6.CAD‐related recommendations

6.1 CAD Working Group membership

The Committee formed a Working Group to consider CAD‐related services, including CTCA, ICA and PCI. This Working Group subsumed the PCI Review Working Group, which was created prior to the MBS Review. The CSCC Working Group reviewed and accepted the PCI Review report, which was prepared under the direction of the PCI Review Working Group (43). The PCI Review Report is available online at http://www.health.gov.au/internet/main/publishing.nsf/Content/ReviewsCMFM.

The CAD Working Group included the following members:

  • ΔProfessor Derek Chew (Chair) – Professor of Cardiology, Flinders University; Regional Director of Cardiology, Southern Adelaide Local Health Network.
  • ΔDr Ruth Arnold – Cardiologist, Orange Health Service; Chair, Rural Working Party, Cardiology, Agency for Clinical Innovation (ACI), New South Wales.
  • ΔAssociate Professor Jayme Bennetts - Department of Surgery, Flinders University; Director, Cardiac and Thoracic Surgery, Flinders Medical Centre; Chair, Government Relations, Australian and New Zealand Society of Cardiac and Thoracic Surgeons.
  • ΔDr Brett Forge – Cardiologist and General Physician.
  • ΔAssociate Professor Andrew MacIsaac – Director of Cardiology Services and Deputy Chief Medical Officer, St Vincent’s Hospital, Melbourne; Immediate Past President, Cardiac Society of Australia and New Zealand.
  • ΔMs Anne McKenzie – Independent consumer.
  • ΔDr David Muller – Director of Cardiac Catheterisation Laboratories, St Vincent’s Hospital, Sydney; Associate Professor of Medicine, University of New South Wales.
  • ΔAssociate Professor Ian Scott – Director, Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital; School of Medicine, University of Queensland.
  • ΔAssociate Professor John Troupis – Adjunct Associate Professor, Department of Medical Imaging & Radiation Science, Monash University; Unit Head Musculoskeletal Imaging and Co Unit Head Cardiac CT, Monash Health.
  • ΔProfessor Darren Walters – Cardiology Director, The Prince Charles Hospital; Executive Director Heart and Lung Stream, Metro North Hospital and Health Service.
  • ΔDr Noela Whitby AM – General Practitioner; Deputy Chair, RACGP Queensland Faculty Board; Director, the Australian Council on Healthcare Standards.
  • ΔProfessor Richard Harper (Ex-Officio) – Emeritus Director of Cardiology, Monash Medical Centre; Adjunct Professor of Medicine, Monash University (Ex-Officio).

The following recommendations were developed by the CAD Working Group and accepted unanimously.

The Committee also endorsed the recommendations unanimously.

6.2 Angiography

Current item descriptors and MBS data from FY 2014/15

Item 38200 – Schedule fee: $445.40
Services: 1,409  Total Benefits: $380,027  Average annual growth: 20.2%

Right heart catheterisation,, with any one or more of the following: fluoroscopy, oximetry, dye dilution curves, cardiac output measurement by any method, shunt detection or exercise stress test (Anaes.)

Item 38203 – Schedule fee: $531.55
Services: 44  Total Benefits: $11,634  Average annual growth: 1.4%

Left heart catheterisation by percutaneous arterial puncture, arteriotomy or percutaneous left ventricular puncture with any one or more of the following fluoroscopy, oximetry, dye dilution curves, cardiac output measurements by any method, shunt detection or exercise stress test (Anaes.)

Item 38206 – Schedule fee: $642.65
Services: 2,495  Total Benefits: $468,509  Average annual growth: 19.7%

Right heart catheterisation with left heart catheterisation via the right heart or by any other procedure with any one or more of the following: fluoroscopy, oximetry, dye dilution curves, cardiac output measurements by any method, shunt detection or exercise stress test (Anaes.)

Item 38215 – Schedule fee: $354.90
Services: 5,019  Total Benefits: $1,284,875  Average annual growth: 12.2%

Selective coronary angiography, placement of catheters and injection of opaque material into the native coronary arteries, not being a service associated with a service to which item 38218, 38220, 38222, 38225, 38228, 38231, 38234, 38237, 38240 or 38246 applies (Anaes.)

Item 38218 – Schedule fee: $532.25
Services: 54,211  Total Benefits: $21,889,745  Average annual growth: 1.3%

Selective coronary angiography, placement of catheters and injection of opaque material with right or left heart catheterisation or both, or aortography, not being a service associated with a service to which item 38215, 38220, 38222, 38225, 38228, 38231, 38234, 38237, 38240 or 38246 applies (Anaes.)

Item 38220 – Schedule fee: $177.40
Services: 14  Total Benefits: $1,601  Average annual growth: -1.4%

Selective coronary graft angiography placement of catheter(s) and injection of opaque material into free coronary graft(s) attached to the aorta (irrespective of the number of grafts), not being a service associated with a service to which item 38215, 38218, 38222, 38225, 38228, 38231, 38234, 38237, 38240 or 38246 applies (Anaes.)

