Education guide - Medicare ultrasound services
Information about servicing and claiming requirements for Medicare ultrasound services.
This information outlines key requirements for providing Medicare Benefits Schedule (MBS) ultrasound services, items 55005-55855. Make sure you read the relevant Medicare Benefits Schedule (MBS) item descriptions and explanatory notes at MBS Online.
Types of ultrasound services (R and NR)
Medicare benefits for R-type (requested) ultrasound services in the MBS are only payable if the rendering practitioner receives a relevant request from an eligible requesting practitioner prior to the service being provided.
Requesting practitioners must ensure that the service or services being requested are clinically relevant and necessary.
An ultrasound to determine the sex of a foetus would generally only be clinically relevant if there is an indication the service will determine further courses of treatment. For example, where there is a genetic risk of a sex-related disease or condition.
Rendering practitioners should also assess requests and the patient to determine if the service being requested is appropriate. More information about additional and substituted services is below.
NR-type (non-requested) services
Some R-type services have corresponding NR-type (non-requested) items in the MBS. Providers should claim the corresponding NR-type services if the requirements for requests below are not met.
More information about circumstances where a request is required is below.
Providing ultrasounds under specific circumstances
The R and NR type services can be used in a range of circumstances. The below table outlines how they can be used and claimed.
|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 referring practitioner||The patient has a request and a specialist in diagnostic radiology provides or supervises the service. No services other than those requested by the referring practitioner are needed||Yes||Yes – if the service is provided as an additional or substituted service. See additional services or substituted services for more information||None|
|Patient does not have a request from an eligible practitioner||The patient does not have a request and has gone directly to the specialist is diagnostic radiology for the service(s)||No||Yes – provided the service is reasonably required for the patient’s condition||None|
|Specialist or consultant physician providing an ultrasound service who is not a diagnostic imaging specialist||A cardiologist determines that an echocardiogram is required for one of their patients based on the patient’s presentation. The echocardiogram was not specifically requested by the referring practitioner||Yes – if they are 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 referring practitioner 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 practitioner, or takes all reasonable steps to do so, before providing the substituted service||Yes – if the referring practitioner is eligible to request the service||Yes||‘SS’ (substituted service)|
|Remote areas||A medical 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 is 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 practitioner that the request had been made||Yes||NA||‘lost request’|
See note IN.0.1 in the MBS for more information about diagnostic imaging services.
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. Supervision can be from either 1 of the following:
- a specialist in the practice of their specialty
- a consultant physician in the practice of their specialty.
A practitioner who isn’t a specialist or consultant physician can supervise ultrasound services. This is provided they meet the requirements according to the MBS.
This rule doesn’t apply to items 55600, 55601 and 55603.
Apart from in the above circumstances, providers can claim a Medicare benefits for ultrasound services either:
- in an emergency
- in a location that is further than 30 kilometres by the most direct road route from another practice. This is outlined in the Diagnostic Imaging Services Table (DIST).
The purpose of this supervision is to:
- monitor and influence the conduct and diagnostic quality of the examination
- personally attend the patient if necessary.
The practitioner supervising ultrasound services should:
- be capable of personally attending the patient when medically necessary
- decide to personally attend in accordance with accepted medical practice
- be able to attend the patient during the patient’s original appointment. The patient should only have to wait a short period of time and should not have to re-book.
The specialist or consultant physician must personally attend and examine the patient when performing musculoskeletal ultrasound scans.
Providing multiple ultrasound services
In some circumstances it may be more efficient to perform multiple services on the same occasion. Several rules may apply when calculating Medicare benefits for providing multiple ultrasound services at the same attendance. Some items for services may not be payable with other services (restriction) provided in the same attendance. The benefit may also be reduced if multiple services are claimed together.
Claims for ultrasound services should be notated with ‘non-contiguous body areas’ where all of the following apply:
- more than 1 ultrasound is required on same occasion
- the scans relate to not adjoining body areas for the patient
- the scans are clinically relevant.
Providers should only ask patients to return on a separate occasion for scans for contiguous body areas if it’s clinically relevant.
Multiple service rules
There are service rules that determine how Medicare benefits are paid if multiple ultrasound services are provided in the same attendance.
Services rules reduce the schedule fee of the diagnostic imaging service where an imaging service is provided with other services. There are 3 rules (A, B, and C) relating to multiple diagnostic imaging services. More than 1 rule may apply in a patient episode.
|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 55014 and item 55032). Item 55032 has the highest schedule fee, therefore: 55032 = $109.10 55014 = $50.65 (usually $55.65, but is reduced by $5 due to Rule A)|
|B||A diagnostic imaging service provided with consultation items (items 1 to 10816 inclusive in the MBS)||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 55014) a consultation (item 105).As the consultation item 105 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 General Medical Services Table (GMST)||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 11000 to 12533, Category 3 items 13020 to 51318, Category 4 items 51700 to 53460, and items 75001 to 75854 for Cleft Lip and Cleft Palate services||
A patient sees you for an abdominal ultrasound (item 55036) and a blood volume estimation (item 12500).The schedule fee for item 55036 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:
Per rule B and C, the total deductions are $40.00. This does not exceed the schedule fee for the diagnostic imaging item (55036 @ $112.95)
More information about multiple service rules is available in note IN.1.10 of the MBS.
