EXPLANATORY STATEMENT
HEALTH INSURANCE ACT 1973
SECTION 4BA
HEALTH INSURANCE (PATHOLOGIST-DETERMINABLE SERVICES) AMENDMENT DETERMINATION 2012
Section 4BA of the Health Insurance 1973 (the Act) provides that the Minister may determine, following consultation with the Royal College of Pathologists of Australasia (RCPA), that a particular pathology service, or pathology services included in a class of pathology services, are pathologist-determinable services.
Section 16A of the Act specifies that certain requirements have to be met for the payment of Medicare benefits in relation to pathology services. Subsections 16A(1), (3) and (6) provide that a Medicare benefit is not payable in respect of a pathology service unless the service was rendered pursuant to a request or is a pathologist-determinable service.
The purpose of the pathologist-determinable services determination is to obviate the need for a request from a treating practitioner and allow for the payment of Medicare benefits to cover specific circumstances where:
- Services are requested and performed by an Approved Pathology Practitioner (APP) for their own patients; or
- Services are deemed necessary to perform in the interest of the patient by the APP, in light of results obtained from earlier tests performed in response to a request from the treating practitioner.
An example of the former is a haematologist or immunologist performing pathology services for their own patients. An example of the latter is the receipt of a request by a histopathologist for the examination of a biopsy specimen and following examination the histopathologist determines that further tests are necessary to complete the diagnosis. The histopathologist would be able to undertake further testing without the need to seek another request from the treating practitioner.
The RCPA identified the need to have item 73332 (a genetic test for human epidermal growth factor receptor 2 (HER2) gene amplification in tumour tissue from breast cancer patients) as a pathologist-determinable service. Tissue pathology items 72849 and 72850 were listed on the pathology services table in 2008 however were not included as pathologist-determinable services at that time in error. Tissue pathology items 72838, 72827 and 72828 should also be listed as originally requested items in line with other similar items on the PST.
Antigen detection items 69364, 69365 and 69367 were listed in the 2006 Determination however these items were renumbered in May 2007 as 69494, 69495 and 69496 and not amended in the Determination. This amendment replaces the old item numbers with the new item numbers. Item 73320 (detection of HLA-B27 by nucleic acid amplification) was incorrectly transposed as 73220.
This Amendment Determination includes new pathologist-determinable items, lists additional originally requested items and corrects the errors in item numbers.
The RCPA has been consulted concerning the amendments, as required by section 4BA of the Act.
Details of the amendments are set out in the Attachment.
This Determination is a legislative instrument for the purposes of the Legislative Instruments Act 2003.
This Determination commences on 1 January 2013.
ATTACHMENT
Details Of The Health Insurance (Pathologist-determinable Services) Amendment Determination 2012
Section 1 – Name of Determination
This section provides for the Determination to be referred to as the Health Insurance (Pathologist-determinable Services) Amendment Determination 2012.
Section 2 – Commencement
This section provides for the Determination to commence on 1 January 2013.
Section 3 – Amendment of the Health Insurance (Pathologist-determinable Services) Determination 2006 (No. 3)
This section provides that Schedule 1 of this Determination amends the Health Insurance (Pathologist-determinable Services) Determination 2006 (No.3).
Schedule 1 Amendments
Item [1] - Section 5
This item amends the reference to the Health Insurance Act 1973 from paragraph 4BA(b) to section 4BA as paragraph 4BA(b) specifically relates to pathology services in a class of pathology services whereas this Schedule relates to individual pathology services.
Item [2] - Subparagraph 5(b)(iii), table
This item substitutes the table to: include items 73332, 72849 and 72850 as “pathologist -determinable services” and 72827, 72828 and 72838 as “originally requested services”; and to substitute the incorrect item number 73220 for the detection of HLA-B27 by nucleic acid amplification with 73320.
Items 73332 (in-situ hybridization testing for human epidermal growth factor receptor 2 gene amplification) and 72849 and 72850 ((immunohistochemical examination) are rendered as pathologist-determinable services if an approved pathology practitioner determines that the service is necessary based on information provided by the requesting practitioner, the nature or appearance of the specimen, or as a consequence of information resulting from a pathology service mentioned in items 72813, 72816, 72817, 72818, 72823, 72824,72825,72826, 72827, 72828, 72830, 72836 or 72838.
Item [3] - Paragraph 5(c)
This item replaces the old item numbers for antigen detection items 69364, 69365 and 69367 with the new item numbers 69494, 69495 and 69496.