PROCEDURE BANDING LIST

Transcription

1 PROCEDURE BANDING LIST EFFECTIVE: 1 NOVEMBER 2014 (PLEASE NOTE ALSO INCLUDES ADVICE REGARDING BAND INCREMENTS TO MOHS & SHOULDER PROCEDURES FROM 1 NOVEMBER 2014) Whilst APHA believes the information be based on reliable sources, no warranty is given as its accuracy and the persons relying on the information do so at their own risk. APHA and its employees disclaim all liability 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 November 2014 and incorporating all amendments since previous update dated 1 July

2 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 in account incorporated amendments up Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No 4) compilation start date 20 September 2014 F2014C01137 and including Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No 5)F2014L01434 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 accepted medical practice provide the procedure 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 November 2014 and incorporating all amendments since previous update dated 1 July

3 ADVANCED SURGICAL: Definition from Schedule 1 Overnight Accommodation Private Health Insurance (Benefit Requirements) Rules 2011 as amended taking in account incorporated amendments up Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No 4) compilation start date 20 September 2014 F2014C01137 and including Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No 5) F2014L01434 (1) Advanced Surgical Patient has the meaning given by this clause. (2) A patient is taken be an advanced surgical patient upon admission 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 the patient at that hospital, unless the particular advanced surgical procedure be rendered is recognised as requiring a longer pre-operative period; or b) If a longer pre-operative period than that referred 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 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) a professional service, being a service for which a Medicare benefit is payable, is that a professional service must have been provided the patient for the minimum benefit apply (3) The item numbers for this clause are only those items which have a fee in the MBS greater than $ SURGICAL: Definition from Schedule 1 Overnight Accommodation Private Health Insurance (Benefit Requirements) Rules 2011 as amended taking in account incorporated amendments up Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No 4) compilation start date 20 September 2014 F2014C01137 and including Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No 5)F2014L01434 (1) Surgical Patient has the meaning given by this clause. (2) A patient shall be taken be a surgical patient upon admission a hospital from and including: Summary of Changes Procedure Banding Amended with effect 1 November 2014 and incorporating all amendments since previous update dated 1 July

4 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 the patient at that hospital, unless the particular surgical procedure be rendered is recognised as requiring a longer pre-operative period; or 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 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) a professional service, being a service for which a Medicare benefit is payable, is that a professional service must have been provided the patient for the minimum benefit apply (3) The item numbers for this clause are only those items which have a fee in the MBS within the range of $ $ OBSTETRIC PATIENT Definition from Schedule 1 Overnight Accommodation Private Health Insurance (Benefit Requirements) Rules 2011 as amended taking in account incorporated amendments up Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No 4) compilation start date 20 September 2014 F2014C01137 and including Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No 5) F2014L01434 (1) In this schedule, obstetric patient has the meaning given by this clause: (2) A patient shall be taken be an obstetric patient during an admission a hospital from and including: (a) Whichever is the earlier of: (i) the day on which the patient commences labour leading delivery in that hospital or (ii) the day on which a professional service with the item number 16406, 16515; 16518; 16519; (excluding caesarean) or 16525, or is rendered 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 and (including caesarean) is rendered the patient at that hospital, unless the particular obstetric procedure be rendered is recognised as requiring a longer pre-operative period (c) The day on which the professional service with the item number or is rendered 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 November 2014 and incorporating all amendments since previous update dated 1 July

5 PSYCHIATRIC PATIENT Definition from Schedule 1 Overnight Accommodation Private Health Insurance (Benefit Requirements) Rules 2011 as amended taking in account incorporated amendments up Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No 4) compilation start date 20 September 2014 F2014C01137 and including Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No 5) F2014L01434 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 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 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 in account incorporated amendments up Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No 4) compilation start date 20 September 2014 F2014C01137 and including Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No 5) F2014L01434 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 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 be in the category of other patient. OTHER: In this schedule other patient is deemed 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 be in the category of other patient. Summary of Changes Procedure Banding Amended with effect 1 November 2014 and incorporating all amendments since previous update dated 1 July

