Information on claiming criteria for Medicare Benefits Schedule (MBS) items 30071, 30072, 31206 to 31225 and 31356 to 31376.
You should refer to the relevant MBS item descriptors and explanatory notes available on the MBS Online website when determining the appropriate item to bill in each circumstance.
Diagnostic biopsy of skin - item 30071 and diagnostic biopsy of mucous membrane - item 30072
MBS item 30071 can be claimed for a diagnostic biopsy of skin or item 30072 for a diagnostic biopsy of mucous membrane when the biopsy:
- is performed as an independent procedure
- specimen is sent for pathological examination
- is clinically necessary to confirm the diagnosis for appropriate management of the lesion
If the shave biopsy results in a definitive excision of the lesion, only MBS items 30071 or 30072 can be claimed.
Removal of mucous membrane lesions – items 31206 to 31221 and 31225
The MBS item descriptors outline the lesion size, the location and the histopathological requirements when choosing the correct MBS items to claim.
Removal of skin lesions –items 31220 to 31225 and 31356 to 31376
The MBS item descriptors outline the histopathological requirements, lesion size and location which must be considered when choosing the correct MBS item to claim.
Histology requirements for claiming skin excision items
You can claim MBS skin excision items 31220 to 31225 and 31356 to 31376, excluding item 31245, when the excised specimen is sent for histological examination.
If the histological report shows the lesion is benign, use MBS items 31220, 31225, 31357, 31360, 31362, 31364, 31366, 31368 and 31370. Practitioners are required to keep copies of histological reports.
Malignant skin tumours, such as basal cell carcinoma (BCC), squamous cell carcinoma (SCC), malignant melanoma and other aggressive skin tumours, are covered under MBS items 31356, 31358, 31359, 31361, 31363, 31365, 31367, 31369, 31371 to 31376.
You must receive histological confirmation before claiming the relevant skin malignancy item.
Determining lesion size for MBS item selection
The necessary excision diameter (or defect size) refers to the lesion size plus a clinically appropriate margin of healthy tissue required with the intent of complete surgical excision. Measurements should be taken prior to excision. Margin size should be determined in line with NHMRC guidelines: Clinical practice guide - Basal cell carcinoma, squamous cell carcinoma (and related lesions)-a guide to clinical management in Australia. November 2008. Cancer Council Australia; and Clinical Practice Guidelines for the Management of Melanoma in Australia and New Zealand (2008).
For the purpose of Items 31356 to 31376 the defect size is calculated by the average of the width and the length of the skin lesion and an appropriate margin. Therefore the necessary excision diameter is calculated as follows:
Practitioners must retain copies of histological reports and any other supporting evidence (patient notes, photographs etc). Photographs should include scale.
An episode of care includes both the excision and closure for the same defect, even when excision and closure occur at separate attendances.
An incomplete surgical excision of a malignant skin lesion with curative intent should be billed as a malignant skin lesion excision item even when further surgery is needed.
Skin lesion excision items grouped by location
Skin lesion excision items are grouped according to the following locations:
- face – (anterior to the hairline and above the jawline), neck – (anterior to the sternomastoid muscles), scalp, nipple – areola complex (of the breast), distal lower limb (distal to or including the knee), or distal upper limb (distal to or including the ulnar styloid)
- nose, eyelid, eyebrow, lip, ear, digit, genitalia or from a contiguous area
- body areas not covered by the previous 2 groups
Excision of malignant melanoma and other aggressive skin tumours - items 31371 to 31376
Definitive surgical excision for items 31371 to 31376 is defined as "surgical removal with curative intent with an adequate margin".
Post-operative treatment (Aftercare)
Medicare benefits are not payable where routine post-operative care is provided by the medical practitioner who performed the procedure. However, they are payable where the aftercare is provided by a general practitioner who did not perform the procedure.
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