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About the guide
This guide outlines the ART services covered in the Medicare Benefits Schedule (MBS). Make sure you read the relevant MBS item descriptors and explanatory notes at MBS Online before billing any ART services.
ART services include a range of treatments to achieve pregnancy including:
- in-vitro fertilisation (IVF)
- gamete intrafallopian transfer (GIFT)
- intracytoplasmic sperm injection (ICSI)
- intrauterine insemination (IUI).
We pay Medicare benefits for clinically relevant services. ART services are clinically relevant when accepted by the medical profession as necessary to appropriately treat a patient’s medical infertility. Services performed must also comply with relevant state and territory laws.
Note that Reciprocal Health Care Agreement (RHCA) patients aren't eligible for MBS ART services.
Treatment cycle
A treatment cycle is a series of treatments for ART services.
An ART treatment cycle starts on either:
- the day the patient starts treatment with superovulatory drugs
- the first day of the patient’s menstrual cycle, if not given superovulatory drugs.
An ART treatment cycle ends no more than 30 days after the treatment cycle starts, or the day after the last:
- oocyte retrieval
- transfer of embryos or both ova and sperm, or preparation of sperm for artificial insemination.
There's no limit on the number of ART treatment cycles a patient can have.
ART global items
Services provided as part of an ART treatment cycle are covered under ART global items and can’t be billed separately to Medicare.
The first day of the treatment cycle is the date of service for billing ART global items.
The following MBS items are global items:
These items cover all services related to an ART treatment cycle and include consultations, pathology, and diagnostic imaging services.
Services that aren’t related to the ART treatment cycle are still eligible for Medicare benefits.
We may ask you to verify in writing that these services weren’t related to ART treatment.
Pathology and diagnostic imaging services
If you request pathology or diagnostic imaging services under an ART treatment cycle you should indicate on the request that the services aren't eligible for a Medicare benefit.
If an ART clinic requests pathology or diagnostic imaging services and it’s unclear if they relate to a treatment cycle, check with the requesting practitioner before billing the services.
We pay Medicare benefits in accordance with the Health Insurance Act 1973 (the Act). Under subsection 129 AC (1), the Commonwealth may recover incorrectly paid Medicare benefits from the practitioner who provided the service, even if the benefit was not paid to them.
Embryology laboratory services
Embryology laboratory services for items 13200 and 13201 include:
- egg recovery from aspirated follicular fluid
- semen preparation
- monitoring of fertilisation and embryo development
- insemination
- preparation of gametes or embryos for transfer or freezing.
Pre-implantation genetic testing (PGT) services
PGT is used by couples or individuals who know they carry a serious genetic disorder. PGT is applied within the IVF process to detect specific genetic or chromosomal abnormalities prior to implantation and pregnancy.
During the IVF cycle, the created embryos have a small number of cells extracted and tested for specific genetic variations.
PGT services include:
- one ART surgical item for an embryo biopsy from a couple at high risk of having a child affected by a genetic disorder (item 13207)
- pathology tests (items 73384, 73385, 73386, 73387).
Surrogacy
You can't use MBS ART items 13200 to 13221 for patients with surrogacy arrangements.
You can use item 13251 for patients with surrogacy arrangements when male factor infertility applies.
Surrogacy arrangements occur when a person:
- agrees to become pregnant and to bear a child for another person
- transfers guardianship and custodial rights to the other person at or shortly after birth.