6 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 in account incorporated amendments up Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No 4) compilation start date 20 September 2014 F2014C01137 and including Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No 5) F2014L01434 (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 accepted medical practice provide the procedure 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 in account incorporated amendments up Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No 4) compilation start date 20 September 2014 F2014C01137 and including Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No 5) F2014L01434 (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, Summary of Changes Procedure Banding Amended with effect 1 November 2014 and incorporating all amendments since previous update dated 1 July

7 it would be contrary accepted medical practice provide the procedure the patient unless the patient is given hospital treatment at the hospital for a period that includes part of an overnight stay. 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 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 explanary 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 Band Band Band Band Band 1A Band Band Band Band Band Band Band Band Band A Denotes a Band lower than 9 but higher than 8 4. Item No TURP Where a bipolar device is used it is not included in the Band 5 and is an add on 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 MBS Advanced Surgical and Surgical items from 1 November 2012 and fees noted in this update reflect MBS fees as of 1 November There has been no MBS fee increase affecting items in this list, since 1 November If a Band has a # after the number, please refer the item description as it denotes that the National Procedure Banding Committee has attached a comment the Band for example Item # = # Only for use with Multiple Procedure Claims Summary of Changes Procedure Banding Amended with effect 1 November 2014 and incorporating all amendments since previous update dated 1 July

8 GENERAL REMINDER TO HOSPITAL BILLING STAFF 7. When billing for more than one item number, hospitals are advised check the MBS descriprs ensure that no restrictions apply two examples of such restrictions are noted in italics below Orthopaedic: Shoulder, arthroscopic surgery of, involving any 1 or more of: removal of loose bodies; decompression of calcium deposit, debridement of labrum, synovium or rotar cuff; or chondroplasty not being a service associated with any other arthroscopic procedure of the shoulder region Urological: cysscopy 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 which item applies. Summary of Changes Procedure Banding Amended with effect 1 November 2014 and incorporating all amendments since previous update dated 1 July

9 SUMMARY OF CHANGES Please note this list only contains items which have been amended since the last update dated 1 July 2014 SUMMARY OF CHANGES Updated with effect from 1 November 2014 NEW ITEM NUMBERS effective 1 November 2014 New Item Recommended Band Comments Classification A# #Banding excludes Botulinum Toxin Type A Purified Neuroxin Complex (Box) product split in new item and amended which include reference clinical indications which service applies. Medical Type B Surgical DELETED ITEMS EFFECTIVE 1 JULY AMENDED DESCRIPTION or RE- CLASSIFICATION EFFECTIVE 1 NOVEMBER 2014 Please note item numbers with an amended description are listed in green ADVANCED SURGICAL SURGICAL MEDICAL Summary of Changes Procedure Banding Amended with effect 1 November 2014 and incorporating all amendments since previous update dated 1 July

10 TYPE B - SURGICAL TYPE B - MEDICAL TYPE C - SURGICAL TYPE C - MEDICAL CLASSIFICATION OMISSIONS PRIVATE HEALTH INSURANCE (BENEFIT REQUIREMENTS) RULES November 2011 Private Health Insurance (Benefit Requirements) Rules 2011 as amended taking in account incorporated amendments up Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No 4) compilation start date 20 September 2014 F2014C01137 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 (AND CLASSIFICATION LISTED IN PROCEDURE BANDING MANUAL) MBS SCHEDULE FEE Listed in PHI (Benefit Requirements) Amendment Rules 2013 (No 1) as Surgical, however based on fee, should be Advanced Surgical Listed in PHI Benefit Requirements as Type B Medical, however, based on fee should be Surgical Advanced Surgical $1, Type B Surgical $ Summary of Changes Procedure Banding Amended with effect 1 November 2014 and incorporating all amendments since previous update dated 1 July