Item 38222 – Schedule fee: $354.90
Services: 13  Total Benefits: $3,154  Average annual growth: 21.1%

Selective coronary graft angiography, placement of catheter(s) and injection of opaque material into direct internal mammary artery graft(s) to one or more coronary arteries (irrespective of the number of grafts), not being a service associated with a service to which item 38215, 38218, 38220, 38225, 38228, 38231, 38234, 38237, 38240 or 38246 applies (Anaes.)

Item 38225 – Schedule fee: $532.35
Services: 114  Total Benefits: $41,966  Average annual growth: -1.7%

Selective coronary angiography, placement of catheters and injection of opaque material into the native coronary arteries and placement of catheter(s) and injection of opaque material into free coronary graft(s) attached to the aorta (irrespective of the number of grafts), not being a service associated with a service to which item 38215, 38218, 38220, 38222, 38228, 38231, 38234, 38237, 38240 or 38246 applies (Anaes.)

Item 38228 – Schedule fee: $709.90
Services: 95  Total Benefits: $51,498  Average annual growth: 9.3%

Selective coronary angiography, placement of catheters and injection of opaque material into the native coronary arteries and placement of catheter(s) and injection of opaque material into direct internal mammary artery graft(s) to one or more coronary arteries (irrespective of the number of grafts), not being a service associated with a service to which item 38215, 38218, 38220, 38222, 38225, 38231, 38234, 38237, 38240 or 38246 applies (Anaes.)

Item 38231 – Schedule fee: $887.25
Services: 440  Total Benefits: $312,619  Average annual growth: 6.8%

Selective coronary angiography, placement of catheters and injection of opaque material into the native coronary arteries and placement of catheter(s) and injection of opaque material into the free coronary graft(s) attached to the aorta (irrespective of the number of grafts), and placement of catheter(s) and injection of opaque material into direct internal mammary artery graft(s) to one or more coronary arteries (irrespective of the number of grafts), not being a service associated with a service to which item 38215, 38218, 38220, 38222, 38225, 38228, 38234, 38237, 38240 or 38246 applies (Anaes.)

Item 38234 – Schedule fee: $709.75
Services: 477  Total Benefits: $242,610  Average annual growth: -5.1%

Selective coronary angiography, placement of catheters and injection of opaque material with right or left heart catheterisation or both, or aortography and placement of catheter(s) and injection of opaque material into free coronary graft(s) attached to the aorta (irrespective of the number of grafts), not being a service associated with a service to which item 38215, 38218, 38220, 38222, 38225, 38228, 38231, 38237, 38240 or 38246 applies (Anaes.)

Item 38237 – Schedule fee: $887.20
Services: 470  Total Benefits: $321,566  Average annual growth: 0.7%

Selective coronary angiography, placement of catheters and injection of opaque material with right or left heart catheterisation or both, or aortography and placement of catheter(s) and injection of opaque material into direct internal mammary artery graft(s) to one or more coronary arteries (irrespective of the number of grafts), not being a service associated with a service to which item 38215, 38218, 38220, 38222, 38225, 38228, 38231, 38234, 38240 or 38246 applies (Anaes.)

Item 38240 – Schedule fee: $1064.60
Services: 4,717  Total Benefits: $3,849,507  Average annual growth: 0%

Selective coronary angiography, placement of catheters and injection of opaque material with right or left heart catheterisation or both, or aortography and placement of catheter(s) and injection of opaque material into free coronary graft(s) attached to the aorta (irrespective of the number of grafts) and placement of catheter(s) and injection of opaque material into direct internal mammary artery graft(s) to one or more coronary arteries (irrespective of the number of grafts), not being a service associated with a service to which item 38215, 38218, 38220, 38222, 38225, 38228, 38231, 38234, 38237 or 38246 applies (Anaes.)

Item 38241 – Schedule fee: $469.70
Services: 3,692  Total Benefits: $676,644  Average annual growth: 50.3%

Use of a coronary pressure wire during selective coronary angiography to measure fractional flow reserve (FFR) and coronary flow reserve (cfr) in one or more intermediate coronary artery or graft lesions (stenosis of 30-70%), to determine whether revascularisation should be performed where previous stress testing has either not been performed or the results are inconclusive (Anaes.)

Item 38243 – Schedule fee: $443.60
Services: 5,479  Total Benefits: $787,641  Average annual growth: 2.2%

Placement of catheter(s) and injection of opaque material into any coronary vessel(s) or graft(s) prior to any coronary interventional procedure, not being a service associated with a service to which item 38246 applies (Anaes.)