Vascular ultrasound multiple service rule
Vascular ultrasound services are subject to further multiple service rules that affect the benefit paid 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.
Where multiple vascular ultrasound items are performed that have the same fee value, the formula still applies. The item with the lower item number will be taken 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. Where this occurs the multiple vascular ultrasound items will be treated as one combined service. This means the Rule A change occurs only once.
Learn more about the rules that apply to multiple ultrasound services.
Multiple Echocardiogram Services Rule (MESR)
The MESR applies to plain and stress echocardiograms in Category 5, Group I1, Sub-group 7 of the MBS. This includes both of the following:
- plain echocardiography items 55126-55129, 55132-55134 and 55137
- stress echocardiography items 55141, 55143, 55145-55146
Read the current factsheet for safe and best practice cardiac imaging services on the Department of Health mbsonline website.
If you provide a patient with multiple services from Sub-group 7 on the same day, your scheduled fees will be reduced. 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.
Diagnostic Imaging Multiple Services Rule (DIMSR) and MESR both apply
When both MESR and DIMSR apply, the affected echocardiograms items are treated as 1 combined service.
Medicare benefits are calculated in the following order:
- The MESR at rates of 100%, 60%, 60%.
- 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, the affected items are treated as:
- 1 combined echocardiography service. This is for the total sum of fees for all items where MESR has been applied.
- 1 combined vascular ultrasound service. This is for the total sum of fees for all items where MVUSSR has been applied.
The DIMSR rule is 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 A, B and C.
Musculoskeletal ultrasound items 55812 to 55895
Medicare benefits are only payable for a musculoskeletal ultrasound service if the responsible medical practitioner:
- personally attends during the performance of the service
- personally examines the patient.
Services that are performed in a remote area because of medical necessity are exempt from this requirement. A remote area is more than 30 kilometres, by the most direct road route, from another practice. This is further outlined in the DIST.
Multiple musculoskeletal ultrasound scans
Medicare benefits are payable for more than 1 musculoskeletal ultrasound service that a provider 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 descriptor, they can only bill the relevant item once.
Providers should avoid asking patients to make a second appointment if multiple scans are required.
If a provider scans both of a patient’s shoulders, they should still only bill item 55830 once. This is because the item descriptor states ‘1 or both sides’.
Similarly, if the item descriptor refers to a scan of '1 or more areas' providers should only bill the item once. This is the case for item 55844.
Ultrasound reporting requirements
For Medicare purposes, the rendering practitioner is the medical 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 provider.
Sonographers performing medical ultrasound examinations, either R- or NR-type items, on behalf of a medical practitioner must be:
- suitably qualified
- involved in a relevant and appropriate Continuing Professional Development program
- registered on the Register of Accredited Sonographers.
The name of the sonographer must be included on the report. This could be recorded either electronically or by hand.
The patient copy of the report does not require the name of the sonographer to be included.
Ultrasound services where Medicare benefits are not payable
Medicare benefits are not payable for ultrasound services where the:
- service is not reasonably required for managing the patient’s medical condition
- service doesn’t meet the MBS item descriptor.
As stated in the item descriptor, providers can only claim ultrasound item 55828 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.
Providers can’t claim this item for any reason other than those listed in the item descriptor. If a provider claimed this item for non-specific knee or shoulder pain it would not meet the MBS item descriptor. It also wouldn’t be reasonably required to treat the patient’s condition. Therefore it would not be eligible for a Medicare benefit.
Reports provided by practitioners located outside Australia
Medicare benefits are not payable for ultrasound services if a medical practitioner located outside of Australia reported on them.
Medical practitioners must complete all elements of the service, including preparation of the report, in Australia.
All practitioners who provide or initiate a service for which a Medicare benefit is payable must maintain adequate records. They must keep their records up to date. It must be simple to retrieve a record using the patient’s name and the date of the service.
The records must include the report by the providing practitioner for the service. If a sonographer performs a service on behalf of a medical practitioner, they must record their initial and surname in the report.
Where the provider substitutes a service, their records must include either:
- words indicating that they consulted the requesting practitioner and when they consulted them
- sufficient information to demonstrate that they have taken all reasonable steps to consult the requesting practitioner.
If a providing practitioner loses a request, they must:
- write in the records that they lost the request
- confirm the information from the request with the requesting practitioner
- 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 medical practitioner who provides an R-type ultrasound service in response to a request must keep that request for 2 years commencing on the day the service was rendered.
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Page last updated: 31 March 2021
This information was printed 16 June 2021 from https://www.servicesaustralia.gov.au/organisations/health-professionals/topics/education-guide-medicare-ultrasound-services/33206. It may not include all of the relevant information on this topic. Please consider any relevant site notices at https://www.servicesaustralia.gov.au/individuals/site-notices when using this material.