Download private hospitals` association of queensland

PROCEDURE BANDING LIST
EFFECTIVE: 1 JULY 2014
(PLEASE NOTE ALSO INCLUDES ADVICE REGARDING BAND INCREMENTS TO MOHS & SHOULDER PROCEDURES FROM 1 AUGUST 2014)
Whilst APHA believes the information to be based on reliable sources, no warranty is given as to its accuracy and the persons relying on
the information do so at their own risk. APHA and its employees disclaim all liability to any person relying on the information contained
in its communication in respect of any loss or damage (including consequential loss or damage) which may be suffered or arise directly as
a consequence or in respect of the use of or reliance on such information.
Summary of Changes – Procedure Banding – Amended with effect 1 July 2014 and incorporating all amendments since previous update dated 1 March 2014
1
EXPLANATORY NOTES TO APHA PROCEDURE BANDING LIST:
1.
Procedures marked with a “(B)” or "(C)" in the “Status” column denote Type B (Day Only) procedures or Type C (Exclusion)
items.
The non-band specified items listed in the Procedure Banding Manual will qualify for day benefits at the level of Band 2, 3 or 4
depending on anaesthetic type and where applicable, theatre time. If a non-band specific Type B procedure does involve
anaesthetic or theatre times the minimum benefit is the benefit for Band 1 treatment.
Band 2: means procedures (other than Band 1) carried out under local anaesthetic with no sedation.
Band 3: means procedures (other than Band 1) carried out under general or regional anaesthesia or intravenous sedation where the
theatre time, being the actual time in theatre, is less than one hour
Band 4: means procedures (other than Band 1) carried out under general or regional anaesthesia or intravenous sedation where the
theatre time, being the actual time in theatre, is one hour or more.
Continuous period of hospitalisation, for the purpose of counting days of hospital treatment, includes any two periods during
which a patient was, or is, receiving hospital treatment as a patient at a hospital whether or not the same hospital, where the periods
are separated from each other by a period of not more than 7 days during which the patient was not receiving hospital treatment as a
patient at any hospital.
CERTIFIED TYPE C PROCEDURE
Definition – Clause 7 – Schedule 3 – Same Day Accommodation – Private Health Insurance Benefit Requirements) Rules 2011
as amended taking into account incorporated amendments up to Private Health Insurance (Benefit Requirements) Amendment
Rules 2014 (No 1) compilation prepared 17 April 2014 – start date 20 March 2014 F2014C00745
Note: Type C procedures are procedures that do not normally require hospital treatment.
(1) Benefits for day only accommodation are payable for patients receiving a Type C procedure only if certification under
subclause (2) is provided.
(2) Certification must be provided as follows – the medical practitioner providing the professional service must certify in writing
that:
(a) because of the medical condition of the patient specified in the certificate; or
(b) because of the special circumstances specified in the certificate,
it would be contrary to accepted medical practice to provide the procedure to the patient unless the patient is given hospital
treatment at the hospital for a period that does not include part of an overnight stay.
Summary of Changes – Procedure Banding – Amended with effect 1 July 2014 and incorporating all amendments since previous update dated 1 March 2014
2
ADVANCED SURGICAL:
Definition from Schedule 1 – Overnight Accommodation – Private Health Insurance (Benefit Requirements) Rules 2011 as
amended taking into account incorporated amendments up to Private Health Insurance (Benefit Requirements) Amendment
Rules 2014 (No 1) compilation prepared 17 April 2014 – start date 20 March 2014 F2014C00745
(1) Advanced Surgical Patient has the meaning given by this clause.
(2) A patient is taken to be an advanced surgical patient upon admission to a hospital:
a) From and including the day before a professional service of the type identified by the item number in the MBS which is
specified in subclause (3) is rendered to the patient at that hospital, unless the particular advanced surgical procedure to be
rendered is recognised as requiring a longer pre-operative period; or
b) If a longer pre-operative period than that referred to in paragraph (a) is required, from and including the day of admission
of the patient for the purpose of providing the professional service of the type mentioned in paragraph (a); or
c) If the advanced surgery is rendered to a patient during an admission, from the day the advanced surgery involving a
professional service of the type mentioned in paragraph (a) is performed (not the day before).
