Medicare Criteria: Requirements for Rebate Most pathology tests automatically qualify for a Medicare rebate; however, for some tests, Medicare requires that the patient satisfy certain clinical criteria before the rebate applies, or limits the frequency of testing, or both. Some tests do not qualify for a rebate under any circumstances. Please note that this list is not comprehensive. A large number of specialised tests in the general areas of metabolic and molecular genetic testing, occupational health, and environmental and nutritional testing, are not included. Activated Protein C (APC Resistance 1. 2. Personal proven history of venous thromboembolism, or Has a first-degree relative with proven APC Resistance. Alpha Fetoprotein (AFP): Serum (Tumour Marker A Medicare rebate is available for test(s) performed in monitoring malignancy, or in the detection or monitoring of hepatic tumours, gestational trophoblastic disease, or germ cell tumour. A Medicare rebate is only available for up to 2 tumour marker tests per episode (AFP, BhCG, CA 125, CA 15.3, CA 19.9, CEA). Antithrombin III 1. 2. Personal proven history of venous thromboembolism, or Has a first-degree relative with proven Antithrombin III. BhCG (Beta Human Chorionic Gonadotrophin) Total Serum (Pregnant) A Medicare rebate is available for one test performed in the diagnosis of threatened abortion, or follow-up of abortion, or diagnosis of ectopic pregnancy. BhCG (Beta Human Chorionic Gonadotrophin) Total Serum (Tumour Marker)) A Medicare rebate is available for test(s) performed in monitoring malignancy, or in the detection or monitoring of hepatic tumours, gestational trophoblastic disease, or germ cell tumour. A Medicare rebate is only available for up to 2 tumour marker tests per episode (AFP, BhCG, CA 125, CA 15.3, CA 19.9, CEA). CA 125, CA 15.3, CA19.9 A Medicare rebate is available for test(s) performed in monitoring malignancy, or in the detection or monitoring of hepatic tumours, gestational trophoblastic disease, or germ cell tumour. A Medicare rebate is only available for up to 2 tumour marker tests per episode (AFP, BhCG, CA 125, CA 15.3, CA 19.9, CEA). CEA (Carcinoembryonic Antigen) A Medicare rebate is available for test(s) performed in monitoring malignancy, or in the detection or monitoring of hepatic tumours, gestational trophoblastic disease, or germ cell tumour. A Medicare rebate is only available for up to 2 tumour marker tests per episode (AFP, BhCG, CA 125, CA 15.3, CA 19.9, CEA). Free T3 (Triiodothyronine) FT3 only available with TSH. For both FT3 and TSH, thyroid history and medications must be included in clinical notes. If no thyroid history is given to satisfy Medicare criteria, only the TSH will be performed. If FT3 is requested and no history is given, it will only be performed if the TSH is abnormal. Free T4 (Thyroxine) FT4 only available with TSH. For both FT4 and TSH, thyroid history and medications must be included in clinical notes. If no thyroid history is given to satisfy Medicare criteria, only the TSH will be performed. If FT4 is requested and no history is given, it will only be performed if the TSH is abnormal. Fructosamine 1. 2. The patient has established diabetes. No more than 4 tests per patient per year. Haemochromatosis Gene Test 1. 2. 3. The patient has an elevated transferrin saturation or elevated serum ferritin on testing of repeated specimens, or The patient has a first-degree relative with haemochromatosis, or The patient has a first-degree relative with homozygosity for the C282Y genetic mutation, or with compound heterozygosity for recognised genetic mutations for haemochromatosis Haemoglobin A1c 1. 