Medicare Billing Changes explained

If you struggle to understand the latest changes in Medicare billing for skin services, please view the short video below with Dr Tony Dicker. The experienced skin cancer doctor provides a simple explanation on the key changes you need to be aware of and what they mean for your skin cancer work.

 
 

Skin Cancer Item Number Guide

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SKIN CANCER ITEM NUMBER DESCRIPTORS

Item #

Item Descriptor

30071

Diagnostic biopsy of skin, as an independent procedure, if the biopsy specimen is sent for pathological examination

30072

Diagnostic biopsy of mucous membrane, as an independent procedure, if the biopsy specimen is sent for pathological examination

31206

Tumour, cyst, ulcer or scar (other than a scar removed during the surgical approach at an operation), removal of and suture, if:

a) the lesion size is not more than 10 mm in diameter; and

b) the removal is from a mucous membrane by surgical excision (other than by shave excision); and

c) the specimen excised is sent for histological examination

31211

Tumour, cyst, ulcer or scar (other than a scar removed during the surgical approach at an operation), removal of and suture, if:

a) the lesion size is more than 10 mm, but not more than 20 mm, in diameter; and

b) the removal is from a mucous membrane by surgical excision (other than by shave excision); and

c) the specimen excised is sent for histological examination

31216

 

Tumour, cyst, ulcer or scar (other than a scar removed during the surgical approach at an operation), removal of and suture, if:

a) the lesion size is more than 20 mm in diameter; and

b) the removal is from a mucous membrane by surgical excision (other than by shave excision); and

c) the specimen excised is sent for histological examination

31220

 

Tumours (other than viral verrucae (common warts) and seborrheic keratoses), cysts, ulcers or scars (other than scars removed during the surgical approach at an operation), removal of 4 to 10 lesions and suture, if:

a) the size of each lesion is not more than 10 mm in diameter; and

b) each removal is from cutaneous or subcutaneous tissue by surgical excision (other than by shave excision); and

c) all of the specimens excised are sent for histological examination

31221

 

Tumours, cysts, ulcers or scars (other than scars removed during the surgical approach at an operation), removal of 4 to 10 lesions, if:

a) the size of each lesion is not more than 10 mm in diameter; and

b) each removal is from a mucous membrane by surgical excision (other than by shave excision); and

c) each site of excision is closed by suture; and

d) all of the specimens excised are sent for histological examination

31225

Tumours (other than viral verrucae (common warts) and seborrheic keratoses), cysts, ulcers or scars (other than scars removed during the surgical approach at an operation), removal of more than 10 lesions, if:

a) the size of each lesion is not more than 10 mm in diameter; and

b) each removal is from cutaneous or subcutaneous tissue or mucous membrane by surgical excision (other than by shave excision); and

c) each site of excision is closed by suture; and

d) all of the specimens excised are sent for histological examination

31340

 

Muscle, bone or cartilage, excision of one or more of, if clinically indicated, and if:

a) the specimen excised is sent for histological confirmation; and

b) a malignant tumour of skin covered by item 31356, 31358, 31359, 31361, 31363, 31365, 31367, 31369, 31371, 31372, 31373, 31374, 31375 or 31376 is excised

31356

 

Malignant skin lesion (other than a malignant skin lesion covered by item 31371, 31372, 31373, 31374, 31375 or 31376), surgical excision (other than by shave excision) and repair of, if:

a) the lesion is excised from nose, eyelid, eyebrow, lip, ear, digit or genitalia, or from a contiguous area; and

b) the necessary excision diameter is less than 6 mm; and

c) the excised specimen is sent for histological examination; and

d) malignancy is confirmed from the excised specimen or previous biopsy;

e) not in association with item 45201

31357

 

Non-malignant skin lesion (other than viral verrucae (common warts) and seborrheic keratoses), including a cyst, ulcer or scar (other than a scar removed during the surgical approach at an operation), surgical excision (other than by shave excision) and repair of, if:

a) the lesion is excised from nose, eyelid, eyebrow, lip, ear, digit or genitalia, or from a contiguous area; and

b) the necessary excision diameter is less than 6 mm; and

c) the excised specimen is sent for histological examination;

d) not in association with item 45201

31358

 