Item 38246 – Schedule fee: $887.20
Services: 14,729  Total Benefits: $9,865,778  Average annual growth: 6.6%

Selective coronary angiography, placement of catheters and injection of opaque material with right or left heart catheterisation or both, or aortography followed by placement of catheters prior to any coronary interventional procedure, not being a service associated with a service to which item 38215, 38218, 38220, 38222, 38225, 38228, 38231, 38234, 38237, 38240 or 38243 applies (Anaes.)

Item 59903 – Schedule fee: $114.55
Services: 233  Total Benefits: $18,419  Average annual growth: 14.2%

Angiocardiography, including the service mentioned in item 59970, 59974, 61109 or 61110, not being a service to which item 59912 or 59925 applies (R) (K) (Anaes.))

Item 59912 – Schedule fee: $305.20
Services: 13,723  Total Benefits: $3,080,390  Average annual growth: 4.3%

Selective coronary arteriography, including the service mentioned in item 59970, 59974, 61109 or 61110, not being a service to which item 59903 or 59925 applies (R) (K) (Anaes.)

Item 59925 – Schedule fee: $362.45
Services: 69,508  Total Benefits: $18,438,657  Average annual growth: 1.9%

Selective coronary arteriography and angiocardiography, including a service mentioned in item 59903, 59912, 59970, 59974, 61109 or 61110 (R) (K) (Anaes.))

Item 59970 – Schedule fee: $168.30
Services: 698  Total Benefits: $87,665  Average annual growth: -0.4%

Angiography and/or digital subtraction angiography with fluoroscopy and image acquisition using a mobile image intensifier, one or more regions including any preliminary plain films, preparation and contrast injection (R) (K) (Anaes.)

Item 59971 – Schedule fee: $57.30
Services: 66  Total Benefits: $3,474  Average annual growth: 45.9%

Angiocardiography, including the service mentioned in item 59970, 59974, 61109 or 61110, not being a service to which item 59972 or 59973 applies (R) (NK) (Anaes.)

Item 59972 – Schedule fee: $152.60
Services: 918  Total Benefits: $108,256  Average annual growth: 41.8%

Selective coronary arteriography, including the service mentioned in item 59970, 59974, 61109 or 61110, not being a service to which item 59971 or 59973 applies (R) (NK) (Anaes.)

Item 59973 – Schedule fee: $181.25
Services: 394  Total Benefits: $54,572  Average annual growth: 2.9%

Selective coronary arteriography and angiocardiography, including a service mentioned in item 59970, 59971, 59972, 59974, 61109 or 61110 (R) (NK) (Anaes.))

Public data from 2014-15 (Department of Human Services).

Recommendation 12.1
  • ΔConsolidate the 23 existing MBS items for ICA into 13 revised items, which are summarised here and outlined with detailed proposed descriptors below.
  •  – Three items for ICA with native arteries—one for acute coronary syndrome (ACS), one for stable CAD, and one for pre-operative coronary assessment—with three duplicate items for ICA with coronary artery grafts.
  •  – One item for fractional flow reserve (FFR), as an add-on to ICA or PCI.
  •  – One item for right heart catheterisation as an add-on to any ICA number.
  •  – Three items for right, left and bilateral heart catheterisation (not associated with ICA)
  •  – Items 59970 and 59971 retained for non-cardiology use.
Recommendation 12.2
  • ΔThe 13 angiography items be created on the DIST and removed from the current locations on the schedule in order to utilise the Diagnostic Imaging Accreditation Scheme to provide accreditation and credentialing.

Table 13: Summary of changes to ICA items

Summary of changes to ICA items

Items 38200, 38203 and 38206: Retained and 3820X added for use with ICA.

Items 38215, 38218, 38220, 38222, 38225, 38228, 38231, 38234, 38237 and 38240: Replaced with items 38218A–C (native) and 38220A–C (grafts).

Items 38243 and 38246: Incorporated into new PCI items (replacing item 38306).

Item 38241: Retained.

Items 59903, 59912 and 59925: Deleted and incorporated into ICA items.

Items 59970 and 59971: Retained for non-cardiologist use, not to be claimed on the same day as an ICA/PCI item.

Items 59972 and 59973: Deleted and incorporated into the associated procedures.


Item 38218A

Selective coronary angiography, placement of catheters and injection of opaque material with or without left heart catheterisation, left ventriculography or aortography, as part of the management of a symptomatic patient for:

  1. Acute coronary syndromes evidenced by: ST segment elevation; or troponin elevation above the local upper reference limit; or resting wall motion abnormalities or perfusion defect at a time when it is too early to document troponin status; or
  2. Cardiogenic shock, resuscitated cardiac arrest, ventricular fibrillation or sustained VT.

Claimable once in any 3 month period unless a new ACS or equivalent occurs within this period and meets requirements 1 or 2 above.
Procedure report to include documentation of how the indication requirements of this descriptor were met.
Not being a service associated with a service to which items 38218B, 38218C, 38220A–C apply. (Anaes.)

