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MBS Colonoscopy Item Numbers - Consultation CLOSES TODAY

Monday 08, Oct 2018

The MBS Review Taskforce is undertaking a program of work to consider how the more than 5,700 items on the MBS can be aligned with contemporary clinical evidence and practice in order to improve health outcomes for patients. The Taskforce has established clinical committees and working groups to undertake clinical reviews of MBS items.

Accordingly, the Taskforce has reviewed the MBS items within its remit and made recommendations based on rapid evidence review and clinical expertise.

At the request of the Minster for Health (the Minister), the Taskforce reconsidered additional membership to develop new MBS items to revise colonoscopy items 32090 and 32093. Consideration was also given to items 32088 and 32089. The Taskforce assured that key organisations such as the Australian Medical Association, Royal Australasian College of General Practitioners, Royal Australian College of Physicians, Royal Australian College of Surgeons, Colorectal Surgical Society of Australia and New Zealand, and the Gastroenterological Society of Australia were part of these considerations.

At its face-to-face meeting in Canberra on 21 August 2018, the Committee developed recommendations based on clinical evidence and expertise, in consultation with relevant stakeholders. The recommendations and the process by which they were developed are detailed below.

PURPOSE OF THE REVIEW

The Taskforce agreed on the key aims of developing recommendations for colonoscopy MBS items that:

  1. facilitate the provision of effective, evidence-based colonoscopy services;
  2. reduce low-value care;
  3. improve access to MBS-funded colonoscopy services for those who need it; and
  4. are implementable and practical.

Following the development of recommendations, a short period of stakeholder consultation will be undertaken before advice regarding new colonoscopy items is provided directly to the Minister. The Department of Health has commissioned the Gastroenterological Society of Australia to undertake provider education regarding the use of the new items, prior to the implementation of new colonoscopy items.

OUTCOMES OF THE REVIEW

Following its deliberations, the Committee recommended that:

  1. Colonoscopy items be amended in line with revisions recommended at Attachment A.
  2. Colonoscopy items 32088 and 32089 be deleted from the MBS.
  3. Eight new colonoscopy items be added to the MBS to replace items 32090 and 32093. The complete list of recommended items and item descriptors is given at Attachment B.

KEY ISSUES CONSIDERED

During the development of these outcomes, the Committee considered and discussed Medicare data, clinical practice guidelines and stakeholder feedback regarding in-scope items.

Key considerations leading to the development of the above recommendations included:

  • Acknowledgement that there is over-servicing of colonoscopy in some areas and underservicing in others but low rates of colonoscopy in some parts of Australia may not be addressed through modifications to the MBS.
  • Items should be informed by clinical practice guidelines but not tied to them.
  • Items should permit some flexibility for professional autonomy but clarify appropriate frequency of colonoscopy services for different clinical situations.
  • In some instances, a clinician may not be reasonably able to obtain the information required to ensure clinical indications are met and a patient should not be disadvantaged by this.

STAKEHOLDER INPUT

The Taskforce is now seeking feedback and comments from key stakeholders to review the recommended changes to colonoscopy items. You are invited to provide comments and feedback based on your areas of expertise, knowledge and interests. The Committee will consider feedback from stakeholders then provide recommendations to the Minister.

In particular, please detail your views (and the views of your organisation) on the following questions:

  1. Do you agree/disagree with the recommended changes to colonoscopy MBS items given at Attachment A?
  2. Do you agree/disagree with each of the recommended new colonoscopy MBS items given at Attachment B?

Please support your views with relevant clinical evidence.

Your written feedback on the recommendations is welcomed by COB Friday 19 October 2018. Responses can be sent via email at MBSReviews@health.gov.au. Please mark your email for the attention of Dr Jill Padrotta at the Department of Health.

 

Attachment A – Summary of agreed changes to colonoscopy items (download word document HERE)

 

 

Summary of agreed changes to colonoscopy items

1

Reimbursement should be aligned with best clinical practice for colonoscopy agreed across relevant medical specialties.

2

Items should be restructured to reflect clinical indications and surveillance intervals for colonoscopy. A new suite of items is recommended.

3

Current colonoscopy items require examination ‘beyond the hepatic flexure’. This should be amended ‘to the caecum’ to emphasise the importance of a complete colonoscopy. For patients post-right hemicolectomy this examination should be to the anastomosis.

4

Reference to ‘fibre optic’ should be removed as all contemporary colonoscopes are digital.

5

Reference to ‘flexible’ should be removed as all colonoscopes are flexible.