Billing for ART services
Billing MBS items for ART services
| MBS items | Brief description | Billing date | Item notes | |||
|---|---|---|---|---|---|---|
|
Initial cycle - superovulated treatment cycle proceeding to oocyte retrieval |
First day of treatment cycle |
Nil |
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|
Subsequent cycle - superovulated treatment cycle proceeding to oocyte retrieval |
First day of treatment cycle |
You must have previously billed an item 13200 or 13202 in the same calendar year. |
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|
Superovulated treatment cycle - cancelled before oocyte retrieval |
First day of treatment cycle |
For an initial or subsequent cycle that is cancelled before oocyte retrieval. |
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|
Ovulation monitoring services for artificial insemination |
First day of treatment cycle |
Nil |
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|
Embryo biopsy for Pre-implantation Genetic Testing (PGT) |
Date service provided |
The patient fulfils the criteria of item 73384. Payable per embryo produced in an ART treatment cycle. |
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|
Planning and management for treatment by either:
|
First day of treatment cycle |
Bill with the same date of service as the appropriate global item - 13200, 13201, 13202, 13203 or 13218. |
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|
Oocyte retrieval for ART purposes |
Date service provided |
Provide in conjunction with 1 of the following items: 13200 or 13201. |
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|
Transfer of embryos, or both ova and sperm, to the uterus or fallopian tubes |
Date service provided |
Provide in conjunction with 1 of the following items: 13200, 13201 or 13218. |
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|
Preparation of frozen or donated embryos, or donated oocytes, for transfer to the uterus or fallopian tubes |
First day of treatment cycle |
Do not provide in conjunction with items 13200, 13201, 13202, 13203 or 13212. |
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|
Preparation of semen for artificial insemination |
Date service provided |
Do not provide for IVF purposes Provide in conjunction with item 13203. |
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|
Open surgical testicular sperm retrieval, unilateral, using operating microscope |
Date service provided |
Only performed as inpatient service. Not with item 13218 or 37604. |
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|
Intracytoplasmic sperm injection for male factor infertility |
Date service provided |
Don’t provide with item 13203 or 13218 in the same treatment cycle. Items 37605 and 37606 cover sperm retrieval procedures for intracytoplasmic sperm injection. Items 13251, 37605 and 37606 don’t include services for artificial insemination. |
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Billing for failed treatment cycle
| Treatment cycle fails | Cycle is | MBS item billing |
|---|---|---|
| After oocyte retrieval | Unsuccessful | 13200 - initial cycle or 13201 - subsequent cycle |
| Before oocyte retrieval | Incomplete |
13202 |
MBS items for billing donor and recipient services
You must bill services for donated ova against the donor and not the recipient. You can only perform ART services on a donor if you've identified a medically infertile recipient. This is because under Medicare a medically infertile recipient is a precondition for receiving ART services. Medicare benefits can only apply if there's a medical condition that requires treatment.
Donor services
Billing MBS items for patients donating their ova:
| MBS items | Item notes |
|---|---|
| 13200, 13201, 13202 | These items don’t include artificial insemination services. |
| 13209 | Nil |
| 13212 | Nil |
| 13221 |
For the preparation of sperm for artificial insemination. Can be billed if performed in association with item 13203. This item excludes sperm preparation for ART using IVF. |
| 13251 | Nil |
Recipient services
Billing MBS items for patients receiving donated ova, sperm or embryos.
| MBS items | Item notes |
|---|---|
| 13209 | Nil |
| 13215, 13218 | These items don’t include services provided for artificial insemination. |
Common billing errors and useful tips
You must provide the correct start date of a treatment cycle on Medicare claims or we may reject your claim. This table outlines some of the common reasons for rejected claims and useful tips.
| Items | Reasons for rejection | Useful billing tips |
|---|---|---|
| 13200, 13201, 13202, 13203, 13218 |
Associated service already paid Maximum number of services already paid |
Check the date of service is the first day of the treatment cycle. Each treatment cycle ends no more than 30 days after this date. When the date of service of a subsequent global item is within 26 days of a previous global item, you can note ‘short cycle’ on the account. Check the item descriptor. Item 13200 or 13202 are for the initial cycle in the calendar year. Item 13201 is for subsequent cycles. |
| 13209 |
No referral details Associated service not claimed or IVF service conditions not met |
Check the referral details. Patients must be referred to a specialist for ART planning and management. You need to include current referral details on the account. Check date of service is the date of the first day of treatment cycle. This is the same date as global treatment items 13200, 13201, 13202, 13203, and 13218. |
| 13212, 13215, 13221 | Associated service not claimed |
Check the global item is present, either on the same account or previously paid. Check the date of service. Each treatment cycle ends no more than 30 days after the date of the global item. When any of these item numbers have a date of service 30 days or more after the global item, you can note ‘long cycle’ on the account. |
Fertility cryopreservation
You can bill item 13260 for processing and cryopreservation of semen.
This item applies to post-pubertal patients referred by a specialist or consultant physician to preserve fertility when undergoing gonadotoxic treatment - radiation or chemotherapy. RHCA patients are eligible for this item.
A patient can have a maximum of 2 semen collection cycles. A cycle involves taking up to 3 semen samples on alternate days.
You should collect the:
- first cycle before the patient has the first cytotoxic or radiation treatment
- second cycle if the patient has relapsed and requires more treatment.
Item 13260 doesn’t cover ongoing storage costs of the sperm sample.
More information
Read more about:
- the Schedule on MBS Online
- education services for health professionals
- our website disclaimer.
Contact us for Medicare provider enquiries.