Note: The effect of the reference in subclause 2 (a) to a professional service, being a service for which a Medicare benefit is payable, is that a
professional service must have been provided to the patient for the minimum benefit to apply
(3) The item numbers for this clause are only those items which have a fee in the MBS greater than $852.95 (fee amended by Private
Health Insurance (Benefit Requirements) Amendment Rules 2012 (No 7) – F2012L02114)
SURGICAL:
Definition from Schedule 1 – Overnight Accommodation – Private Health Insurance (Benefit Requirements) Rules 2011 as
amended taking into account incorporated amendments up to Private Health Insurance (Benefit Requirements) Amendment
Rules 2014 (No 1) compilation prepared 17 April 2014 – start date 20 March 2014 F2014C00745
(1) Surgical Patient has the meaning given by this clause.
(2) A patient shall be taken to be a surgical patient upon admission to a hospital from and including:
a) the day before a professional service of the type identified by the item number in the MBS which is specified in subclause
(3) is rendered to the patient at that hospital, unless the particular surgical procedure to be rendered is recognised as
requiring a longer pre-operative period; or
Summary of Changes – Procedure Banding – Amended with effect 1 July 2014 and incorporating all amendments since previous update dated 1 March 2014
3
b) If a longer pre-operative period is required, from and including the day of admission of the patient for the purpose of
providing the professional service of the type mentioned in paragraph (a); or
c) If the surgery is rendered to a patient during an admission, from the day the surgery involving a professional service of the
type mentioned in paragraph (a) is performed (not the day before).
Note: The effect of the reference in subclause 2 (a) to a professional service, being a service for which a Medicare benefit is payable, is that a
professional service must have been provided to the patient for the minimum benefit to apply
(3) The item numbers for this clause are only those items which have a fee in the MBS within the range of $254.00 to $852.95
(fee amended by Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No 7) – F2012L02114)
OBSTETRIC PATIENT
Definition from Schedule 1 – Overnight Accommodation – Private Health Insurance (Benefit Requirements) Rules 2011 as
amended taking into account incorporated amendments up to Private Health Insurance (Benefit Requirements) Amendment
Rules 2014 (No 1) compilation prepared 17 April 2014 – start date 20 March 2014 F2014C00745
(1) In this schedule, obstetric patient has the meaning given by this clause:
(2) A patient shall be taken to be an obstetric patient during an admission to a hospital from and including:
(a) Whichever is the earlier of:
(i) the day on which the patient commences labour leading to delivery in that hospital or
(ii) the day on which a professional service with the item number 16406, 16515; 16518; 16519; 16522 (excluding
caesarean) or 16525, 16527 or 16528 is rendered to the patient in that hospital or
(b) If the circumstances in paragraph (a) do not apply, the day before a professional service with the item number 16520 and
16522 (including caesarean) is rendered to the patient at that hospital, unless the particular obstetric procedure to be
rendered is recognised as requiring a longer pre-operative period
(c) The day on which the professional service with the item number 82120 or 82125 is rendered to the patient by a
participating midwife.
(3) In this clause, the item numbers specified are the item numbers in the general medical services table.
Summary of Changes – Procedure Banding – Amended with effect 1 July 2014 and incorporating all amendments since previous update dated 1 March 2014
4
PSYCHIATRIC PATIENT
Definition from Schedule 1 – Overnight Accommodation – Private Health Insurance (Benefit Requirements) Rules 2011 as
amended taking into account incorporated amendments up to Private Health Insurance (Benefit Requirements) Amendment
Rules 2014 (No 1) compilation prepared 17 April 2014 – start date 20 March 2014 F2014C00745
In this schedule a Psychiatric Patient is a patient in a hospital who is admitted for the purposes of undertaking a specific psychiatric
treatment program that is deemed by the insurer to be relevant and appropriate for the treatment of the patient’s disease, injury or
condition.
Note: If a patient is receiving psychiatric treatment that is not under a specific psychiatric treatment program, the patient is taken to
be in the category of ‘other patient’.
