Medicare Criteria: Requirements for Rebate

Medicare Criteria:
Requirements for
Rebate
Most pathology tests automatically qualify for a Medicare rebate; however, for some tests,
Medicare requires that the patient satisfy certain clinical criteria before the rebate applies, or
limits the frequency of testing, or both. Some tests do not qualify for a rebate under any
circumstances.
Please note that this list is not comprehensive. A large number of specialised tests in the general
areas of metabolic and molecular genetic testing, occupational health, and environmental and
nutritional testing, are not included.
Activated Protein C (APC Resistance
1.
2.
Personal proven history of venous thromboembolism, or
Has a first-degree relative with proven APC Resistance.
Alpha Fetoprotein (AFP): Serum (Tumour
Marker
A Medicare rebate is available for test(s) performed in
monitoring malignancy, or in the detection or monitoring of
hepatic tumours, gestational trophoblastic disease, or germ cell
tumour. A Medicare rebate is only available for up to 2 tumour
marker tests per episode (AFP, BhCG, CA 125, CA 15.3, CA
19.9, CEA).
Antithrombin III
1.
2.
Personal proven history of venous thromboembolism, or
Has a first-degree relative with proven Antithrombin III.
BhCG (Beta Human Chorionic
Gonadotrophin) Total Serum (Pregnant)
A Medicare rebate is available for one test performed in the
diagnosis of threatened abortion, or follow-up of abortion, or
diagnosis of ectopic pregnancy.
BhCG (Beta Human Chorionic
Gonadotrophin) Total Serum (Tumour
Marker))
A Medicare rebate is available for test(s) performed in
monitoring malignancy, or in the detection or monitoring of
hepatic tumours, gestational trophoblastic disease, or germ cell
tumour. A Medicare rebate is only available for up to 2 tumour
marker tests per episode (AFP, BhCG, CA 125, CA 15.3, CA
19.9, CEA).
CA 125, CA 15.3, CA19.9
A Medicare rebate is available for test(s) performed in
monitoring malignancy, or in the detection or monitoring of
hepatic tumours, gestational trophoblastic disease, or germ cell
tumour. A Medicare rebate is only available for up to 2 tumour
marker tests per episode (AFP, BhCG, CA 125, CA 15.3, CA
19.9, CEA).
CEA (Carcinoembryonic Antigen)
A Medicare rebate is available for test(s) performed in
monitoring malignancy, or in the detection or monitoring of
hepatic tumours, gestational trophoblastic disease, or germ cell
tumour. A Medicare rebate is only available for up to 2 tumour
marker tests per episode (AFP, BhCG, CA 125, CA 15.3, CA
19.9, CEA).
Free T3 (Triiodothyronine)
FT3 only available with TSH. For both FT3 and TSH, thyroid
history and medications must be included in clinical notes. If no
thyroid history is given to satisfy Medicare criteria, only the TSH
will be performed. If FT3 is requested and no history is given, it
will only be performed if the TSH is abnormal.
Free T4 (Thyroxine)
FT4 only available with TSH. For both FT4 and TSH, thyroid
history and medications must be included in clinical notes. If no
thyroid history is given to satisfy Medicare criteria, only the TSH
will be performed. If FT4 is requested and no history is given, it
will only be performed if the TSH is abnormal.
Fructosamine
1.
2.
The patient has established diabetes.
No more than 4 tests per patient per year.
Haemochromatosis Gene Test
1.
2.
3.
The patient has an elevated transferrin saturation or
elevated serum ferritin on testing of repeated specimens,
or
The patient has a first-degree relative with
haemochromatosis, or
The patient has a first-degree relative with homozygosity
for the C282Y genetic mutation, or with compound
heterozygosity for recognised genetic mutations for
haemochromatosis
Haemoglobin A1c
1.
2.
The patient has established diabetes.
No more than 4 tests per patient per year.
Hepatitis B (HBV) Viral Load
Medicare criteria (four per year):
Patient is hepatitis B surface antigen positive and has chronic
hepatitis B, and is receiving antiviral therapy.
Hepatitis C Virus (HCV) Genotyping
Medicare criteria (one per year):
1.
The test is requested by a specialist or consulting physician
managing the patient’s treatment, and
2.
Patient is hepatitis C Virus (HCV) PCR positive and being
evaluated for antiviral therapy of chronic HCV hepatitis.
Hepatitis C Virus (HCV) PCR: Qualitative
Factor V Leiden PCR
Medicare criteria (one per year):
1.
The patient is hepatitis C seropositive, or
2.
The patient’s serological status is uncertain after testing,
or
3.
The test is performed for the purpose of:
a.
determining the hepatitis C status of an
immunosuppressed or
immunocompromised patient, or
b. the detection of acute hepatitis C prior to
seroconversion where considered necessary
for the clinical management of the patient,
Fragile X Gene Test
Hepatitis C Virus (HCV) PCR: Qualitative
(assessment of antiviral therapy of HCV)
Eosinophil Cationic Protein (ECP)
For monitoring the response to therapy in cortiscosteroid
treated asthma. Medicare rebate is available only for patients
under 12 years of age. Maximum of 3 assays in 1 year.
1.
2.
1.
2.
Proven DVT/PE in patient, or
Proven defect of this mutation in a first-degree relative.
The patient exhibits one or more of the clinical features of
fragile X (A) syndrome, including intellectual disabilities, or
The patient has a relative with a fragile X (A) mutation.
Medicare criteria (4 per year):
Patient is undertaking antiviral therapy for hepatitis C.
Hepatitis C Virus (HCV) PCR: Quantitative
Medicare criteria (2 per year):
1.
The test is requested by a specialist or consulting physician
managing the patient’s treatment, and