Malignant skin lesion (other than a malignant skin lesion covered by item 31371, 31372, 31373, 31374, 31375 or 31376), surgical excision (other than by shave excision) and repair of, if:

a) the lesion is excised from nose, eyelid, eyebrow, lip, ear, digit or genitalia, or from a contiguous area; and

b) the necessary excision diameter is 6 mm or more; and

c) the excised specimen is sent for histological examination; and

d) (d) malignancy is confirmed from the excised specimen or previous biopsy

31359

 

Malignant skin lesion (other than a malignant skin lesion covered by item 31371, 31372, 31373, 31374, 31375 or 31376), surgical excision (other than by shave excision), if:

a) the lesion is excised from nose, eyelid, eyebrow, lip, ear, digit or genitalia (the applicable site); and

b) the necessary excision area is at least one third of the surface area of the applicable site; and

c) the excised specimen is sent for histological examination; and

d) malignancy is confirmed from the excised specimen or previous biopsy

31360

 

Non-malignant skin lesion (other than viral verrucae (common warts) and seborrheic keratoses), including a cyst, ulcer or scar (other than a scar removed during the surgical approach at an operation), surgical excision (other than by shave excision) and repair of, if:

a) the lesion is excised from nose, eyelid, eyebrow, lip, ear, digit or genitalia, or from a contiguous area; and

b) the necessary excision diameter is 6 mm or more; and

c) the excised specimen is sent for histological examination

31361

 

Malignant skin lesion (other than a malignant skin lesion covered by item 31371, 31372, 31373, 31374, 31375 or 31376), surgical excision (other than by shave excision) and repair of, if:

a) the lesion is excised from face, neck, scalp, nipple-areola complex, distal lower limb (distal to, and including, the knee) or distal upper limb (distal to, and including, the ulnar styloid); and

b) the necessary excision diameter is less than 14 mm; and

c) the excised specimen is sent for histological examination; and

d) malignancy is confirmed from the excised specimen or previous biopsy;

e) not in association with item 45201

31362

 

Non-malignant skin lesion (other than viral verrucae (common warts) and seborrheic keratoses), including a cyst, ulcer or scar (other than a scar removed during the surgical approach at an operation), surgical excision (other than by shave excision) and repair of, if:

a) the lesion is excised from face, neck, scalp, nipple-areola complex, distal lower limb (distal to, and including, the knee) or distal upper limb (distal to, and including, the ulnar styloid); and

b) the necessary excision diameter is less than 14 mm; and

c) the excised specimen is sent for histological examination;

d) not in association with item 45201

31363

 

Malignant skin lesion (other than a malignant skin lesion covered by item 31371, 31372, 31373, 31374, 31375 or 31376), surgical excision (other than by shave excision) and repair of, if:

a) the lesion is excised from face, neck, scalp, nipple-areola complex, distal lower limb (distal to, and including, the knee) or distal upper limb (distal to, and including, the ulnar styloid); and

b) the necessary excision diameter is 14 mm or more; and

c) the excised specimen is sent for histological examination; and

d) malignancy is confirmed from the excised specimen or previous biopsy

31364

 

Non-malignant skin lesion (other than viral verrucae (common warts) and seborrheic keratoses), including a cyst, ulcer or scar (other than a scar removed during the surgical approach at an operation), surgical excision (other than by shave excision) and repair of, if:

a) the lesion is excised from face, neck, scalp, nipple-areola complex, distal lower limb (distal to, and including, the knee) or distal upper limb (distal to, and including, the ulnar styloid); and

b) the necessary excision diameter is 14 mm or more; and

c) the excised specimen is sent for histological examination

31365

 