REHABILITATION PATIENT
Definition from Schedule 1 – Overnight Accommodation – Private Health Insurance (Benefit Requirements) Rules 2011 as
amended taking into account incorporated amendments up to Private Health Insurance (Benefit Requirements) Amendment
Rules 2014 (No 1) compilation prepared 17 April 2014 – start date 20 March 2014 F2014C00745
In this schedule, a Rehabilitation Patient is a patient in a hospital who is admitted for the purposes of undertaking a specific
rehabilitation treatment program that is deemed by the insurer to be relevant and appropriate for the treatment of the patient’s
disease, injury or condition.
Note: If a patient is receiving rehabilitation treatment that is not under a specific rehabilitation treatment program, the patient is
taken to be in the category of ‘other patient.’
OTHER:
In this schedule other patient is deemed to be a patient at a hospital who is receiving any treatment that involves part of an
overnight stay, but who is not: an advanced surgical patient, a surgical patient, an obstetric patient, a psychiatric patient or a
rehabilitation patient.
Note: A patient receiving hospital treatment that is palliative care as described in Item 1 of the table in subsection 72-1(2) of the Act is deemed to be in the
category of ‘other patient.’
Summary of Changes – Procedure Banding – Amended with effect 1 July 2014 and incorporating all amendments since previous update dated 1 March 2014
5
OVERNIGHT BENEFITS IN RELATION TO CERTIFIED TYPE B PROCEDURES:
Definition from Schedule 1 –Part 3 – Private Health Insurance (Benefit Requirements) Rules 2011 as amended taking into
account incorporated amendments up to Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No 1)
compilation prepared 17 April 2014 – start date 20 March 2014 F2014C00745
(1) Minimum benefits for overnight accommodation are payable for patients receiving a Type B procedure only if certification
under subclause (2) is provided.
(2) Certification must be provided as follows:
a. The practitioner providing the Type B procedure; or
b. A professional employed by a hospital who is involved in the provision of the procedure provided by that hospital
Must certify in writing that:
c. Because of the medical condition of the patient specified in the certificate; or
d. Because of the special circumstances specified in the certificate,
it would be contrary to accepted medical practice to provide the procedure to the patient unless the patient is given hospital
treatment at the hospital for a period that includes part of an overnight stay.
OVERNIGHT BENEFITS IN RELATION TO CERTIFIED TYPE C PROCEDURES
Definition from Schedule 1 Part 3 – Private Health Insurance (Benefit Requirements) Rules 2011 as amended taking into
account incorporated amendments up to Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No 1)
compilation prepared 17 April 2014 – start date 20 March 2014 F2014C00745
(1) Minimum benefits for overnight accommodation are payable for patients receiving a certified Type C procedure only if:
(a) certification has first been provided for the Type C procedure in accordance with Clause 7 of Schedule 3; and
(b) certification under subclause (2) is also provided.
(2) Certification must be provided as follows – the practitioner providing the certified Type C procedure must certify in writing
that:
(a) Because of the medical condition of the patient specified in the certificate; or
(b) Because of the special circumstances specified in the certificate,
it would be contrary to accepted medical practice to provide the procedure to the patient unless the patient is given hospital
treatment at the hospital for a period that includes part of an overnight stay.
Summary of Changes – Procedure Banding – Amended with effect 1 July 2014 and incorporating all amendments since previous update dated 1 March 2014
6
2.
BUNDLED ENDOSCOPY PROCEDURES – UNDERLYING PROCEDURE BANDS
Health Funds mostly rebate endoscopy procedures on a case based payment arrangement detailed in the HPPA. The band noted
may be used as a default band in some cases where an HPPA is silent on how benefits are to be paid for overnight patients
undergoing these procedures or for the purpose of patient billing only where there is no HPPA. These bands are noted in BLUE in
the Banding Schedule accompanied by a #. This explanatory note, also in blue italic and commencing with # is noted in the
description column at the end of the MBS description of procedure. NB: This wording in italics was amended – effective July 2013.
30473
30475
30476
30478
32072
32075
32078
32081
32084
32087
32090
32093
32094
32095
Band 1
Band 2
Band 1
Band 1
Band 1A
Band 2
Band 2
Band 3
Band 1
Band 1
Band 2
Band 3
Band 3
Band 1
3.
9A Denotes a Band lower than 9 but higher than 8
4.
Item No 37203 TURP – Where a bipolar device is used it is not included in the Band 5 and is an add on to the Band 5 benefit.
