Message from the Medical Director

Firstly, a big thank you to Sally Muir and the entire SunDoctors Head Office team for the effort they put into making this year’s Sydney Summit so successful.

Thank you also to all those who submitted questions relating to Medicare billing. To address these questions and ensure we are all aware of the correct information, please see below for my responses.

I am very happy to discuss these answers with you further.

Dr Jonny Levy – Medical Director 

Supplementary Medicare Questions from the Clinical Seminar

Q: When you excise a lesion for pathology and the result requires further excision, do you include the original excision diameter in determining the follow-on excision?

A: My understanding is no. You must consider the measurements and margins of the lesion that is currently present (in this instance the scar) and not the previous lesion which was removed.

In the addendum at the end of this document you may find a specific example of how to work out the measurements for this scenario.

Q: If you take an entire lesion with a punch tool and close with sutures, is this counted as an ‘excision’?

A: Yes. Think of the punch as a ‘round scalpel’ in this scenario.

Q: Why are items 45200, 45203, 45206, 45207 for flap closures still in the MBS schedule?

A: Just because they are unable to be used in conjunction with a malignant / melanoma / TCUS (tumour, cyst, ulcer, scar) item, doesn’t mean you cannot use them alone.
(Angelo – Thank you for your insight)

Example: <14mm defect BCC on the face. A better cosmetic outcome would be achieved with a flap. Your choices are:

a) Claim 31361 – direct closure, with poorer cosmetic outcome ($186.70 – Schedule Fee)

b) Claim 31361 – close with a flap (flap is non-rebatable) ($186.70 – Schedule fee)

c) Claim 45200, but not 31361 – close with a simple flap; best cosmetic outcome ($284.35 – Schedule fee)

Q: 31376 for a Melanoma >30mm was not on the cheatsheet?

A: Thank you for pointing out and my apologies.

Q: Do you charge multiple 30195s; one for each actinic keratosis treated in a single session?

A: No; just the once per session.
Supplementary clinical question: Do I give local anaesthetic beforehand?
No. Hyfrecator set on 3 and select appropriate lesions (and appropriate patient).

Q: How should 30196 be billed?

A: There are two methods of claiming this.

a) Curette (properly) each lesion, send for pathology and put billing on hold until results in. Then for each, bill either: i. a 30196 for a correct treatment ii. a 30071, because this turned out to be something other than what you would consider a clinically definitive treatment with a curette (e.g. you thought it was a superficial BCC, but it turned out to be morpheic and will need wide excision). The 30196 Medicare accompanying notes clearly state that the treatment must have the result that: “…all extensions and infiltrations of the lesion are removed…” or

b) Biopsy each lesion (assuming that you clinically judge that it needs biopsy) and bill 30071s. Follow this by the appropriate management and billings – including 30196, if appropriate. I prefer Option b) which is to biopsy then treat as: – It makes more clinical sense – It is clinically logical to the patient – Avoids the hassle of storing & chasing ‘held billings’ and ensuring all paid to me – Avoids any clinical surprise. Any subsequent curettings (in the treatment) should also go to the lab:

  • We should not throw any skin removals in the bin
  • There is still the possibility (though remote) of a differing diagnosis on the deeper curette (especially if my initial biopsy was a shave or my initial punch went through a portion of the BCC / IEC that showed only a superficial cancer and the
    curette found another subtype / SCC.

Q: Do you bill an excisional biopsy (where you remove the entire lesion by shave excision and send it to pathology) a 30195 or a 30071.

A: I rarely shave biopsy in a way that would be deemed ‘treatment’. I would recommend that you typically bill a 30071 for the biopsy and then the appropriate curettage / excision item number for the definitive treatment. The billing of 30195 and 30071 comes down to clinical intent:

  • If the intent is solely ‘biopsy’ – 30071
  • If the intent is solely ‘treatment’ – 30195

If the intent was biopsy, but you happen to fully excise – 30071 must be billed. As per MBS Note T8.7:

“If the shave biopsy results in a definitive excision of the lesion, only 30071 or 30072 can be claimed”.

Q: Related to the question above: if you send a shave specimen to pathology (and hold billing) and then it comes back as a seb K, can you bill a 30195? Or is it a 30071?

A: 30195 specifically precludes seb Ks. This would be a 30071.

Please bear-in-mind, though, that a large number of seb Ks being biopsied might raise all sorts of red flags.
But further bear-in-mind the following article about a significant number of skin cancer masquerading as Seb Ks:

 Benign Seborrheic Keratosis May Mimic Cancer  J Cutan Pathol; ePub 2017 Jun 7; Chen, et al

Q: When you have a wound come back to you that needs another suture – either it dehisced or it was bleeding and needed another suture – what do you bill for that? I am aware that you need NNAC.

A: My reading of MBS Note T8.127 is that this is billed only as an attendance; there is no procedural item associated:

“An episode of care includes both the excision and closure for the same defect, even when excision and closure occur at separate attendances”.

This is ‘closure’, but not the normal ‘run of events’ – hence a ‘not normal aftercare’ and a consultation item number in keeping with the time spent.