Malignant skin lesion (other than a malignant skin lesion covered by item 31369, 31370, 31371, 31372 or 31373), surgical excision (other than by shave excision) and repair of, if:

a) the lesion is excised from any part of the body not covered by item 31356, 31358, 31359, 31361 or 31363; and

b) the necessary excision diameter is less than 15 mm; and

c) the excised specimen is sent for histological examination; and

d) malignancy is confirmed from the excised specimen or previous biopsy;

e) not in association with item 45201

31366

 

Non-malignant skin lesion (other than viral verrucae (common warts) and seborrheic keratoses), including a cyst, ulcer or scar (other than a scar removed during the surgical approach at an operation), surgical excision (other than by shave excision) and repair of, if:

a) the lesion is excised from any part of the body not covered by item 31357, 31360, 31362 or 31364; and

b) the necessary excision diameter is less than 15 mm; and

c) the excised specimen is sent for histological examination;

d) not in association with item 45201

31367

 

Malignant skin lesion (other than a malignant skin lesion covered by item 31371, 31372, 31373, 31374, 31375 or 31376), surgical excision (other than by shave excision) and repair of, if:

a) the lesion is excised from any part of the body not covered by item 31356, 31358, 31359, 31361 or 31363; and

b) the necessary excision diameter is at least 15 mm but not more than 30 mm; and

c) the excised specimen is sent for histological examination; and

d) malignancy is confirmed from the excised specimen or previous biopsy;

e) not in association with item 45201

31368

 

Non-malignant skin lesion (other than viral verrucae (common warts) and seborrheic keratoses), including a cyst, ulcer or scar (other than a scar removed during the surgical approach at an operation), surgical excision (other than by shave excision) and repair of, if:

a) the lesion is excised from any part of the body not covered by item 31357, 31360, 31362 or 31364; and

b) the necessary excision diameter is at least 15 mm but not more than 30mm; and

c) the excised specimen is sent for histological examination;

d) not in association with item 45201

31369

 

Malignant skin lesion (other than a malignant skin lesion covered by item 31371, 31372, 31373, 31374, 31375 or 31376), surgical excision (other than by shave excision) and repair of, if:

a) the lesion is excised from any part of the body not covered by item 31356, 31358, 31359, 31361 or 31363; and

b) the necessary excision diameter is more than 30 mm; and

c) the excised specimen is sent for histological examination; and

d) malignancy is confirmed from the excised specimen or previous biopsy

31370

 

Non-malignant skin lesion (other than viral verrucae (common warts) and seborrheic keratoses), including a cyst, ulcer or scar (other than a scar removed during the surgical approach at an operation), surgical excision (other than by shave excision) and repair of, if:

a) the lesion is excised from any part of the body not covered by item 31357, 31360, 31362 or 31364; and

b) the necessary excision diameter is more than 30 mm; and

c) the excised specimen is sent for histological examination

31372

 

Malignant melanoma, appendageal carcinoma, malignant connective tissue tumour of skin or merkel cell carcinoma of skin, definitive surgical excision (other than by shave excision) and repair of, if:

a) the tumour is excised from face, neck, scalp, nipple-areola complex, distal lower limb (distal to, and including, the knee) or distal upper limb (distal to, and including, the ulnar styloid); and

b) the necessary excision diameter is less than 14 mm; and

c) (c) the excised specimen is sent for histological examination; and

d) malignancy is confirmed from the excised specimen or previous biopsy; not in association with item 45201

308.70

31373

 

Malignant melanoma, appendageal carcinoma, malignant connective tissue tumour of skin or merkel cell carcinoma of skin, definitive surgical excision (other than by shave excision) and repair of, if:

a) the tumour is excised from face, neck, scalp, nipple-areola complex, distal lower limb (distal to, and including, the knee) or distal upper limb (distal to, and including, the ulnar styloid); and

b) the necessary excision diameter is 14 mm or more; and

c) the excised specimen is sent for histological examination; and

d) malignancy is confirmed from the excised specimen or previous biopsy

31374

 