5.
New Procedures are clearly identifiable by the red font in the Excel Spreadsheet
Amended Descriptions/classifications are clearly identifiable by the green font in the Excel Spreadsheet.
A 1.9% fee increase was applied to MBS Advanced Surgical and Surgical items from 1 November 2012 and fees noted in this
update reflect MBS fees as of 1 November 2012. There has been no MBS fee increase affecting items in this list, since 1 November
2012.
6.
If a Band has a # after the number, please refer to the item description as it denotes that the National Procedure Banding Committee
has attached a comment to the Band for example Item 38220 2# = # Only for use with Multiple Procedure Claims
Summary of Changes – Procedure Banding – Amended with effect 1 July 2014 and incorporating all amendments since previous update dated 1 March 2014
7
GENERAL REMINDER TO HOSPITAL BILLING STAFF
7.
When billing for more than one item number, hospitals are advised to check the MBS descriptors to ensure that no restrictions
apply – two examples of such restrictions are noted in italics below
48948 – Orthopaedic: Shoulder, arthroscopic surgery of, involving any 1 or more of: removal of loose bodies; decompression of
calcium deposit, debridement of labrum, synovium or rotator cuff; or chondroplasty – not being a service associated with any other
arthroscopic procedure of the shoulder region
36812 – Urological: cystoscopy with urethroscopy, with or without urethral dilatation, not being a service associated with any
other urological endoscopic procedure on the lower urinary tract except a service to which item 37327 applies.
Please Note:
Special Arrangements – Transitional Period
Where the description, item number or schedule fee for an item has been amended, the following rule will apply:Where an item refers to a service in which treatment continues over a period of time in excess of one day and the treatment commenced before
1 November 2012 and continues beyond that date, the general rule is that the 1 November 2011 level of fees and benefits would apply.
MBS BOOK
With effect from the 1 November 2008 edition, the MBS book is no longer routinely available in hard copy. For the information of users, an electronic
copy of the 1 November 2012 MBS book is provided on the CD circulated with the 1 November 2012 Procedure Banding update
Summary of Changes – Procedure Banding – Amended with effect 1 July 2014 and incorporating all amendments since previous update dated 1 March 2014
8
SUMMARY OF CHANGES
Please note this list only contains items which have been amended since the last update dated 1 March 2014
SUMMARY OF CHANGES – Updated with effect from 1 JULY 2014
NEW ITEM NUMBERS – effective 1 JULY 2014
New Item
Recommended Band
Comments
Merging of four mastectomy item numbers
(31518; 31521; 31524 and 31527) into 3 items
31519; 31524 and 31525 to remove gender
specific terminology. (31524 is an amended
description rather than a new item number)
Classification
31519
6
31525
38273
5
9
Surgical
Advanced Surgical
38274
9
Advanced Surgical
Surgical
DELETED ITEMS – EFFECTIVE 1 JULY 2014
31518
31521
31527
42621
42659
42737
42797
AMENDED DESCRIPTION or RE- CLASSIFICATION – EFFECTIVE 1 JULY 2014
Please note – item numbers with an amended description are listed in green
ADVANCED SURGICAL
31524
38368
38654
38751
42653
SURGICAL
38365
38371
45585
TYPE C - SURGICAL
42744
TYPE C - MEDICAL
42794
14124 – effective 1/8/14
Summary of Changes – Procedure Banding – Amended with effect 1 July 2014 and incorporating all amendments since previous update dated 1 March 2014
9
CLASSIFICATION OMISSIONS – PRIVATE HEALTH INSURANCE (BENEFIT REQUIREMENTS)
RULES 2011 – 1 November 2011
as amended taking into account incorporated amendments up to Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No 1) compilation prepared
17 April 2014 – start date 20 March 2014 F2014C00745
ITEM NUMBER
CLASSIFICATION AS PER PHI BENEFIT
RULES 2011 AS AMENDED BY PRIVATE
HEALTH INSURANCE (BENEFIT
REQUIREMENTS) AMENDMENT RULES 2013
(NO 7) COMPILATION OF 20/2/2014
CORRECT CLASSIFICATION
BASED ON MBS FEE
MBS SCHEDULE FEE
(AND CLASSIFICATION LISTED IN
PROCEDURE BANDING MANUAL)
37245
Listed in PHI (Benefit Requirements)
Amendment Rules 2013 (No 1) as Surgical,
however based on fee, should be Advanced
Surgical
Advanced Surgical
$1,262.15
55118
Listed in PHI Benefit Requirements as Type
B – Medical, however, based on fee should
be Surgical
Type B – Surgical
$275.50
AMENDED BANDINGS – effective 7 DECEMBER 2012 RELATING TO SHOULDERS AND Mohs
The National Procedure Banding Committee at its meeting of 22 November 2012 having re-costed Shoulder and Mohs
procedures resolved the following, but please note the resolutions are in two parts:
The Shoulder procedures have been costed using the current banding model and now fall into the following procedure bands:
48903
48909
48930
48933
48936
48948
48951
48954
48957
48960
Band 8
Band 9
Band 8
Band 8
Band 8
Band 9
Band 9
Band 9
Band 10
Band 10
The current bands are to be incremented two bands with effect from 7 December 2012 then the bands will be incremented by
one band per year on 1 November each year until the agreed band is reached.”