11 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 in the following procedure bands: Band Band Band Band Band Band Band Band Band Band 10 The current bands are 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 AND TABLE ON PAGE 12 REGARDING 1/11/13 INCREMENTS) (Please note: In accordance with this recommendation, the Band numbers for items noted below in Blue have been adjusted in this edition) will increase Band 6 on 7 Dec 2012, Band 7 on 1 Nov 2013 and Band 8 on 1 Nov will increase Band 7 on 7 Dec 2012, Band 8 on 1 Nov 2013 and Band 9 on 1 Nov , 48933, will increase Band 7 on 7 Dec 2012 and Band 8 on 1 Nov will increase 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 , will increase Band 7 on 7 Dec 2012, Band 8 on 1 Nov 2013 and Band 9 on 1 Nov will increase Band 8 on 7 Dec 2012, Band 9 on 1 Nov 2013 and Band 10 on 1 Nov will increase 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 Summary of Changes Procedure Banding Amended with effect 1 November 2014 and incorporating all amendments since previous update dated 1 July

12 And for Mohs procedures a similar recommendation: The Mohs procedures have been costed using the current banding model and now fall in the following procedure bands: Band Band Band 7 The current bands are 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) (Please note: In accordance with this recommendation, the Band numbers for items noted below in Blue have been adjusted in this edition effective from 1 November 2014)) will increase Band 3 on 7 Dec 2012, band 4 on 1 Nov 2013 and band 5 on 1 Nov will increase Band 4 on 7 Dec 2012, band 5 on 1 Nov 2013 and band 6 on 1 Nov will increase 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 BECAME PAYABLE FROM 1 AUGUST FUTURE INCREMENTS AS NOTED IN THIS DOCUMENT AND IN THE PROCEDURE BANDING LIST WILL TAKE EFFECT WHEN THEY FALL DUE. 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 TOOK EFFECT FROM 1 AUGUST 2014 Item Number Amended Band Comments Classification To increase Band 4 on 1 November 2013 and Band 5 on 1 November 2014 Surgical Summary of Changes Procedure Banding Amended with effect 1 November 2014 and incorporating all amendments since previous update dated 1 July

13 To increase Band 5 on 1 November 2013 and Band 6 on 1 November To increase Band 5 on 1 November 2013 and Band 6 on 1 November 2014 and Band 7 on 1 November To increase Band 7 on 1 November 2013 and Band 8on 1 November To increase Band 8 on 1 November 2013 and Band 9 on 1 November 2014 Surgical Advanced Surgical Surgical Surgical To increase Band 8 on 1 November 2013 Surgical To increase Band 8 on 1 November 2013 Advanced Surgical To increase Band 8 on 1 November 2013 Surgical To increase Band 7 on 1 November 2013 and Band 8 on 1 November 2014 and Band 9 on 1 November To increase Band 8 on 1 November 2013 and Band 9 on 1 November To increase Band 8 on 1 November 2013 and Band 9 on 1 November To increase Band 9 on 1 November 2013 and Band 10 on 1 November To increase Band 8 on 1 November 2013 and Band 9 on 1 November 2014 and Band 10 on 1 November 2015 Surgical Advanced Surgical Advanced Surgical Advanced Surgical Advanced Surgical BANDING COMMITTEE AMENDED ANNOTATION ITEM NUMBER Please note: In the March 2013 update - Item (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 amend this annotation read: Interim band 3 plus net additional cost of the RF Catheters and sizing balloon where used. The annotation for has been amended as per the wording above. Summary of Changes Procedure Banding Amended with effect 1 November 2014 and incorporating all amendments since previous update dated 1 July

14 AMENDED ANNOTATION Bundled Endoscopy Procedures Underlying Procedure Bands Please note: The annotation relating 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 the following item numbers: 30473, 30475, 30476, 30478, 32072, 32075, 32078, 32081, 32084, 32087, 32090, 32093, 32094, 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 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 explanary note, also in blue italic and commencing with # is noted in the description column at the end of the MBS description of procedure. Amendment Annotation in Procedure Banding List re Items Numbers and The NPBC agreed at its meeting of 22/11/2012 remove the current annotation against Item Numbers and which reads #see explanary 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 November 2014 and incorporating all amendments since previous update dated 1 July