EXPLANATORY STATEMENT
HEALTH INSURANCE ACT 1973
SECTION 4BA
HEALTH INSURANCE (PATHOLOGIST-DETERMINABLE SERVICES)
DETERMINATION 2005
Section 4BA of the Health Insurance Act 1973 (the Act) provides for the Minister to determine that a particular pathology service, or pathology services included in a class of pathology services, be considered as pathologist-determinable services. The Royal College of Pathologists of Australasia have been consulted on this process, as required by section 4BA of the Act.
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 and allow for the payment of Medicare benefits to cover specific circumstances where:
- services are requested and performed by an Approved Pathology Practitioner (APP) such as a specialist pathologist, for their own patients; and
- services which an APP has deemed necessary to perform in the interest of the patient, in light of results obtained from earlier tests performed in response to a request from the requesting practitioner.
An example of the former is a haematologist or immunologist performing pathology services on their own patients. An example of the latter is the receipt of a request by a histopathologist for the examination of a biopsy specimen from an operation and following examination, determine 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.
Pathologists have identified a need to create item 73305 (the southern blot for detection of fragile X mutation) as a pathologist determinable test. This will clarify that the APP does not require a separate request to do this test when the results of the nucleic acid amplification test for the detection of fragile X mutation is inconclusive. Therefore item 73305 is considered pathologist determinable following a request for item 73300.
The following tests are identified as pathologist-determinable–
- items 72846 or 72847 or 72848 following a request for items 72813 – 72836,
- items 73059 or 73060 or 73061 following a request for items 73045 – 73051,
- items 72851 or 72852 following a request for items 72813 – 72836,
- item 73305 following a request for item 73300.
The commencement date for the new determination is 1 May 2005.
Tony Abbott