Malignant melanoma, appendageal carcinoma, malignant connective tissue tumour of skin or merkel cell carcinoma of skin, definitive surgical excision (other than by shave excision) and repair of, if:

a) the tumour is excised from any part of the body not covered by item 31371, 31372 or 31373; and

b) the necessary excision diameter is less than 15 mm; and

c) the excised specimen is sent for histological examination; and

d) malignancy is confirmed from the excised specimen or previous biopsy;

e) not in association with item 45201

31375 

Malignant melanoma, appendageal carcinoma, malignant connective tissue tumour of skin or merkel cell carcinoma of skin, definitive surgical excision (other than by shave excision) and repair of, if:

a)  the tumour is excised from any part of the body not covered by item 31371, 31372 or 31373; and

b)  the necessary excision diameter is at least 15 mm but not more than 30 mm; and

c)  the excised specimen is sent for histological examination; and

d)  malignancy is confirmed from the excised specimen or previous biopsy;

e)  not in association with item 45201

31376 

Malignant melanoma, appendageal carcinoma, malignant connective tissue tumour of skin or merkel cell carcinoma of skin, definitive surgical excision (other than by shave excision) and repair of, if:

a)  the tumour is excised from any part of the body not covered by item 31371, 31372 or 31373; and

b)  the necessary excision diameter is more than 30 mm; and

c)  the excised specimen is sent for histological examination; and

d)  malignancy is confirmed from the excised specimen or previous biopsy

45000 Single stage local muscle flap repair, on eyelid, nose, lip, neck, hand, thumb, finger or genitals not in association with any of items 31356 to 31376 (Anaes.)
45003  Single stage local myocutaneous flap repair to one defect, simple and small not in association with any of items 31356 to 31376
45200  Single stage local flap, if indicated to repair one defect, simple and small, excluding flap for male pattern baldness and excluding H-flap or double advancement flap not in association with any of items 31356 to 31376
45201  Muscle, myocutaneous or skin flap, where clinically indicated to repair one surgical excision made in the removal of a malignant or non-malignant skin lesion (only in association with items 31000, 31001, 31002, 31358, 31359, 31360, 31363, 31364, 31369, 31370, 31371, 31373 or 31376)may be claimed only once per defect
45202 

Muscle, myocutaneous or skin flap, where clinically indicated to repair one surgical excision made in the removal of a malignant or non-malignant skin lesion in a patient, if the clinical relevance of the procedure is clearly annotated in the patient’s record and either:

a)  item 45201 applies and additional flap repair is required for the same defect; or

b)  item 45201 does not apply and either:

c)  the patient has severe pre-existing scarring, severe skin atrophy or sclerodermoid changes; or

d)  the repair is contiguous with a free margin

45203  Single stage local flap, if indicated to repair one defect, complicated or large, excluding flap for male pattern baldness and excluding H-flap or double advancement flap not in association with any of items 31356 to 31376 (Assist.)
45206  Single stage local flap if indicated to repair one defect, on eyelid, nose, lip, ear, neck, hand, thumb, finger or genitals and excluding H-flap or double advancement flap not in association with any of items 31356 to 31376
45207  H-flap or double advancement flap if indicated to repair one defect, on eyelid, eyebrow or forehead not in association with any of items 31356 to 31376
30192

PREMALIGNANT SKIN LESIONS (including solar keratoses), treatment of, by ablative technique (10 or more lesions)

30195 BENIGN NEOPLASM OF SKIN, other than viral verrucae (common warts) seborrheic keratoses, cysts and skin tags, treatment by electrosurgical destruction, simple curettage or shave excision, or laser photocoagulation, not being a service to which item 30196, 30197, 30202, 30203 or 30205 applies (1 or more lesions)
30196

MALIGNANT NEOPLASM OF SKIN OR MUCOUS MEMBRANE proven by histopathology or confirmed by specialist opinion, removal of, by serial curettage or carbon dioxide laser or erbium laser excision-ablation, including any associated cryotherapy or diathermy, not being a service to which item 30197 applies