2. The patient has established diabetes. No more than 4 tests per patient per year. Hepatitis B (HBV) Viral Load Medicare criteria (four per year): Patient is hepatitis B surface antigen positive and has chronic hepatitis B, and is receiving antiviral therapy. Hepatitis C Virus (HCV) Genotyping Medicare criteria (one per year): 1. The test is requested by a specialist or consulting physician managing the patient’s treatment, and 2. Patient is hepatitis C Virus (HCV) PCR positive and being evaluated for antiviral therapy of chronic HCV hepatitis. Hepatitis C Virus (HCV) PCR: Qualitative Factor V Leiden PCR Medicare criteria (one per year): 1. The patient is hepatitis C seropositive, or 2. The patient’s serological status is uncertain after testing, or 3. The test is performed for the purpose of: a. determining the hepatitis C status of an immunosuppressed or immunocompromised patient, or b. the detection of acute hepatitis C prior to seroconversion where considered necessary for the clinical management of the patient, Fragile X Gene Test Hepatitis C Virus (HCV) PCR: Qualitative (assessment of antiviral therapy of HCV) Eosinophil Cationic Protein (ECP) For monitoring the response to therapy in cortiscosteroid treated asthma. Medicare rebate is available only for patients under 12 years of age. Maximum of 3 assays in 1 year. 1. 2. 1. 2. Proven DVT/PE in patient, or Proven defect of this mutation in a first-degree relative. The patient exhibits one or more of the clinical features of fragile X (A) syndrome, including intellectual disabilities, or The patient has a relative with a fragile X (A) mutation. Medicare criteria (4 per year): Patient is undertaking antiviral therapy for hepatitis C. Hepatitis C Virus (HCV) PCR: Quantitative Medicare criteria (2 per year): 1. The test is requested by a specialist or consulting physician managing the patient’s treatment, and 2. The patient has undergone pre-treatment evaluation for antiviral therapy for chronic hepatitis C. Hepatitis Serology A Medicare rebate is available on up to 2 hepatitis serology tests per episode, unless clinical notes indicate hepatitis – e.g. abnormal Liver Function Tests (LFT), in which case 3 tests per episode will be covered by Medicare. Some conditions apply to combinations of tests. Antenatal Hepatitis Testing Only HBs Ag and Hep C Ab can be performed alongside other antenatal serology, unless the patient has clinical notes indicating current hepatitis infection. Immunity testing would have to be performed on another collection, separate to any other antenatal serology testing. Non-Pregnant Hepatitis Testing 1 test (69475) — One test for hepatitis antigens or antibodies to determine immune status or viral carriage following exposure to, or vaccination against, Hepatitis A, Hepatitis B, Hepatitis C or Hepatitis D. Item 69478 = 2 tests described in 69475 Choose two tests from either the acute or the immune options listed below. Acute: Hep A IgM, HBs Ag, Hep C Ab, Hep D Ab or Immune: Hep A IgG, HBs Ab, HBc IgG, HBe AB, Hep C Ab. Item 69481 = 3 tests described in 69475 for the investigation of infectious causes of acute or chronic hepatitis. (Note it is for acute and chronic, not immune, hepatitis) (Item subject to Rule 11) Three tests may be performed only if the clinical notes indicate the patient has acute or chronic hepatitis, or if the Dr’s request (NOTE: NOT this episode’s laboratory results, unless as an added test) says there are clinical or laboratory indications of hepatitis — e.g. hepatomegaly, jaundice, abnormal liver function, vomiting and diarrhoea etc. THREE TESTS — choose three tests (See restrictions listed above) from the acute or chronic options listed below. Hep A IgM, HBs Ag, HBc Ab IgM, HBcAb IgG, HBe Ag, HBe Ab, Hep C Ab, Hep D Ab. The immune tests HBs Ab and Hep A IgG would not be included unless added by the laboratory as an aid to diagnosis. Note: 2 tests (69478) or three tests (69481 + P16.8) Hepatitis B core IgM Ab, Hepatitis Be Antigen and Hepatitis Be Ab will not be performed unless the Hepatitis B surface antigen is known or has been tested to be positive. In the latter case, they will be added as supplemental tests by the laboratory. Human Papillomavirus (HPV) DNA Typing Medicare criteria are that, within the last 2 years: 1. Patient has received excisional or ablative treatment for high-grade squamous intraepithelial (HSIL) abnormalities of the cervix; or 2. Patient has had a positive HPV test after excisional or ablative treatment for high-grade intraepithelial abnormalities of the cervix, or is already undergoing annual cytological review for follow-up of previously treated HSIL. A Medicare rebate is available for up to 2 tests per 24month period. Methylene Tetrahydrofolate Reductase Gene Test 1. 