Medicare ultrasound services

Information about servicing and claiming requirements for Medicare ultrasound services.

This information outlines the main requirements for providing Medicare Benefits Schedule (MBS) ultrasound services, items 55028-55895.

Make sure you read the relevant MBS item descriptions and explanatory notes on the MBS online website.

Types of ultrasound services (R and NR)

R-type (requested) services

We’ll pay Medicare benefits for R-type ultrasound services if:

  • an eligible health professional sends you a request in writing
  • you get the request in writing before providing the service.

Rendering practitioners need to check the patient to decide if the requested services are appropriate.

NR-type (non-requested) services

Some R-type services have similar NR-type items in the MBS. You can claim them if the requirement for the requests doesn’t meet specific circumstances.

Providing ultrasounds under specific circumstances

You can use the R and NR type services for a range of circumstances.

Situation Example Can claim R-Type item? Can claim NR-Type item? Notation required on the claim
Specialist or consultant physician providing ultrasound service specifically requested by the requesting health professional The patient has a request and a specialist in diagnostic radiology provides or supervises the service. No services other than those requested by the requesting health professional are needed Yes

Yes, if the service is provided as an additional or substituted service

None
Patient doesn’t have a request from an eligible practitioner The patient doesn’t have a request and has gone directly to the specialist in diagnostic radiology for the service No Yes, provided the service is reasonably required for the patient’s condition None

Specialist or consultant physician who isn’t a diagnostic imaging specialist providing an ultrasound service

A cardiologist determines that an echocardiogram is required for their patient based on the patient’s presentation. The echocardiogram wasn’t specifically requested by the requesting health professional

Yes, if they’re treating the patient in their specialty Yes ‘SD’ (self-determined)
Additional Services The patient has a request for a specific ultrasound service, but the specialist in diagnostic radiology providing the service determines that an additional ultrasound is required based on the results obtained from the requested service Yes, if the requesting health professional is eligible to request the service Yes Items provided as an additional service must be notated with ‘SD’ (self-determined)
Substituted Services The patient has a request for a specific ultrasound service, but the rendering practitioner determines that a different ultrasound service is required based on the presentation of the patient. The rendering practitioner consults with the requesting health professional, or takes all reasonable steps to do so, before providing the substituted service Yes, if the requesting health professional is eligible to request the service Yes ‘SS’ (substituted service)
Remote areas A practitioner with a remote area exemption performs an ultrasound in an area more than 30 kilometres by road from a hospital that performs radiology services or a free-standing radiology clinic Yes, only if the remote area exemption has been granted for the service and the practitioner Yes None
Emergencies A health professional who’s eligible to provide diagnostic imaging services determined that the service should be performed as quickly as possible because the need for the service arose in an emergency Yes Yes emergency
Lost requests The patient had a request but has lost it. The rendering practitioner gets confirmation from the requesting health professional that the request had been made Yes NA lost request

Read more about requests for diagnostic imaging services in Note IN.0.6 on the MBS online website.

Read more about notation requirements in Note IN.0.8 on the MBS online website.

Professional supervision for R-type ultrasound services

Ultrasound services marked with the symbol (R) are only eligible for a Medicare benefit if they’re performed under professional supervision. This rule doesn’t apply to items 55600 and 55603.

Supervision can be from either a:

  • specialist in the practice of their specialty
  • consultant physician in the practice of their specialty.

A practitioner who isn’t a specialist or consultant physician can supervise ultrasound services if they meet the requirements in Note IN.0.13.

Practitioners can also claim Medicare benefits for ultrasound services either in:

  • an emergency
  • a location that is further than 30 kilometres by the most direct road route from another practice.

Find out more in the Diagnostic Imaging Services Table (DIST) on the MBS online website.

The purpose of this supervision is to:

  • monitor and influence the conduct and diagnostic quality of the examination
  • examine the patient face-to-face if necessary.

Personal attendance

The practitioner supervising ultrasound services should examine the patient face-to-face when medically necessary.

The patient should have a short waiting time and not have to re-book.

Providing multiple ultrasound services

You may perform multiple ultrasound services on the same occasion in some circumstances. Several rules may apply when calculating Medicare benefits for providing multiple services.

Some items for services may not be payable with other services (restriction) you provided in the same attendance. We may also reduce the benefit if you claim multiple services together.