Item 38220A

Selective coronary graft angiography, placement of catheter(s) and injection of opaque material into free coronary graft(s) attached to the aorta (irrespective of the number of grafts) and/or into direct internal mammary artery graft(s), with or without left heart catheterisation, left ventriculography or aortography, as part of the management for:

  1. Acute coronary syndromes evidenced by: ST segment elevation; or troponin elevation above the local upper reference limit; or resting wall motion abnormalities or perfusion defect at a time when it is too early to document troponin status; or
  2. Cardiogenic shock, resuscitated cardiac arrest, ventricular fibrillation or sustained VT.

Claimable once in any 3 month period unless a new ACS or equivalent occurs within this period and meets requirements 1 or 2 above.
Procedure report to include documentation of how the indication requirements of this descriptor were met.
Not being a service associated with a service to which items 38218A–C, 38220B, 38220C apply. (Anaes.)

Item 38218B

Selective coronary angiography, placement of catheters and injection of opaque material with or without left heart catheterisation, left ventriculography or aortography, as part of the management of a patient with suspected or known coronary artery disease who has limiting angina (CCS class II-IV) despite an adequate trial of optimal medical therapy, and has high risk features including at least one of:

  1. Ischaemia involving >10% of left ventricle or >2 myocardial segments, or stress dilatation/dysfunction on functional testing; or
  2. Functional testing with high risk features (ST segment elevation or sustained ST depression, hypotension, Duke treadmill score <=-11, or resting wall abnormalities); or
  3. CTCA evidence of left main stenosis >50% or evidence of non-LM significant obstructive disease (>70% stenosis) with symptoms consistent with ischaemia despite optimal medical management; or
  4. LV dysfunction (EF <40%) with evidence of myocardial viability (PET, CMR, Nuclear, Dobutamine Echo) in dysfunctional segment; or
  5. Persistent symptoms despite optimal medical therapy with discordant finding on functional testing (e.g. little (<5%) or no ischaemia with intermediate or high-risk stress ECG changes).

Procedure report to include documentation of how the indication requirements of this descriptor were met.
Claimable once in any 3 month period, including services for 38218 A–C and 38220A–C.
Not being a service associated with a service to which items 38218A, 38218C, 38220A–C apply. (Anaes.)

Item 38220B

Selective coronary graft angiography placement of catheter(s) and injection of opaque material into free coronary graft(s) attached to the aorta (irrespective of the number of grafts) and/or into direct internal mammary artery graft(s), with or without left heart catheterisation, left ventriculography or aortography, as part of the management of a patient with suspected or known coronary artery disease who has limiting angina (CCS class II–IV) despite an adequate trial of optimal medical therapy, and has high risk features including at least one of:

  1. Ischaemia involving >10% of left ventricle or >2 myocardial segments, or stress dilatation/dysfunction on functional testing; or
  2. Functional testing with high risk features (ST segment elevation or sustained ST depression, hypotension, Duke treadmill score <=-11, or resting wall abnormalities); or
  3. CTCA evidence of left main stenosis >50% or evidence of non-LM significant obstructive disease (>70% stenosis) with symptoms consistent with ischaemia despite optimal medical management; or
  4. LV dysfunction (EF <40%) with evidence of myocardial viability (PET, CMR, Nuclear, Dobutamine Echo) in dysfunctional segment; or
  5. Persistent symptoms despite optimal medical therapy with discordant finding on functional testing (e.g. little (<5%) or no ischaemia with intermediate or high-risk stress ECG changes).

Procedure report to include documentation of how the indication requirements of this descriptor were met.
Claimable once in any 3 month period.
Not being a service associated with a service to which items 38218A–C, 38220A, 38220C apply. (Anaes.)

Item 38218C

Selective coronary angiography, placement of catheters and injection of opaque material with or without left heart catheterisation, left ventriculography or aortography, as part of the management of a symptomatic patient with valvular or other non-coronary structural heart disease for:

  1. Pre-operative assessment for planning non-coronary cardiac surgery, including by transcatheter approach.
  2. Evaluation of valvular heart disease or other non-coronary structural heart disease where clinical impression is discordant with non-invasive assessment.

Procedure report to include documentation of how the indication requirements of this descriptor were met.
Claimable once in any 12 month period.
Not being a service associated with a service to which items 38218A, 38218B, 38220A–C apply. (Anaes.)

Item 38220C

Selective coronary graft angiography, placement of catheter(s) and injection of opaque material into free coronary graft(s) attached to the aorta (irrespective of the number of grafts) and/or into direct internal mammary artery graft(s), with or without left heart catheterisation, left ventriculography or aortography, as part of the management of valvular heart disease or other non-coronary structural heart disease for:

  1. Pre-operative assessment for planning non-coronary cardiac surgery, including by transcatheter approach.
  2. Evaluation of valvular heart disease or other non-coronary structural heart disease where clinical impression is discordant with non-invasive assessment.