Summary of Changes – Procedure Banding – Amended with effect 1 July 2014 and incorporating all amendments since previous update dated 1 March 2014
10
This means that: (PLEASE ALSO REFER TO NOTE IN RED BELOW AND TABLE ON PAGE 12 REGARDING 1/11/13 INCREMENTS)
48903 will increase to Band 6 on 7 Dec 2012, Band 7 on 1 Nov 2013 and Band 8 on 1 Nov 2014
48909 will increase to Band 7 on 7 Dec 2012, Band 8 on 1 Nov 2013 and Band 9 on 1 Nov 2014
48930, 48933, 48936 will increase to Band 7 on 7 Dec 2012 and Band 8 on 1 Nov 2013
48948 will increase to Band 6 on 7 Dec 2012, Band 7 on 1 Nov 2013 and Band 8 on 1 Nov 2014 and Band 9 on 1 Nov 2015
48951, 48954 will increase to Band 7 on 7 Dec 2012, Band 8 on 1 Nov 2013 and Band 9 on 1 Nov 2014
48957 will increase to Band 8 on 7 Dec 2012, Band 9 on 1 Nov 2013 and Band 10 on 1 Nov 2014
48960 will increase to Band 7 on 7 Dec 2012, Band 8 on 1 Nov 2013 and Band 9 on 1 Nov 2014 and Band 10 on 1 Nov 2015
And for Mohs procedures a similar recommendation:
“The Mohs procedures have been costed using the current banding model and now fall into the following procedure bands:
31000 Band 5
31001 Band 6
31002 Band 7
The current bands are to be incremented two bands with effect from 7 December 2012 then the bands will be incremented by
one band per year on 1 November each year until the agreed band is reached.”
This means that: (PLEASE ALSO REFER TO NOTE IN RED BELOW REGARDING 1/11/13 INCREMENTS)
31000 will increase to Band 3 on 7 Dec 2012, band 4 on 1 Nov 2013 and band 5 on 1 Nov 2014
31001 will increase to Band 4 on 7 Dec 2012, band 5 on 1 Nov 2013 and band 6 on 1 Nov 2014
31002 will increase to Band 4 on 7 Dec 2012, band 5 on 1 Nov 2013, band 6 on 1 Nov 2014 and Band 7 on 1 Nov 2015
These resolutions are presented in tabular form below – HOWEVER:
PLEASE NOTE: THE 1 NOVEMBER 2013 PROPOSED INCREMENTS NOTED ABOVE AND IN THE TABLE OVERLEAF WERE
FROZEN PENDING A REVIEW OF NPBC COSTING METHODOLOGY.
THIS REVIEW HAS NOW BEEN COMPLETED AND ACCEPTED BY THE NATIONAL PROCEDURE BANDING COMMITTEE AND
THEREFORE THE NOVEMBER 2013 INCREMENTS FOR THESE PROCEDURES WILL BE PAYABLE FROM 1 AUGUST 2014.
FUTURE INCREMENTS AS NOTED IN THIS DOCUMENT AND IN THE PROCEDURE BANDING LIST WILL TAKE EFFECT WHEN
THEY FALL DUE.
