoral adjustment to the new arrangements and to encourage relocation of MRI service to underserviced areas.

DIL.11 Review

These arrangements will be reviewed within 18 months. During this time, data will be collected on MRI clinical use and delivery and some support will be provided for research into the clinical role and value of MRI and other diagnostic imaging modalities.

DIL.12 General Medical Services Table - Anaesthetic item 18013

Item 18013 which relates to anaesthesia performed in connection with MRI services has been amended to cover anaesthesia performed in connection with any of items 63000 to 63946.

DIL.13 New Applications of MRI

New clinical applications of MRI not listed in this Schedule will require consideration by the Medicare Services Advisory Committee (MSAC) prior to inclusion in the Schedule. To contact MSAC write to:

The Secretary
Medicare Services Advisory Committee
MDP 107
GPO Box 9848
Canberra ACT 2601
Email msac.secretariat@health.gov.au
Fax: 61-2-6289 8799

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