Education guide - Medicare ultrasound services

Information about servicing and claiming requirements for Medicare ultrasound services.

This information outlines key requirements for the provision of Medicare Benefits Schedule (MBS) ultrasound services (items 55005-55855). Comprehensive information on ultrasound services is available at MBS Online on the Department of Health website.

Performance of multiple ultrasound services

Several rules may apply when calculating Medicare benefits payable for multiple diagnostic imaging (DI) services provided to a patient at the same attendance (on the same day). These rules were developed in association with the DI profession representative organisations and reflect that there are efficiencies to the provider when these services are performed on the same occasion.

Any decision to have a patient return on a different day to complete a multi-area DI service should only be made on the basis of clinical necessity.

Additional services

A written request is not required for an ultrasound service if that service was:

  1. provided after another DI service which has been formally requested, and
  2. the providing practitioner determines that, on the basis of the results obtained from the requested service, that an additional service was necessary

You cannot determine an additional ultrasound service unless you meet the requirements as described above.

Substituted services

A provider may substitute a service for the service originally requested when:

  1. the provider determines, from the clinical information provided on the request, that the substituted service would be more appropriate for the diagnosis of the patient’s condition, and
  2. the provider has consulted with the requesting practitioner or taken all reasonable steps to do so before providing the substituted service, and
  3. the substituted service was one that would be accepted as a more appropriate service in the circumstances by the practitioner’s speciality group

Requested (R-type) ultrasound services

These services cannot be claimed as an ‘additional service’ or ‘substituted service’ where:

  1. the ultrasound item descriptor states that a referral is required. Practitioners should claim the non-requested (NR) item in these circumstances, as per the below example, or
  2. the ultrasound item is not otherwise able to be requested by the original requesting practitioner

Example:

Item 55032 cannot be used as an additional service or substituted service as the descriptor states a referral is required.

Item 55032 – NECK, 1 or more structures of, ultrasound scan of, where:

  1. the patient is referred by a medical practitioner for ultrasonic examination not being a service associated with a service to which an item in Subgroups 2 or 3 of this Group applies, and
  2. the referring medical practitioner is not a member of a group of practitioners of which the providing practitioner is a member (R)

In this instance, the non-referred item 55033 should be used.

Item 55033 – NECK, 1 or more structures of, ultrasound scan of, where the patient is not referred by a medical practitioner, not being a service associated with a service to which an item in Subgroups 2 or 3 of this Group applies (NR)

Professional supervision for ultrasound services – R-type eligible services

Ultrasound services marked with the symbol (R) with the exception of items 55600, 55601, 55603 and 55604 are not eligible for a Medicare benefit unless the DI procedure is performed under the professional supervision of a:

  1. specialist or a consultant physician in the practice of his or her specialty who is available to monitor and influence the conduct and diagnostic quality of the examination, and if necessary to personally attend the patient, or
  2. practitioner who is not a specialist or consultant physician but meets the requirements according to the MBS. Refer to the explanatory notes DIK of the MBS Online on the Department of Health website

If the above cannot be complied with, ultrasound services are eligible for a Medicare rebate:

  1. in an emergency, or
  2. in a location that is not less than 30 kilometres by the most direct road route from another practice as outlined in the Diagnostic Imaging Services Table (DIST)

Personal attendance

The radiologist should be capable of personally attending the patient when medically necessary. The decision to personally attend should be made in accordance with accepted medical practice. Such an attendance should be on the same day, not a subsequent day, and it is reasonable to expect the radiologist should be able to attend during the session allocated to the patient, or that the patient would only have to wait a short period of time.

Other than described at 1 and 2 above, the radiologist must personally attend and examine the patient for the performance of musculoskeletal ultrasound scans.

Sonographers

Sonographers performing medical ultrasound examinations, either R or NR type items, on behalf of a medical practitioner must be:

  1. suitably qualified
  2. involved in a relevant and appropriate Continuing Professional Development program, and
  3. be registered on the Register of Accredited Sonographers held by us

Report requirements

The sonographer's initial and surname is to be written on the report. The name of the sonographer is not required to be included on the copy of the report given to the patient.

Musculoskeletal ultrasound items 55800 - 55854

Medicare benefits are only payable for a musculoskeletal ultrasound service if the medical practitioner responsible for the conduct and report of the examination personally attends during the performance of the scan and personally examines the patient.

It is reasonable to expect personnel other than the radiologist may position the patient and the machine and set the machine and press the button, where the regulations allows this and they meet any qualifications or credentials required, but the radiologist must ensure this occurred in a satisfactory manner which allows them to appropriately undertake the imaging.