Procedure report to include documentation of how the indication requirements of this descriptor were met.
Claimable once in any 12 month period.
Not being a service associated with a service to which items 38218A–C, 38220A, 38220B apply. (Anaes.)

Item 3820X

Right heart catheterisation performed at the same time as invasive coronary angiography, with any one or more of the following: fluoroscopy, oximetry, dye dilution curves, cardiac output measurement by any method, shunt detection or exercise stress test.

Claimed in association with invasive coronary angiography (items 38218A–C or 38220A–C). (Anaes.)

Item 38200

Right heart catheterisation, with any one or more of the following: fluoroscopy, oximetry, dye dilution curves, cardiac output measurement by any method, shunt detection or exercise stress test.

Not claimed in association with invasive coronary angiography (items 38218A–C or 38220A–C) or left heart catheterisation. (Anaes.)

Item 38203

Left heart catheterisation by percutaneous arterial puncture, arteriotomy or percutaneous left ventricular puncture with any one or more of the following: fluoroscopy, oximetry, dye dilution curves, cardiac output measurements by any method, shunt detection or exercise stress test.

Not claimed in association with invasive coronary angiography (items 38218A–C or 38220A–C) or left heart catheterisation. (Anaes.)

Item 38206

Right heart catheterisation with left heart catheterisation via the right heart or by any other procedure with any one or more of the following: fluoroscopy, oximetry, dye dilution curves, cardiac output measurements by any method, shunt detection or exercise stress test.

Not claimed in association with invasive coronary angiography (items 38218A–C or 38220A–C) or left heart catheterisation. (Anaes.)

Item 38241

Use of a coronary pressure wire during selective coronary angiography to measure fractional flow reserve (FFR) and coronary flow reserve (CFR) in one or more intermediate coronary artery or graft lesions (stenosis of 90%), to determine whether revascularisation is appropriate where previous stress testing has either not been performed or the results are inconclusive. (Anaes.)

Rationale

The recommendations focus on quality of care and are based on the following observations.

  • ΔThe Committee agreed that despite relatively clear indications for angiography—including appropriateness criteria published by the ACC, the AHA and the Society for Coronary Angiography and Intervention (43)—substantial variation remains in the provision of coronary angiography across Australia (Figure 18). Existing item numbers have been developed to encompass substantial complexity in coronary angiography provision, but these have not captured the indications for these investigations.
Figure 18: Geographical variation in angiography services

Figure 18 depicts bar graphs that show the geographical variation in ICA services. There are two bar graphs, one that depicts state-based variation and another for rurality based variation. State-based variations shows a 2 fold variation with NSW, TAS, and ACT are the highest at 9, 10, and 12 services per 100,000 population respectively. VIC, and WA have 8 and 7, with QLD and SA both at 5 services per 100,000 population. There were no MBS services recorded in the NT.Rurality-based breakdown shows major cities, inner regional and outer regional areas are 8, 7 and 7 respectively. Remote services are 4 and very remote 1 service per 100,000 population.

ICA items 38215, 38218, 38220, 38222, 38225, 38228, 38231, 38234, 38237, 38240, 38246, 59973, 59925, 59970, and 59971. Unpublished data for services for 2014‐15 by date of service extracted on 20 June 2016. (Department of Health). Remoteness Area classes are based on ARIA. Reference: ASGS: Volume 5 – Remoteness Structure Australia July 2011, 1270.0.55.005. The patient postcode is linked to the Remoteness Area Concordance file.


