MBS INFORMATION

Medicare rebates apply to many of our services.

The Australian Government provides Medicare rebates for certain diagnostic imaging services. To be eligible for a Medicare rebate, examinations must meet specific criteria. The criteria must be stated on the imaging request form.

BONE MINERAL DENSITY

Must be at least 24 months since any previous BMD if performed for:

  • 1 or more fractures occurring after minimal trauma (this can only be used once for each fracture); or
  • Monitoring of osteoporosis proven by previous BMD at least 2 years prior with Z score of -1.50 or lower, or a T score of -2.50 or lower

Must be at least 12 months since any previous BMD if performed for:

  • Prolonged & current glucocorticoid therapy (as per dose limits outlined in the MBS);
  • Conditions associated with excess glucocorticoid secretion;
  • Male hypogonadism;
  • Female hypogonadism lasting more than 6 months before the age of 45.

Must be 24 months since any previous BMD if performed for:

  • Primary hyperparathyroidism;
  • Chronic liver disease;
  • Chronic renal disease;
  • Proven malabsorptive disorders (e.g. Coeliac or Crohn’s disease);
  • Rheumatoid arthritis; or
  • Conditions associated with thyroxine excess.

Must be either:
The first time the patient is having BMD OR at least five years since any previous BMD if performed for:

  • A person aged 70 years or over and not had a scan before
  • A person aged 70 years or over and found to have no to mild osteopaenia (T-score 0 to 1.5) on previous scan

Must be at least 12 months since any previous BMD if performed for:

  • 12 months following a significant change in therapy

Must be at least 24 months since any previous BMD if performed for:

  • A person aged 70 years or over found to have moderate to marked osteopaenia (T-score -1.5 to -2.5) on previous scan

CT ANGIOGRAM

These items are only claimable if:

  • They are requested by a specialist or consultant physician; or
  • They are requested by a general practitioner and the request indicates that the patient’s case has been discussed with a specialist or consultant physician
  • The service is performed for the exclusion of arterial stenosis, occlusion, aneurysm or embolism; and not a study performed to image the coronary arteries
  • Are not in conjunction with any other CT on the same day.
 

CT angiography with intravenous contrast medium of any or all, or any part of:

  • The pulmonary arteries and their branches;

For the exclusion of pulmonary embolism this item can be requested by a medical practitioner (other than a specialist or consultant physician).

CT angiography with intravenous contrast medium of any or all, or any part of:

  • The arch of the aorta; OR
  • The carotid arteries; OR
  • The vertebral arteries and their branches (head and neck)

Only claimable once in a 12 month period.

CT angiography with intravenous contrast medium of any or all, or any part of:

  • The ascending and descending aorta; OR
  • The common iliac and abdominal branches including upper limbs (chest, abdomen and upper limbs)

Only claimable once in a 12 month period.

CT angiography with intravenous contrast medium of any or all, or any part of:

  • The descending aorta: OR
  • The pelvic vessels (aorto iliac segment) and lower limbs;

Only claimable once in a 12 month period.

ECHOCARDIOGRAM

*Claimable once every 2 years
Can be referred by GP or specialists/specialist consultants

  • Cannot be claimed within 24 months of any resting echo item.
  • Can be ordered for any suspected heart condition.

Can be referred by specialists/specialist consultants

  • For serial assessment of previously diagnosed valvular disease.

Can be referred by GPs in Modified Monash areas 3-7*
*Modified Monash areas 3-7 relate to remote to very remote locations.

Can be referred by GP or specialists/specialist consultants

  • Repeat echocardiograms in patients with isolated pericardial effusion OR who has commenced medication for non-cardiac purposes that have cardio toxic side effects, and if the patient has a normal baseline study which requires echocardiograms to comply with requirements of PBS.

Can be referred by specialists/specialist consultants

  • Repeat echocardiogram in patients not covered by other rare indications.