30202

MALIGNANT NEOPLASM OF SKIN OR MUCOUS MEMBRANE proven by histopathology or confirmed by specialist opinion, removal of, BY LIQUID NITROGEN CRYOTHERAPY using repeat freeze-thaw cycles, not being a service to which item 30203 applies

30203

MALIGNANT NEOPLASM OF SKIN OR MUCOUS MEMBRANE proven by histopathology or confirmed by specialist opinion, removal of, BY LIQUID NITROGEN CRYOTHERAPY using repeat freeze-thaw cycles (10 OR MORE LESIONS)

30219

HAEMATOMA, FURUNCLE, SMALL ABSCESS OR SIMILAR LESION not requiring admission to a hospital - INCISION WITH DRAINAGE OF (excluding aftercare)

31345

LIPOMA, removal of by surgical excision or liposuction, where lesion is subcutaneous and 50mm or more in diameter, or is sub-fascial, where the specimen is sent for histological confirmation of diagnosis

45030

ANGIOMA (haemangioma or lymphangioma or both) of skin and subcutaneous tissue (excluding facial muscle or breast) or mucous surface, small, excision and suture of

45033

ANGIOMA, (haemangioma or lymphangioma or both), large or involving deeper tissue including facial muscle or breast, excision and suture of

45035

ANGIOMA (haemangioma or lymphangioma or both), large and deep, involving muscles or nerves, excision of

 

Explanatory Notes

Multiple Operation Rule T8.2

The fees for two or more operations, listed in Group T8 (other than Subgroup 12 of that Group), performed on a patient on the one occasion (except as provided in paragraph T8.2.3) are calculated by the following rule:

100% for the item with the greatest Schedule fee

plus 50% for the item with the next greatest Schedule fee

plus 25% for each other item.

Note:

  1. Fees so calculated which result in a sum which is not a multiple of 5 cents are to be taken to the next higher multiple of 5 cents.
  2. Where two or more operations performed on the one occasion have Schedule fees which are equal, one of these amounts shall be treated as being greater than the other or others of those amounts.
  3. The Schedule fee for benefits purposes is the aggregate of the fees calculated in accordance with the above formula.
  4. For these purposes the term "operation" only refers to all items in Group T8 (other than Subgroup 12 of that Group).

This rule does not apply to an operation which is one of two or more operations performed under the one anaesthetic on the same patient if the medical practitioner who performed the operation did not also perform or assist at the other operation or any of the other operations, or administer the anaesthetic. In such cases the fees specified in the Schedule apply.

Where two medical practitioners operate independently and either performs more than one operation, the method of assessment outlined above would apply in respect of the services performed by each medical practitioner.

If the operation comprises a combination of procedures which are commonly performed together and for which a specific combined item is provided in the Schedule, it is regarded as the one item and service in applying the multiple operation rule.

There are a number of items in the Schedule where the description indicates that the item applies only when rendered in association with another procedure. The Schedule fees for such items have therefore been determined on the basis that they would always be subject to the "multiple operation rule".

Where the need arises for the patient to be returned to the operating theatre on the same day as the original procedure for further surgery due to post-operative complications, which would not be considered as normal aftercare - see paragraph T8.2, such procedures would generally not be subject to the "multiple operation rule". Accounts should be endorsed to the effect that they are separate procedures so that a separate benefit may be paid.

Biopsy for Diagnostic Purposes - (Items 30071 to 30096) T8.7

Needle aspiration biopsy attracts benefits on an attendance basis and not under item 30078.

Item 30071 (diagnostic biopsy of the skin) or 30072 (diagnostic biopsy of mucous membrane) should be used when a biopsy (including shave) of a lesion is required to confirm a diagnosis and would facilitate the appropriate management of that lesion. If the shave biopsy results in a definitive excision of the lesion, only 30071 or 30072 can be claimed.

Items 30071-30096 require that the specimen be sent for pathological examination.

The aftercare period for item 30071 or 30072 is 2 days rather than the standard aftercare period for skin excision of 10 days.