  • ΔThe Committee agreed that the current item numbers should be revised to reduce practice variability and align the MBS with contemporary practice. The current item numbers have been rebuilt to capture two dimensions: complexity and indication in line with best practice (44). The coronary angiography item numbers have been divided into three broad indications:
  •  – Strong practice preferences exist, supported by robust evidence for a high likelihood of revascularisation.
  •  – There is more limited evidence and a lower likelihood that revascularisation is indicated.
  •  – The patient is undergoing cardiac surgery and a pre-operative assessment of coronary status is required.
  • ΔEach of these indications is then divided into a “simple” coronary angiogram with or without contrast left ventriculography (LV gram) and a “complex” coronary angiogram with or without LV gram with any number and location of grafts. The Committee agreed that due to unique patient anatomy, any ICA may be simpler or more complex than average. As it is impossible to objectively define this distinction, it was agreed that such variation is a ‘swings and roundabouts’ situation and should be covered by a single item. However, angiograms performed in patients with coronary artery grafts were agreed to generally be more complex, and the Committee therefore recommended differentiating these services to reflect the increased complexity.
  • ΔAdditional codes have been recommended for right heart catheterisation with and without cardiac output and shunt assessment, and physiologic assessments of lesions have been retained as add-ons. The Committee agreed that these services were not appropriate for inclusion as part of a complete medical service for two reasons. Firstly, right heart catheterisation is not a routine part of angiography, and when performed, it increases the time taken to complete the procedure. As such, the Committee felt that the item would be more appropriately retained as an add-on item. Secondly, although the Committee agreed that FFR for the physiologic assessment of lesions is a clinically valuable study, it felt that it should be retained as an add-on item because: (i) the FFR wire is not available on the Prostheses List and therefore the procedure is costly to perform; (ii) FFR is not available in rural areas that do not have access to an interventional cardiologist; and (iii) it is not appropriate to perform FFR on normal or minimally stenosed vessels.
  • ΔThe Committee retained stand-alone right and/or left heart catheterisation as a discrete procedure, acknowledging that there are non-coronary indications for these services, including for paediatric populations. These have been consolidated into a single item.
  • ΔAdditional items will be affected by the proposed restructure of ICA items. Items 59912 and 59925 should be incorporated into the proposed new angiography items in a cost-neutral manner in order to create a complete medical service. Items 59970 and 59971 have been retained, but they should not be co-claimed with any ICA, PCI or cardiac catheterisation items. (Item 59970 is claimed primarily by GPs and non-cardiac surgeons, and item 59971 is claimed primarily by radiologists.) All other codes should be considered obsolete and removed from the MBS.
  • ΔThe Committee discussed co-claiming ICA (and PCI) with consultations. It noted that ICA is unlike other diagnostic imaging services, as the results are frequently discussed with the patient after the procedure, with changes made to medications and care plans as needed. It was also noted that patients may present for a consultation with acute coronary syndrome (ACS) and be rushed immediately to the catheterisation lab for ICA, with or without PCI. In such instances, it would be appropriate to co-claim a consultation if the provider performing the ICA determined during the consultation that ICA was required. It would not be appropriate if another provider had determined the need for ICA or PCI and referred the patient to the operator. The Committee agreed that co-claiming a consultation is also not appropriate if the patient has a primary cardiologist who is not the operator for the ICA, except in paediatric angiography (non-coronary). It was agreed that some operators, particularly in paediatric practice, routinely discuss the results of the study (and the implications) with the family at length following a procedure, this is considered part of the procedure and should not be billed as a consult. These recommendations align with the recommendations of the Principles and Rules Committee regarding co-claiming of consultations, aftercare is discussed separately.
  • ΔECG services were also co-claimed in over 35 per cent of episodes. The Committee agreed that these should be considered a core part of the procedure.
  • ΔThe Committee discussed the creation of an accreditation scheme for procedural services, similar to the Diagnostic Imaging Accreditation Scheme. This was primarily due to concerns that funding reallocation within the DIST had previously occurred, with pressure for some services to have a lower rebate. The Department clarified that the reallocation of funds within the DIST no longer occurs, removing the need for specific ‘cordoning-off’ of funds. A listing on the DIST means that providers must be accredited to perform the services they are billing, as is the case for echo services. The Diagnostic Imaging Accreditation Scheme manages accreditation, and changes to accreditation requirements are recommended by the multidisciplinary Diagnostic Imaging Advisory Committee. In light of this, the Committee accepted that it would be appropriate for ICA items to be recreated on the DIST to access the accreditation scheme protections.

6.3 PCI and angioplasty

Current item descriptors and MBS data from FY 2014/15

Item 38300 – Schedule fee: $515.35
Services: 1,538  Total Benefits: $322,756  Average annual growth: 6.6%

Transluminal balloon angioplasty of 1 coronary artery, percutaneous or by open exposure, excluding associated radiological services or preparation, and excluding aftercare (Anaes.) (Assist.)

Item 38303 – Schedule fee: $660.80
Services: 222  Total Benefits: $63,254  Average annual growth: 10.8%

Transluminal balloon angioplasty of more than 1 coronary artery, percutaneous or by open exposure, excluding associated radiological services or preparation, and excluding aftercare (Anaes.) (Assist.)

Item 38306 – Schedule fee: $762.35
Services: 26,110  Total Benefits: $8,383,158  Average annual growth: 3.2%

Transluminal stent insertion including associated balloon dilatation for coronary artery, percutaneous or by open exposure, excluding associated radiological services and preparation, and excluding aftertransluminal insertion of stent or stents into 1 occlusional site, including associated balloon dilatation for coronary artery, percutaneous or by open exposure, excluding associated radiological services and preparation, and excluding aftercare care (Anaes.) (Assist.)

Item 38309 – Schedule fee: $885.45
Services: 27  Total Benefits: $17,103  Average annual growth: 6.2%

Percutaneous transluminal rotational atherectomy of 1 coronary artery, including balloon angioplasty with no stent insertion where:- no lesion of the coronary artery has been stented; and- each lesion of the coronary artery is complex and heavily calcified; and- balloon angioplasty with or without stenting is not suitable; excluding associated radiological services or preparation, and excluding aftercare (Anaes.) (Assist.)