2. Proven DVT/PE in patient, or Presence of this mutation in a first-degree relative. Prostate Specific Antigen (PSA): Free/Total ratio Only one test per patient per year in the follow-up of a PSA result that: 1. Lies at or above the age related median but below the age related, method specific 97.5% reference limit – 1 test per 12 month period; or 2. Lies at or above the age related, method specific 97.5% reference limit, but below a value of 10 μg/L – 4 tests per 12 month period. Prostate Specific Antigen (PSA): Total Only one test per patient per year, unless for the monitoring of previously diagnosed prostatic disease. Protein C 1. 2. History of venous thromboembolism, or Has a first-degree relative with proven Protein C deficiency. Protein S 1. 2. Personal proven history of venous thromboembolism, or Has a first-degree relative with proven Protein S deficiency. Prothrombin Gene Mutation (20210) 1. 2. Personal proven history of venous thromboembolism, or Presence of this mutation in a first-degree relative. Quantiferon When testing for latent tuberculosis in immunosuppressed or immunocompromised patients. RAST 1. 2. Up to 4 requests of 4 allergens each may be ordered per year. A maximum of 4 RAST tests may be ordered at any one time. Requests for additional tests on stored serum must be dated 2 weeks apart in order to attract Medicare rebate. Red Cell Folate Maximum of 3 tests per patient per year. Thrombophilia Testing Screen 1. 2. Personal proven history of venous thromboembolism. Has a first-degree relative with a proven defect of Antithrombin III, Protein C, Protein S, or APC Resistance and testing for that defect only. NOTE: This is not an ‘Acceptable Group Test’ for Medicare purposes. To receive a Medicare rebate, the tests within this group must be ordered individually. Thyroglobulin See Tumour Markers. Thyroid Function Tests (TFT) For both TSH and/or FT4, thyroid history and medications must be included in clinical notes. If no thyroid history is given to satisfy Medicare criteria, only TSH test will be performed. If FT4/FT3 is requested and no history is given, they will only be performed if the TSH is abnormal. Tumour Markers (AFP, BhCG, CA125, CA15.3, CA19.9. CEA, Thyroglobulin) A Medicare rebate is available for test(s) performed in monitoring malignancy, or in the detection or monitoring of hepatic tumours, gestational trophoblastic disease, or germ cell tumour. A Medicare rebate is only available for up to 2 tumour marker tests per episode. Vitamin A, B1, B2, B3, C and E in blood, urine or other body fluids — only one request for 1 or more tests within a 6 month period. Medicare criteria for Urine Drug Screening Eligible for rebate    Patients participation in a drug abuse treatment program (maximum of 36 screens in any 12 month period) patients undergoing sleep studies Patients undergoing treatment for psychiatric disorders Not eligible for rebates     Patients requesting self-testing Employment/pre-employment testing Testing for court purposes GCMS confirmations of detected urine drug screens for drugs of abuse (even if the original drug screen was for the monitoring of patients participating in a drugs of abuse treatment program) Correct at time of printing – January 2012. Content may change subject to Medicare Australia criteria Circumstances where Medicare rebate never applies           screening for employment purposes – including pre-employment and WH&S testing screening of students for clinical access testing for court purposes workers compensation insurance testing immigration/visa testing screening of sports people – including serology for boxing medicals surveillance of sports people and athletes for performance improving substances screening of IVF donors testing for elective cosmetic surgery  detection of nicotine and metabolites in smoking withdrawal programs. Clinipath Pathology 647 Murray Street West Perth 6005 T: 08 9476 5222 F: 08 9322 9338 E: [email protected] W: www.clinipathpathology.com.au Clinipath Pathology Pty Ltd trading as Clinipath Pathology and Bunbury Pathology ABN 57 008 811 185 A subsidiary of Sonic Healthcare Limited ABN 24 004 196 909