Claiming ultrasound services and notation requirements

Situation Requirements Notation required on the claim
One ultrasound item claimed per attendance Medicare benefit payable once only for ultrasounds at the one attendance regardless of the areas involved None
Multiple ultrasound items claimed for non-contiguous body areas

Requirements are:

  • more than one ultrasound is required on same occasion
  • the scans relate to non-adjoining body areas for the patient
non-contiguous body areas
Multiple ultrasound items claimed for contiguous body areas

Requirements are:

  • more than one ultrasound is required on same occasion
  • the scans relate to adjoining body areas for the patient
  • a clear difference in set-up and scanning
contiguous body areas with different set-up requirements

Practitioners should only ask patients to return on a separate occasion for scans if it’s clinically relevant.

Diagnostic Imaging Multiple Services Rules (DIMSR)

There’s service rules that determine how we pay Medicare benefits if you provide multiple ultrasound services in the same attendance. Service rules reduce the schedule fee of the diagnostic imaging service if you provided an imaging service with other services.

There’s 3 rules (A, B, and C) relating to multiple diagnostic imaging services. More than one rule may apply in a patient episode.

  Applies to Rule Example
A A diagnostic imaging service provided with other imaging items from the Diagnostic Imaging Services Table (DIST) The schedule fee for the diagnostic imaging service with the highest schedule fee is unchanged. The schedule fee for each additional diagnostic imaging service is reduced by $5

A patient sees you for neck and abdominal ultrasounds (item A and item B). Item B has the highest schedule fee, therefore: B = $109.10 A = $50.65 (usually $55.65, but is reduced by $5 due to Rule A)

B

A diagnostic imaging service provided with consultation items

Read more about multiple services rules in Note IN.0.11 on the MBS online website

 

If at least one R-type diagnostic imaging service and one consultation service is provided to a patient on the same day, the schedule fee for the diagnostic imaging service with the highest schedule fee is reduced based on the consultation item with the highest schedule fee

A patient sees you for an abdominal ultrasound (item A) a consultation (item C)

As the consultation item C has a schedule fee of $44.35, the ultrasound item schedule fee is reduced to $20.65 (from $55.65)

Consultation item schedule fee is more than $40 - the diagnostic imaging service with the highest schedule fee is reduced by $35
Consultation item schedule fee is $15 to $40 - the diagnostic imaging service with the highest schedule fee is reduced by $15
Consultation item schedule fee is less than $15 - the diagnostic imaging service with the highest schedule fee is reduced by the amount of the consultation item schedule fee
C

A diagnostic imaging service provided with non-consultation item(s) from the MBS

Read more about multiple services rules in Note IN.0.11 on the MBS online website

If an R-type diagnostic imaging service and least one non-consultation service are provided to the same patient on the same day, the schedule fee for the diagnostic imaging service with the highest schedule fee is reduced by $5

‘Non-consultation’ items from the MBS are:

  • Category 2 items
  • Category 3 items
  • Category 4 items
  • Cleft Lip and Cleft Palate services

A patient sees you for an abdominal ultrasound (item D) and a blood volume estimation (item E)

The schedule fee for item D is reduced to $107.95 (from $112.95)

B and C Where both rules B and C apply The sum of the deductions in the schedule fee for the diagnostic imaging service with the highest schedule fee must not exceed the original schedule fee (there cannot be a negative schedule fee)

A patient sees you for:

  • an abdominal ultrasound (item D)
  • a consultation (item C with schedule fee above $40)
  • a blood volume estimation (item E).

Per rule B and C, the total deductions are $40.00. This does not exceed the schedule fee for the diagnostic imaging item (D @ $112.95)

Multiple Vascular Ultrasound Services Rule (MVUSSR)

Vascular ultrasound services have a further multiple services rule that affect the benefit we pay for each service.

The following formula applies to the schedule fee for each vascular ultrasound service:

  • 100% for the item with the greatest schedule fee.
  • Plus 60% for the item with the next greatest schedule fee.
  • Plus 50% for each other item.

If you perform multiple vascular ultrasound items that have the same fee value, the formula still applies. We take the item with the lower item number to have a higher value when applying the above fee changes.

If other diagnostic imaging items are performed on the same day, the general multiple services rule (Rule A) applies. We’ll treat multiple vascular ultrasound items as one combined service for Rule A.

Read more about rules that apply to multiple ultrasound services on the MBS online website.

Multiple Echocardiogram Services Rule (MESR)

The MESR applies to plain and stress echocardiograms in Category 5, Group I1, Subgroup 7 of the MBS.