Item 38312 – Schedule fee: $1132.35
Services: 268  Total Benefits: $228,198  Average annual growth: 9.8%

Percutaneous transluminal rotational atherectomy of 1 coronary artery, including balloon angioplasty with insertion of 1 or more stents, where no lesion of the coronary artery has been stented; and each lesion of the coronary artery is complex and heavily calcified; and balloon angioplasty with or without stenting is not suitable; excluding associated radiological services or preparation, and excluding aftercare (Anaes.) (Assist.)

Item 38315 – Schedule fee: $1215.85
Services: 10  Total Benefits: $8,883  Average annual growth: 14.9%

Percutaneous transluminal rotational atherectomy of more than 1 coronary artery, including balloon angioplasty with no stent insertion where:- no lesion of the coronary arteries has been stented; and- each lesion of the coronary arteries is complex and heavily calcified; and- balloon angioplasty with or without stenting is not suitable; excluding associated radiological services or preparation, and excluding aftercare (Anaes.) (Assist.)

Item 38318 – Schedule fee: $1586.35
Services: 49  Total Benefits: $61,181  Average annual growth: 16.3%

Percutaneous transluminal rotational atherectomy of more than 1 coronary artery, including balloon angioplasty, with insertion of 1 or more stents, where:- no lesion of the coronary arteries has been stented; and- each lesion of the coronary arteries is complex and heavily calcified; and- balloon angioplasty with or without stenting is not suitable, excluding associated radiological services or preparation, and excluding aftercare (Anaes.) (Assist.)

Public data from 2014-15 (Department of Human Services).

Recommendation 13.1
  • ΔRestructure the seven existing MBS items for PCI into 11 new or amended items that include associated imaging.
  •  – Three items (for one, two and three vascular territories) for ST elevation myocardial infarction (STEMI), three items for troponin positive ACS, and three items for stable CAD, with the items for revascularisation of STEMI within a door to balloon time of 60 minutes attracting a higher rebate to incentivise rapid revascularisation, offset by a reduction in the rebate for stable PCI.
  •  – One item for rotational atherectomy (rotablation), as an add-on to PCI (amendment to item 38309).
  •  – One item for standalone angioplasty (amendment to item 38303).
Recommendation 13.2
  • ΔItems 38300, 38306, 38312, 38315 and 38318 should be considered obsolete and removed from the MBS.

Item 38306A

Percutaneous transluminal stent(s) insertion in a single coronary vascular territory (Left Anterior Descending, Circumflex or Right Coronary Artery distribution) for the primary treatment of an ST Elevation Myocardial Infarction (STEMI) within the first 12 hours of symptom onset and performed within 60 minutes of the patient’s arrival at or presentation to a PCI accredited hospital.
Including any associated balloon dilatation and angiography.
Procedure report to include documentation of how the indication requirements of this descriptor were met.
Not claimable for subsequent procedures in a multi-day staged revascularisation. Not claimable with any other PCI item number. (Anaes.) (Assist.)

Explanatory notes: For the purposes of this item, door to balloon time is defined as the time from presentation or arrival at a PCI accredited hospital (door) until reperfusion is achieved (balloon). The time limit of 60 minutes for this item applies from arrival at the PCI accredited hospital, even if the patient is transferred from a previous hospital, with or without prior thrombolysis.

Note that this appears to differ from the current HF/CSANZ guideline and ACS Clinical Care Standard recommending that PCI should be performed within 90 minutes of “first medical contact” and where this is not possible, thrombolysis should be performed. The current item focuses on the more auditable time from hospital arrival (door) to primary PCI, which should be performed within 60 minutes. If door to balloon time is greater than 60 minutes, item 38306D would apply.

If a staged procedure is performed over multiple days during a single admission, the stable codes (38306G-I) should be used for subsequent stages.

The item number claimed should reflect the number of coronary vascular territories (Left Anterior Descending, Circumflex or Right Coronary Artery distribution) that are stented during the procedure, not the total number of stented territories the patient has received to date.

Item 38306B

Percutaneous transluminal stent(s) insertion in any two coronary vascular territories (Left Anterior Descending, Circumflex or Right Coronary Artery distribution) or the Left Main Coronary Artery for the primary treatment of an ST Elevation Myocardial Infarction (STEMI) within the first 12 hours of symptom onset and performed within 60 minutes of the patient’s arrival at or presentation to a PCI accredited hospital.

Including any associated balloon dilatation and angiography.

Procedure report to include documentation of how the indication requirements of this descriptor were met.

Not claimable for subsequent procedures in a multi-day staged revascularisation. Not claimable with any other PCI item number. (Anaes.) (Assist.)

Explanatory notes: For the purposes of this item, door to balloon time is defined as the time from presentation or arrival at a PCI accredited hospital (door) until reperfusion is achieved (balloon). The time limit of 60 minutes for this item applies from arrival at the PCI accredited hospital, even if the patient is transferred from a previous hospital, with or without prior thrombolysis.