GP REFERRED MRI - PATINTS 16 YEARS & OLDER

  • Unexplained seizure OR
  • Unexplained chronic headache with suspected intracranial pathology
  • Cervical radiculopathy
  • Suspected cervical spine trauma

Acute knee trauma with either:

  • Inability to extend the knee suggesting the possibility of acute meniscal tear OR
  • Clinical findings suggesting acute anterior cruciate ligament tear AND
  • The patient must be under 50 years of age

GP REFERRED MRI - PATIENTS UNDER 16 YEARS

  • Following general X-ray for any of the following:

    • Unexplained seizure(s) 
    • Unexplained headache where significant pathology is suspected 
    • Paranasal sinus pathology not responsive to conservative therapy
  • Following general X-ray for any of the following:

    • Unexplained back pain where significant pathology is suspected 
    • Unexplained neck or back pain with associated neurological signs 
    • Significant trauma
    • 63513 – Knee 

Following general X-ray for any of the following:

  • Suspected septic arthritis 
  • Suspected slipped femoral capital epiphysis 
  • Suspected Perthes disease

Following general X-ray for any of the following:

  • Suspected significant fracture or avulsion injury, that will change management

Following general X-ray for any of the following:

  • Suspected scaphoid fracture

MAMMOGRAPHY

Medicare will initially be guided by the details as stipulated by the requesting practitioner, regardless of what the patient does or does not state.

A rebate is available for a diagnostic mammogram, if there is a reason to suspect the presence of malignancy because of:

  • Previous breast cancer
  • Significant family history of breast or ovarian cancer
  • Symptoms or indications of breast disease found on examination of the patient by a medical practitioner (indicate area on a diagram),

for example, (but not limited to):

  • Focal pain/tenderness
  • Lump in breast
  • Discharge
  • Thickening
  • Nipple retraction or change
  • Skin changes/dimpling

A mammogram without the necessary, eligible clinical indications present on the request form is considered screening and there is no Medicare rebate.

Medicare will initially be guided by the details as stipulated by the requesting practitioner, regardless of what the patient does or does not state.

A rebate is available for a diagnostic mammogram, if there is a reason to suspect the presence of malignancy because of:

  • Previous breast cancer
  • Significant family history of breast or ovarian cancer
  • Symptoms or indications of breast disease found on examination of the patient by a medical practitioner (indicate area on a diagram),

for example, (but not limited to):

  • Focal pain/tenderness
  • Lump in breast
  • Discharge
  • Thickening
  • Nipple retraction or change
  • Skin changes/dimpling

A mammogram without the necessary, eligible clinical indications present on the request form is considered screening and there is no Medicare rebate.

MYOCARDIAL PERFUSION STUDY

Can be referred by GPs and specialists/specialist consultants

  • Claimable once every 2 years
  • Has any of the following criteria:
    • Patient has body habitus (obesity) OR
    • Unable to exercise OR
    • Clinical indication as per “STRESS” Clinical Indication Criteria outlined below.
 
“STRESS” Clinical Indication Criteria

A. Typical or atypical angina

1) Constricting discomfort in the:

i. Front of chest, or

ii. Neck, or

iii. Shoulders, or

iv. Jaw, or

v. Arms, or

2) Symptoms precipitated by physical exertion: or

3) Symptoms relieved by rest or GTN (Glyceryl TriNitrate)

 

B. Patient has known CAD (Coronary Artery Disease), and displays ischemic symptoms:

1) Not controlled with medical therapy

2) Evolved since last functional study

 

C. Qualifies for at least one of the following indications:

1) Patient with congenital heart lesions with reversible ischemia following surgery

2) ECG changes consistent with CAD or ischemia

3) Uncertain functional significance on CTCA

4) Exertional dyspnoea of unknown cause, potential non-CAD

5) Pre-Op assessment in patients with:

i. Ischemic heart disease, or previous myocardial infarction

ii. Heart failure

iii. Stroke or transient ischemia

iv. Renal dysfunction (creatinine >70umol/L or creatinine clearance

6) Prior to Coronary intervention / bypass surgery

7) Assessment of viable tissue following infarct

8) Before and after cardiac surgery in patients 17yrs or younger

 

9) Suspected perfusion abnormality in poorly communicative patient

 

Can only be referred by specialists or specialist consultants

  • Claimable once in a 12-month period
  • Previous stress / rest MPS in the last 12 months, AND
  • Undergone revascularisation procedure, AND
  • Has any of the following criteria:
    • Patient has body habitus (obesity) OR
    • Inability to have Stress Echo OR
    • Unable to exercise OR
    • Clinical indications as per “STRESS” Clinical Indication criteria outlined below.
 