2.
The patient has undergone pre-treatment evaluation for
antiviral therapy for chronic hepatitis C.
Hepatitis Serology
A Medicare rebate is available on up to 2 hepatitis serology tests
per episode, unless clinical notes indicate hepatitis – e.g.
abnormal Liver Function Tests (LFT), in which case 3 tests per
episode will be covered by Medicare. Some conditions apply to
combinations of tests.
Antenatal Hepatitis Testing
Only HBs Ag and Hep C Ab can be performed alongside other
antenatal serology, unless the patient has clinical notes
indicating current hepatitis infection. Immunity testing would
have to be performed on another collection, separate to any
other antenatal serology testing.
Non-Pregnant Hepatitis Testing
1 test (69475) — One test for hepatitis antigens or antibodies to
determine immune status or viral carriage following exposure to,
or vaccination against, Hepatitis A, Hepatitis B, Hepatitis C or
Hepatitis D.
Item 69478 = 2 tests described in 69475
Choose two tests from either the acute or the immune options
listed below.
Acute:
Hep A IgM, HBs Ag, Hep C Ab, Hep D Ab or
Immune: Hep A IgG, HBs Ab, HBc IgG, HBe AB, Hep C Ab.
Item 69481 = 3 tests described in 69475 for the
investigation of infectious causes of acute or chronic
hepatitis. (Note it is for acute and chronic, not immune,
hepatitis)
(Item subject to Rule 11)
Three tests may be performed only if the clinical notes indicate
the patient has acute or chronic hepatitis, or if the Dr’s request
(NOTE: NOT this episode’s laboratory results, unless as an added
test) says there are clinical or laboratory indications of hepatitis
— e.g. hepatomegaly, jaundice, abnormal liver function,
vomiting and diarrhoea etc.
THREE TESTS — choose three tests (See restrictions listed
above) from the acute or chronic options listed below.
Hep A IgM, HBs Ag, HBc Ab IgM, HBcAb IgG, HBe Ag, HBe Ab,
Hep C Ab, Hep D Ab.
The immune tests HBs Ab and Hep A IgG would not be included
unless added by the laboratory as an aid to diagnosis.
Note: 2 tests (69478) or three tests (69481 + P16.8)
Hepatitis B core IgM Ab, Hepatitis Be Antigen and Hepatitis Be Ab
will not be performed unless the Hepatitis B surface antigen is
known or has been tested to be positive. In the latter case, they
will be added as supplemental tests by the laboratory.
Human Papillomavirus (HPV) DNA Typing
Medicare criteria are that, within the last 2 years:
1.
Patient has received excisional or ablative treatment for
high-grade squamous intraepithelial (HSIL) abnormalities of
the cervix; or
2.
Patient has had a positive HPV test after excisional or
ablative treatment for high-grade intraepithelial
abnormalities of the cervix, or is already undergoing annual
cytological review for follow-up of previously treated HSIL.
A Medicare rebate is available for up to 2 tests per 24month period.
Methylene Tetrahydrofolate Reductase Gene
Test
1.
2.
Proven DVT/PE in patient, or
Presence of this mutation in a first-degree relative.
Prostate Specific Antigen (PSA): Free/Total
ratio
Only one test per patient per year in the follow-up of a PSA
result that:
1.
Lies at or above the age related median but below the age
related, method specific 97.5% reference limit – 1 test per
12 month period; or
2.
Lies at or above the age related, method specific 97.5%
reference limit, but below a value of 10 μg/L – 4 tests per
12 month period.
Prostate Specific Antigen (PSA): Total
Only one test per patient per year, unless for the monitoring of
previously diagnosed prostatic disease.
Protein C
1.
2.
History of venous thromboembolism, or
Has a first-degree relative with proven Protein C deficiency.
Protein S
1.
2.
Personal proven history of venous thromboembolism, or
Has a first-degree relative with proven Protein S deficiency.
Prothrombin Gene Mutation (20210)
1.
2.
Personal proven history of venous thromboembolism, or
Presence of this mutation in a first-degree relative.
Quantiferon
When testing for latent tuberculosis in immunosuppressed or
immunocompromised patients.
RAST
1.
2.
Up to 4 requests of 4 allergens each may be ordered per
year. A maximum of 4 RAST tests may be ordered at any
one time.
Requests for additional tests on stored serum must be
dated 2 weeks apart in order to attract Medicare rebate.
Red Cell Folate
Maximum of 3 tests per patient per year.
Thrombophilia Testing Screen
1.
2.
Personal proven history of venous thromboembolism.
Has a first-degree relative with a proven defect of
Antithrombin III, Protein C, Protein S, or APC Resistance
and testing for that defect only.
NOTE: This is not an ‘Acceptable Group Test’ for Medicare
purposes. To receive a Medicare rebate, the tests within this
group must be ordered individually.
Thyroglobulin
See Tumour Markers.
Thyroid Function Tests (TFT)
For both TSH and/or FT4, thyroid history and medications must
be included in clinical notes. If no thyroid history is given to
satisfy Medicare criteria, only TSH test will be performed. If
FT4/FT3 is requested and no history is given, they will only be
performed if the TSH is abnormal.
Tumour Markers (AFP, BhCG, CA125, CA15.3,
CA19.9. CEA, Thyroglobulin)
A Medicare rebate is available for test(s) performed in monitoring
malignancy, or in the detection or monitoring of hepatic tumours,
gestational trophoblastic disease, or germ cell tumour. A
Medicare rebate is only available for up to 2 tumour marker tests
per episode.
Vitamin A, B1, B2, B3, C and E
in blood, urine or other body fluids — only one request for 1 or
more tests within a 6 month period.
Medicare criteria for Urine Drug Screening
Eligible for rebate