If you provide a patient with multiple echocardiogram services on the same day, we’ll reduce your scheduled fees. The reduction to the items you claim will apply as follows:

  • the item with the highest schedule fee will have no reduction applied
  • the items with the lower schedule fees will be reduced to 60% of the schedule fee.

This rule applies even if you perform the services at different attendances on the same day.

Read more about safe and best practice cardiac imaging services on the MBS online website.

Diagnostic Imaging Multiple Services Rules (DIMSR) and MESR both apply

When both MESR and DIMSR apply, the affected echocardiogram items are treated as one combined service.

We calculate Medicare benefits in the following order:

  1. The MESR at rates of 100%, 60%, 60%.
  2. The DIMSR under rules A, B and C.

Multiple Vascular Ultrasound Services Rule (MVUSSR), MESR and DIMSR all apply

When MESR, MVUSSR and DIMSR all apply, we treat affected items as one combined:

  • echocardiography service, this is for the total sum of fees for all items where MESR has been applied
  • vascular ultrasound service, this is for the total sum of fees for all items where MVUSSR has been applied.

The DIMSR rules are calculated using these 2 services and the remaining affected services for:

  • diagnostic imaging under rules A, B and C
  • consultation or non-consultation under rules B and C.

Musculoskeletal ultrasound items

We only pay Medicare benefits for a musculoskeletal ultrasound service if the responsible practitioner:

  • attends during the performance of the service
  • examines the patient face-to-face.

This requirement doesn’t apply to services they’ve performed because of medical necessity in a remote location. A remote area is more than 30 kilometres, by the most direct road route, from another practice.

Find out more in the Diagnostic Imaging Services Table (DIST) on the MBS online website.

Multiple musculoskeletal ultrasound scans

We’ll pay Medicare benefits for more than one musculoskeletal ultrasound service that a practitioner performs on the same day. These services are subject to Rule A of the general diagnostic imaging multiple services rules.

If a practitioner performs a bilateral ultrasound as per the items description, they can only bill the relevant item once. This also applies if the item description states either:

  • one or both sides
  • left and right.

Practitioners should avoid asking patients to make a second appointment if multiple scans are required.

Example

If the item description refers to a scan of ‘one or more areas’, you should only bill the item once.

Ultrasound reporting requirements

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

Unless an ultrasound item is designed for use in surgery, a report of the requested service must be provided to the requesting health professional.

Sonographers

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

  • suitably qualified
  • involved in a relevant and appropriate Continuing Professional Development program
  • registered on the Register of Accredited Sonographers.

Reporting requirements

The name of the sonographer must be included on the report.

The patient copy of the report doesn’t need the name of the sonographer to be included.

Ultrasound services where Medicare benefits aren’t payable

We don’t pay Medicare benefits for ultrasound services if the service:

  • isn’t reasonably needed for managing the patient’s medical condition
  • doesn’t meet the MBS item description.

Example

For ultrasound item F, the item description states it’s only when a scan is ordered for:

  • abnormality of tendons or bursae about the knee
  • meniscal cyst, popliteal fossa cyst, mass or pseudomass
  • nerve entrapment, nerve or nerve sheath tumour, or injury of collateral ligaments.

Practitioners can’t claim this item for any reason other than those listed in the item description.

If they do claim the item for non-specific knee pain, it wouldn’t meet the MBS item description. It also wouldn’t be reasonably required to treat the patient’s condition, so isn’t eligible for a Medicare benefit.

Reports provided by practitioners located outside Australia

We won’t pay Medicare benefits for ultrasound services if a practitioner located outside of Australia reported on them.

Practitioners must complete all elements of the service, including preparation of the report, in Australia.

Record keeping

All practitioners who provide or initiate a service which we pay a Medicare benefit for must maintain adequate records.

These records must:

  • be kept up to date
  • be easy to retrieve using the patient’s name and the date of the service
  • include the report by the providing practitioner for the service.

If a sonographer performs a service on behalf of a practitioner, they must record their initial and surname in the report.

If the practitioner substitutes a service, they must write in their records they’ve either:

  • consulted the requesting health professional and when they consulted them
  • taken all reasonable steps to consult the requesting health professional.

If a providing practitioner loses a request, they must:

  • write in the records they lost the request
  • confirm the information from the request with the requesting health professional
  • include the date of confirmation and how they received confirmation in their records.

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

Retention of requests

A practitioner who provides an R-type ultrasound service in response to a request must keep that request for 2 years from the day the service was rendered.

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Page last updated: 26 September 2022