Stress Clinical Indication Criteria
  1.  A. Typical or atypical angina

     

    1) Constricting discomfort in the:

    i. Front of chest, or

    ii. Neck, or

    iii. Shoulders, or

    iv. Jaw, or

    v. Arms, or

    2) Symptoms precipitated by physical exertion: or

    3) Symptoms relieved by rest or GTN (Glyceryl TriNitrate)

    B. Patient has known CAD (Coronary Artery Disease), and displays ischemic symptoms:

    1) Not controlled with medical therapy

    2) Evolved since last functional study

     

    C. Qualifies for at least one of the following indications:

    1) Patient with congenital heart lesions with reversible ischemia following surgery

    2) ECG changes consistent with CAD or ischemia

    3) Uncertain functional significance on CTCA

    4) Exertional dyspnoea of unknown cause, potential non-CAD

    5) Pre-Op assessment in patients with:

    i. Ischemic heart disease, or previous myocardial infarction

    ii. Heart failure

    iii. Stroke or transient ischemia

    iv. Renal dysfunction (creatinine >70umol/L or creatinine clearance

    6) Prior to Coronary intervention / bypass surgery

    7) Assessment of viable tissue following infarct

    8) Before and after cardiac surgery in patients 17yrs or younger

    9) Suspected perfusion abnormality in poorly communicative patient

ULTRASOUND

Medicare has rules which apply to rebates for shoulder and knee Ultrasound examinations and will only provide a rebate when the request form specifically includes one of the following conditions or suspected conditions:

Benefits are payable when referred with suspicion of the following clinical conditions:

  • Evaluation of injury to tendon, muscle or tendon/muscle junction including tears, calcification or tendinosis
  • Rotator cuff tear/ calcifications/ tendinosis or biceps, subscapular, supraspinatus or infraspinatus
  • Biceps subluxation
  • Capsulitis and bursitis
  • Evaluation of mass, including
  • Ganglion Occult fracture
  • Acromioclavicular joint pathology

Benefits are not payable when referred for non-specific shoulder pain alone.

Benefits are payable when referred with suspicion of the following clinical conditions:

  • 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 ligament

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

ALLIED HEALTH

The following items are Medicare eligible for physiotherapists and osteopaths.

Item

Description

57712

X-Ray of the Hips

57715

X-Ray of the Pelvis

58100

X-Ray of the Cervical Spine

58103

X-Ray of the Thoracic Spine

58106

X-Ray of the Lumbar Spine

58109

X-Ray of the Sacrum and Coccyx

58112

X-Ray of the Two Region Spine

58120*

X-Ray of the Three Region Spine

28121*

X-Ray of the Four Region Spine

*Claimable once per calendar year

Non Rebateable Items

X-Ray & Imaging welcome non Medicare-eligible musculoskeletal ultrasound & MRI scans from physiotherapists and osteopaths where the areas being imaged are of clinical interest.



The following items are Medicare eligible for chiropractors.

Item

Description

57712

X-Ray of the Hips

57715

X-Ray of the Pelvis

58100

X-Ray of the Cervical Spine

58103

X-Ray of the Thoracic Spine

58106

X-Ray of the Lumbar Spine

58109

X-Ray of the Sacrum and Coccyx

58112

X-Ray of the Two Region Spine



The following items are Medicare eligible for podiatrists.

Item

Description

55890

Ultrasound of ankle or hind foot

55894

Ultrasound of mid foot or fore foot

55844

Ultrasound of mass – skin or subcutaneous structures

57521

X-Ray of ankle, foot, lower leg (below the knee)

57527

X-Ray of two or more regions (below the knee)

 

Non Rebateable Items

X-Ray & Imaging welcome non Medicare-eligible musculoskeletal MRI scans from podiatrists where the areas being imaged are of clinical interest.