6

Restrictions should be introduced on the combined claiming (co-claiming) of more than one colonoscopy service on the same day, for the same patient, during a single episode of sedation/anaesthesia.

7

Reference to the treatment of radiation proctitis, angiodysplasia or post-polypectomy bleeding should be removed from the polyp removal colonoscopy item and a separate item created for this service. It is also recommended that specific reference to Argon Plasma Coagulation be removed to enable any therapy to be used.

8

New colonoscopy items should be created for symptomatic patients, patients with iron deficiency anaemia and for patients following a positive faecal occult blood test (FOBT).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attachment B – Recommended draft colonoscopy items (download word document HERE)

 

RECOMMENDED DRAFT COLONOSCOPY ITEMS

Item

Item Descriptor

Proposed Fee

Explanatory Notes

1

Endoscopic examination of the colon to the caecum by COLONOSCOPY for a patient:

  1. following a positive faecal occult blood test; OR
  2. who is symptomatic; OR
  3. who has iron deficiency anaemia; OR
  4. has an abnormality of the colon on diagnostic imaging; OR
  5. is undergoing the first examination following surgery for colorectal cancer; OR
  6. is undergoing pre-operative evaluation.

(Anaes.) 

$334.35

 

Explanatory Note detailing appropriate colonoscopy intervals for patients with a positive FOBT and subsequent colonoscopy with no abnormalities detected.

2

Endoscopic examination of the colon to the caecum by COLONOSCOPY for a patient with:

  1. a previous history of LOW RISK of adenoma – For a patient with previous history 1-4 adenomas AND all less than 10mm in diameter, with no villous features and no high grade dysplasia; OR
  2. a MODERATE RISK family history (NOTE: A single FDR over the age of 55 does not constitute moderate risk – FOBT should be considered in this group of patients); OR
  3. a past history of colorectal cancer after initial post-operative colonoscopy in the absence of adenomas or colorectal cancer.

Only payable once in a 5 year period (Anaes.)

$334.35

 

Explanatory Note indicating patients with a low-risk family history should undergo FOBT.

 

A patient may be considered at MODERATE risk of colorectal cancer if family history of colorectal cancer (1 FDR less than 55yrs of age at diagnosis OR 2 FDRs OR 1 FDR and 2 SDRs any age at diagnosis).

 

For patients with 1-2 adenoma (<10mm with no high-risk histological features) colonoscopy every 10 years is sufficient.

3

Endoscopic examination of the colon to the caecum by COLONOSCOPY for a patient with:

  1. a MODERATE RISK of colorectal cancer due to history of adenomas (any adenoma greater than 10mm in diameter OR with villous features OR with high grade dysplasia OR an advanced serrated adenoma); OR
  2. a MODERATE RISK of colorectal cancer due to history of adenomas (5-9 adenomas on previous colonoscopy AND all less than 10mm in diameter, with no villous features and no high grade dysplasia).

Only payable once in a 3 year period (Anaes.).

$334.35

 

 

4

Endoscopic examination of the colon to the caecum by COLONOSCOPY for a patient with:

a HIGH RISK of colorectal cancer due to history of adenomas (10 or more adenomas at previous colonoscopy OR incomplete excision of large, sessile adenoma at previous colonoscopy).

Payable up to 4 times per year (Anaes.)

$334.35

 

 

5

Endoscopic examination of the colon to the caecum by COLONOSCOPY for a patient with:

  1. a HIGH RISK of colorectal cancer due to a known or suspected familial condition, such as Familial Adenomatous Polyposis or Lynch syndrome, or Serrated Polyposis Syndrome or who has a genetic mutation associated with hereditary colorectal cancer; OR
  2. inflammatory bowel disease.

Only payable once in a 12 month period (Anaes.).

$334.35

 

Explanatory Note detailing IBD categories where lower frequency of colonoscopy (i.e. less than once every 12 months) would be more appropriate.

 

6

Endoscopic examination of the colon by COLONOSCOPY for the treatment of radiation proctitis, angioectasia or post-polypectomy bleeding, 1 or more of. (Anaes.)

$469.20

 

 

7

EXCEPTION ITEM

Endoscopic examination of the colon by COLONOSCOPY for a patient for whom there is insufficient information to bill items 1-5.

Payable on only one occasion.

$334.35

 

 

8

REMOVAL OF 1 OR MORE POLYPS during COLONOSCOPY, in association with only one of the following items at any one time: 1,2,3,4,5 or 7 (Anaes.).

Total fee to equal $469.20

 

Explanatory Note to be added at the beginning of the section stating that 32084 should be billed if preparation is inadequate to allow visualisation to the caecum.