Summary of Changes – Procedure Banding – Amended with effect 1 July 2014 and incorporating all amendments since previous update dated 1 March 2014
11
AMENDED BANDINGS – effective 7 DECEMBER 2012
PLEASE NOTE: THE 1 NOVEMBER 2013 PROPOSED INCREMENTS NOTED IN THE TABLE BELOW WHICH WERE FROZEN PENDING
A REVIEW OF NPBC COSTING METHODOLOGY WILL NOW TAKE EFFECT FROM 1 AUGUST 2014
Item Number
Amended Band
Comments
31000
3
To increase to Band 4 on 1 November 2013 and
to
Band 5 on 1 November 2014
To increase to Band 5 on 1 November 2013 and
to
Band 6 on 1 November 2014
To increase to Band 5 on 1 November 2013 and
to
Band 6 on 1 November 2014 and to
Band 7 on 1 November 2015
31001
31002
48903
48909
4
4
6
7
48930
48933
7
7
48936
48948
7
6
48951
48954
48957
48960
7
7
8
7
To increase to Band 7 on 1 November 2013 and
to
Band 8on 1 November 2014
To increase to Band 8 on 1 November 2013 and
to
Band 9 on 1 November 2014
To increase to Band 8 on 1 November 2013
To increase to Band 8 on 1 November 2013
To increase to Band 8 on 1 November 2013
To increase to Band 7 on 1 November 2013 and
to
Band 8 on 1 November 2014 and to
Band 9 on 1 November 2015
To increase to Band 8 on 1 November 2013 and
to
Band 9 on 1 November 2014
To increase to Band 8 on 1 November 2013 and
to
Band 9 on 1 November 2014
To increase to Band 9 on 1 November 2013 and
to
Band 10 on 1 November 2014
To increase to Band 8 on 1 November 2013 and
to
Band 9 on 1 November 2014 and to Band 10 on
1 November 2015
Classification
Surgical
Surgical
Advanced Surgical
Surgical
Surgical
Surgical
Advanced Surgical
Surgical
Surgical
Advanced Surgical
Advanced Surgical
Advanced Surgical
Advanced Surgical
Summary of Changes – Procedure Banding – Amended with effect 1 July 2014 and incorporating all amendments since previous update dated 1 March 2014
12
BANDING COMMITTEE AMENDED ANNOTATION – ITEM NUMBER 30687
Please note: In the March 2013 update - Item 30687 (listed 1 November 2012) was detailed as Interim Band 3 plus the net additional cost of the RF
Catheters where used, and the annotation contained a price for various specified catheters.
At the NPBC meeting of 11 July, 2013 it was agreed to amend this annotation to read:
Interim band 3 plus net additional cost of the RF Catheters and sizing balloon where used.
The annotation for 30687 has been amended as per the wording above.
AMENDED ANNOTATION – Bundled Endoscopy Procedures – Underlying Procedure Bands
Please note: The annotation relating to Bundled Endoscopy Procedures – Underlying Procedure Bands has been amended – effective July 2013 (as
detailed in Note 2 of this document on page 7). This amendment applies to the following item numbers: 30473, 30475, 30476, 30478, 32072, 32075,
32078, 32081, 32084, 32087, 32090, 32093, 32094, 32095.
The Annotation now reads:
Health Funds mostly rebate endoscopy procedures on a case based payment arrangement detailed in the HPPA. The band noted may be used as a
default band in some cases where an HPPA is silent on how benefits are to be paid for overnight patients undergoing these procedures or for the purpose
of patient billing only where there is no HPPA. These bands are noted in BLUE in the Banding Schedule accompanied by a #. This explanatory note,
also in blue italic and commencing with # is noted in the description column at the end of the MBS description of procedure.
Amendment to Annotation in Procedure Banding List re Items Numbers 50950 and 50952
The NPBC agreed at its meeting of 22/11/2012 to remove the current annotation against Item Numbers 50950 and 50952 which
reads #see explanatory note regarding banding in accompanying document Summary of Procedure Banding Changes effective 1
May 2006” and replace it with: “Includes the RF Disposable Device”
Summary of Changes – Procedure Banding – Amended with effect 1 July 2014 and incorporating all amendments since previous update dated 1 March 2014
13