Patients participation in a drug abuse treatment program (maximum of 36 screens in any 12 month period)
patients undergoing sleep studies
Patients undergoing treatment for psychiatric disorders
Not eligible for rebates




Patients requesting self-testing
Employment/pre-employment testing
Testing for court purposes
GCMS confirmations of detected urine drug screens for drugs of abuse (even if the original drug screen was for
the monitoring of patients participating in a drugs of abuse treatment program)
Correct at time of printing – January 2012. Content may change subject to Medicare Australia criteria
Circumstances where Medicare rebate never applies

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screening for employment purposes – including pre-employment and WH&S testing
screening of students for clinical access
testing for court purposes
workers compensation
insurance testing
immigration/visa testing
screening of sports people – including serology for boxing medicals
surveillance of sports people and athletes for performance improving substances
screening of IVF donors
testing for elective cosmetic surgery

detection of nicotine and metabolites in smoking withdrawal programs.
Clinipath Pathology
647 Murray Street
West Perth 6005
T: 08 9476 5222
F: 08 9322 9338
E: [email protected]
W: www.clinipathpathology.com.au
Clinipath Pathology Pty Ltd trading as Clinipath Pathology and Bunbury Pathology ABN 57 008 811 185 A subsidiary of Sonic Healthcare Limited ABN 24 004 196 909