Removal of Skin Lesions - (Items 31356 to 31376) T8.22

The excision of warts and seborrheic keratoses attracts benefits on an attendance basis with the exceptions outlined in T8.13 of the explanatory notes to this category. Excision of pre-malignant lesions including solar keratoses where clinically indicated are covered by items 31357, 31360, 31362, 31364, 31366, 31368 and 31370.

The excision of suspicious pigmented lesions for diagnostic purposes attract benefits under items 31357, 31360, 31362, 31364, 31366, 31368 and 31370.

Malignant tumours are covered by items 31356, 31358, 31359, 31361, 31363, 31365, 31367, 31369 and 31371 to 31376.

Items 31357, 31360, 31362, 31364, 31366, 31368, 31370 require that the specimen be sent for histological examination. Items 31356, 31358, 31359, 31361, 31363, 31365, 31367, 31369, 31371-31376 also require that a specimen has been sent for histological confirmation of malignancy, and any subsequent specimens are sent for histological examination. Confirmation of malignancy must be received before itemisation of accounts for Medicare benefits purposes.

Where histological results are available at the time of issuing accounts, the histological diagnosis will decide the appropriate itemisation. If the histological report shows the lesion to be benign, items 31357, 31360, 31362, 31364, 31366, 31368 or 31370 should be used. 

It will be necessary for practitioners to retain copies of histological reports.

Removal of Skin Lesion from Face - (Items 31245, 31361 to 31364, 31372 and 31373) T8.23

For the purposes of these items, the face is defined as that portion of the head anterior to the hairline and above the jawline.

Removal of Skin Lesions - Necessary Excision Diameter - (Items 31356 to 31376) (T8.127)

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).

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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. 

Definitive surgical excision for items 31371 to 31376 is defined as "surgical removal with curative intent with an adequate margin ".

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.

For Items 31356 to 31370, a malignant skin lesion is defined as a basal cell carcinoma; a squamous cell carcinoma (including keratoacanthoma); a cutaneous deposit of lymphoma; or a cutaneous metastasis from an internal malignancy.
 

Local Skin Flap – Definition (T8.95)

Medicare benefits for flaps are only payable when clinically appropriate. Clinically appropriate in this instance means that the flap or graft is required to close the defect because the defect cannot be closed directly, or because the flap is required to adapt scar position optimally with regard to skin creases or landmarks, maintain contour on the face or neck, or prevent distortion of adjacent structures or apertures. 

A local skin flap is an area of skin and subcutaneous tissue designed to be elevated from the skin adjoining a defect requiring closure.  The flap remains partially attached by its pedicle and is moved into the defect by rotation, advancement or transposition, or a combination of these manoeuvres.  A benefit is only payable when the flap is required for adequate wound closure.  A secondary defect will be created which may be closed by direct suture, skin grafting or sometimes a further local skin flap.  This later procedure will also attract benefit if closed by graft or flap repair but not when closed by direct suture.

By definition, direct wound closure (e.g. by suture) does not constitute skin flap repair.  Similarly, angled, curved or trapdoor incisions which are used for exposure and which are sutured back in the same position relative to the adjacent tissues are not skin flap repairs.  Undermining of the edges of a wound prior to suturing is considered a normal part of wound closure and is not considered a skin flap repair.

A "Z" plasty is a particular type of transposition flap repair.  Although 2 flaps are created, benefit will be paid on the basis of Item 45201, claimable once per defect.  Additional flaps are to be claimed under Item 45202, if clinically indicated.

Note: refer to T8.128 for MBS item 45202 for circumstances where other services might involve flap repair.

Flap Repair - (Item 45202) T8.128 

Practitioners must only perform a muscle or skin flap repair where clinical need can be clearly evidenced (i.e. where a patient has severe pre-existing scarring, severe skin atrophy, sclerodermoid changes or where the defect is contiguous with a free margin).

Clinical evidence may be supported by patient notes, photographs of the affected area and pathology reports.