Services that are performed because of medical necessity in a remote area are exempt from this requirement. For the purposes of these items a 'remote area' is one that is more than 30 kilometres, by the most direct road route, from another practice as outlined in the DIST.

Multiple musculoskeletal ultrasound scans

Generally Medicare benefits are payable for more than 1 musculoskeletal ultrasound scan performed on the same day, however the scans are subject to Rule A of the general DI multiple services rules.

It is not permitted, however, to 'split' a bilateral scan. Where bilateral ultrasound scans are performed, the relevant item should be claimed once only.

Example:

If both shoulders are scanned, item 55808 should be claimed once only.

Item 55808 – SHOULDER OR UPPER ARM, 1 or both sides, ultrasound scan of

Similarly where the item descriptor states '1 or more areas', as per item 55844 below, the item should be claimed once only.

Item 55844 – assessment of a mass associated with the skin or subcutaneous structures, not being a part of the musculoskeletal system, 1 or more areas, ultrasound scan of

A patient should not be asked to make a second appointment in order to attract a benefit for multiple scans.

Ultrasound reporting requirements

For Medicare purposes, the rendering practitioner is the medical practitioner who provides the report.

Reports provided by practitioners located outside Australia

Medicare benefits are not payable for DI services which have been reported on by medical practitioners located outside Australia.

All elements of the service, including preparation of the report on the procedure, need to be rendered in Australia.

Record keeping

All practitioners who provide, or initiate, a service for which a Medicare benefit is payable, should ensure they maintain adequate and contemporaneous records.

Providers of DI services must keep records of the services in a manner that facilitates retrieval on the basis of the patient's name and date of service.

The records must include the report by the providing practitioner on the DI service. For ultrasound services, where the service is performed on behalf of a medical practitioner, the report must record the name of the sonographer.

Where the provider substitutes a service for the service originally requested, the provider’s records must include:

  1. words indicating that the providing practitioner has consulted with the requesting practitioner and the date of consultation, or
  2. if the providing practitioner has not consulted with the requesting practitioner, sufficient information to demonstrate that he or she has taken all reasonable steps to do so

For services rendered after a lost request, the records must include words to the effect that the request was lost but confirmed by the requesting practitioner and the manner of confirmation, for example, how and when.

For emergency services, the records must indicate the nature of the emergency.

Retention of requests

A medical practitioner who has rendered an R-type DI service in response to a written request must retain that request for a period of 18 months commencing on the day on which the service was rendered.

Ultrasound services where Medicare benefits are not payable

Medicare benefits are not payable for ultrasound services where the:

  • service is not reasonably required for the management of the medical condition of the patient such as health screening, for example vascular screening for artery blockages
  • service does not meet the MBS item descriptor for the service provided, as per the below examples

Example A:

MBS item 55850 requires a separate diagnostic musculoskeletal ultrasound to be performed prior to the interventional procedure.

Item 55850 – MUSCULOSKELETAL CROSS-SECTIONAL ECHOGRAPHY, in conjunction with a surgical procedure using interventional techniques, inclusive of a diagnostic musculoskeletal ultrasound service

Where the additional ultrasound is not completed, the appropriate item to bill would be 55848.

Item 55848 – MUSCULOSKELETAL CROSS-SECTIONAL ECHOGRAPHY, in conjunction with a surgical procedure using interventional techniques

Example B:

MBS item 55828 where the scan is ordered for any reason other than those listed in the item descriptor.

Item 55828 – KNEE, 1 or both sides, ultrasound scan of, where the service is provided for the assessment of 1 or more of the following conditions or suspected conditions:

  • Abnormality of tendons or bursae about the knee, or
  • Meniscal cyst, popliteal fossa cyst, mass or pseudomass, or
  • Nerve entrapment, nerve or nerve sheath tumour, or
  • Injury of collateral ligaments (R)

Benefits are not payable for musculoskeletal ultrasound services for non-specific knee or shoulder pain alone.

Inappropriate or incorrect claiming of Medicare benefits

Providers should be aware that we are legally obliged to investigate providers suspected of making false or misleading statements, and may refer them for prosecution if the evidence indicates fraudulent charging to Medicare.

If Medicare benefits have been paid inappropriately or incorrectly, we will take recovery action.

Health professional guidelines

We worked with the Department of Health and a number of peak bodies in the health sector to develop health professional guidelines.

These guidelines form a series designed to help health professionals understand what documents they can use to substantiate services if they are asked to participate in a Medicare compliance audit.

More information

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Page last updated: 19 October 2016

This information was printed Sunday 4 December 2016 from humanservices.gov.au/health-professionals/enablers/education-guide-medicare-ultrasound-services It may not include all of the relevant information on this topic. Please consider any relevant site notices at humanservices.gov.au/siteinformation when using this material.