Q: Related to the above – Can you bill item 23 post-excision if there is a complication e.g. wound infection?

A: Yes, you should bill the appropriate length consultation item in this circumstance. Clearly mark the consultation NNAC (Not Normal After Care) in your notes in case you are audited by Medicare.

Consider using “Autofill” for your notes. Please see the addendum at the end of the this document for a specific example of an “Autofill”

Q: To bill for a curette and cautery – Do you need to curette in 3 different directions or do you need to curette, cautery and then, curette and cautery again? I guess this is a clinical question too.

A: You need to curette effectively i.e. This is not a simple shave and cautery of the base. It must be multi-directional and multi-pass. There is debate around how many passes; most variations I have heard are around two vs. three. There is no debate around curetting in every direction.

I would caution against curettage and cryotherapy.  This runs a serious risk of aerosolising the patient’s blood. Diathermy does not carry the infection risk as cryotherapy in this situation would.

Q: Can you bill 23 after a biopsy to discuss the results of the histology?

A: Yes. 30071 does not include discussion of results in the descriptor.

  • Item 23 (and the other consultation items) has explanatory note a5, which includes the section:  “….Counselling or Advice to Patients or Relatives…”
  • For items 23 to 51 and 5020 to 5067 ‘implementation of a management plan’ includes counselling services.
  • The biopsy was to rule in / out skin cancer.  There will be the provision of advice around this. A negative biopsy result should still yield the advice to the patient observe the lesion in case it does not behave as expected.
  • A positive result will require a management plan.
  • For all patients attending, I would advise that they receive preventative health advice as this is integral to their ongoing wellbeing, with regards to skin cancer.
  • All of the above constitutes a ‘consultation’ for the purposes of Medicare.
  • I would advise that this consultation does not occur within 2 days of the biopsy as this falls within the ‘normal aftercare’ period and a billed consultation in this time (even though justified) may raise red flags with Medicare.

Q: Dr Michael Callan (thank you) raises a few item numbers that should be considered for use:

A: Please see some items to be considered for use:

30186 – Remember that this is definitive removal of palmar/plantar warts (<10), not just ablation. Michael uses a punch tool and then ablation at the base.
45030 – Use judiciously and remember it needs to be sutured to qualify.
30207 – This was mentioned but bears repeating. Clinical point: remember to add xylocaine to the mix. It is a painful injection otherwise (and not entirely pain-free with the LA)
45563 – Medicare definition: “NEUROVASCULAR ISLAND FLAP, including direct repair of secondary cutaneous defect if performed” – in this case, Michael was referring to a Keystone Flap.

ADDENDUM 

Example relating to follow on excision measurements: A 15mm x 17mm Level II, 0.3mm melanoma on the chest.

 

Skin-Excision-image

Procedure 1:
Excision Bx with 2mm margins (all round) =
Length = 17mm + 2mm + 2mm = 21mm
Breadth = 15mm + 2mm + 2mm = 19mm
Thus: a 19mm x 21mm defect
This is calculated as: (21+19) / 2
= 20mm
= item 31368

Procedure 2:
Clinically, the area is a little tight and you are very confident that you got a good 2mm clinical margin in the first procedure. So you elect for 8mm further margins around the scar. (NB: this is not a clinical discussion of the rights or wrongs of this.)
Scar is 1mm wide.
Therefore,
Length = 21mm + 8mm + 8mm = 37mm
Breadth = 1mm + 8mm + 8mm = 17mm
Thus: a 17mm x 27mm defect
This is calculated as: (37+17) / 2
= 27mm
= item 31375

Example of an “Autofill” for a consultation post excision where a patient presents with a complication:

Why not create an ‘autofill’ (with ‘deletables’ in italics) so you don’t have to type it? (NB: the below is not definitive nor caters for every situation/nuance. It just to start you off.)

Eg:
Not Normal After Care
Patient re-attended post-procedure.
Complication of:
Wound infection
Wound dehiscence

History & Symptoms:
Pain
Noted redness around wound
Exudate from wound
Offensive smell
Wound noted to have widened
Wound opened

On Examination:
Slightly dehisced wound
Spreading erythema from margins
Light exudate
Frank pus

Management:
Wound cleaned & re-dressed
Antibiosis
Wound edges freshened and wound re-sutured under sterile conditions and local anaesthesia

Advice:
Explained heightened level of care needed now
Ongoing dressings
Explained increased risk of scarring

Planned Review in: 3 / 5 / 7 days (Earlier PRN)

(NB: the planned review may potentially justify a further, required NNAC billing, if ever audited by Medicare).

A note on ‘autofills’; Please consider spending some time writing them now. It will save countless hours in consults in the future + form excellent notes should you ever be medico-legally queried or Medicare audited.

The simplest way to do it is to spend a week writing excellent notes for your patients and then cut/pasting them into a document, playing with the style and then placing them in Best Practise as ‘Autofills’.

The daily benefits of the initial hassle are overwhelmingly worth it.