Note that this appears to differ from the current HF/CSANZ guideline and ACS Clinical Care Standard recommending that PCI should be performed within 90 minutes of “first medical contact” and where this is not possible, thrombolysis should be performed. The current item focuses on the more auditable time from hospital arrival (door) to primary PCI, which should be performed within 60 minutes. If door to balloon time is greater than 60 minutes, item 38306D would apply.

If a staged procedure is performed over multiple days during a single admission, the stable codes (38306G-I) should be used for subsequent stages.

The item number claimed should reflect the number of coronary vascular territories (Left Anterior Descending, Circumflex or Right Coronary Artery distribution) that are stented during the procedure, not the total number of stented territories the patient has received to date.

Item 38306C

Percutaneous transluminal stent(s) insertion in all three coronary vascular territories (Left Anterior Descending, Circumflex or Right Coronary Artery distribution) for the primary treatment of an ST Elevation Myocardial Infarction (STEMI) within the first 12 hours of symptom onset and performed within 60 minutes of the patient’s arrival at or presentation to a PCI accredited hospital.
Including any associated balloon dilatation and angiography.

Procedure report to include documentation of how the indication requirements of this descriptor were met.
Not claimable for subsequent procedures in a multi-day staged revascularisation. Not claimable with any other PCI item number. (Anaes.) (Assist.)

Explanatory notes: For the purposes of this item, door to balloon time is defined as the time from presentation or arrival at a PCI accredited hospital (door) until reperfusion is achieved (balloon). The time limit of 60 minutes for this item applies from arrival at the PCI accredited hospital, even if the patient is transferred from a previous hospital, with or without prior thrombolysis.

Note that this appears to differ from the current HF/CSANZ guideline and ACS Clinical Care Standard recommending that PCI should be performed within 90 minutes of “first medical contact” and where this is not possible, thrombolysis should be performed. The current item focuses on the more auditable time from hospital arrival (door) to primary PCI, which should be performed within 60 minutes. If door to balloon time is greater than 60 minutes, item 38306D would apply.

If a staged procedure is performed over multiple days during a single admission, the stable codes (38306G-I) should be used for subsequent stages.

The item number claimed should reflect the number of coronary vascular territories (Left Anterior Descending, Circumflex or Right Coronary Artery distribution) that are stented during the procedure, not the total number of stented territories the patient has received to date.

Item 38306D

Percutaneous transluminal stent(s) insertion in a single coronary vascular territory (Left Anterior Descending, Circumflex or Right Coronary Artery distribution) in patients with a troponin positive acute coronary syndrome (ACS) including any associated balloon dilatation; including associated angiography.
Requires documentation in the procedure report of how the indication requirements of this descriptor were met for each territory treated. Not claimable with any other PCI item number. (Anaes.) (Assist.)

Explanatory notes: Acute Coronary Syndrome (ACS) is defined as the transient or permanent obstruction of the coronary blood flow leading to myocardial ischaemia and infarction as a result of unstable atheromatous plaques or endothelial disruption.

Serum troponin levels must be elevated greater than the laboratory reference range or item 38306G applies.

The item number claimed should reflect the number of coronary vascular territories (Left Anterior Descending, Circumflex or Right Coronary Artery distribution) that are stented during the procedure, not the total number of stented territories the patient has received to date.

Where a multi-day staged procedure is performed, the subsequent procedures should be coded as stable (38306G–I).

Item 38306E

Percutaneous transluminal stent(s) insertion in any two coronary vascular territories (Left Anterior Descending, Circumflex or Right Coronary Artery distribution) or the Left Main Coronary Artery in patients with a troponin positive acute coronary syndrome (ACS) including any associated balloon dilatation; including associated angiography.
Requires documentation in the procedure report of how the indication requirements of this descriptor were met for each territory treated. Not claimable with any other PCI item number. (Anaes.) (Assist.)

Explanatory notes: Acute Coronary Syndrome (ACS) is defined as the transient or permanent obstruction of the coronary blood flow leading to myocardial ischaemia and infarction as a result of unstable atheromatous plaques or endothelial disruption.

Serum troponin levels must be elevated greater than the laboratory reference range or item 38306H applies.

The item number claimed should reflect the number of coronary vascular territories (Left Anterior Descending, Circumflex or Right Coronary Artery distribution) that are stented during the procedure, not the total number of stented territories the patient has received to date.

Where a multi-day staged procedure is performed, the subsequent procedures should be coded as stable (38306G–I).

Item 38306F

Percutaneous transluminal stent(s) insertion in all three coronary vascular territories (Left Anterior Descending, Circumflex or Right Coronary Artery distribution) in patients with a troponin positive acute coronary syndrome (ACS) including any associated balloon dilatation and associated angiography.
Requires documentation in the procedure report of how the indication requirements of this descriptor were met for each territory treated. Not claimable with any other PCI item number. (Anaes.) (Assist.)

Explanatory notes: Acute Coronary Syndrome (ACS) is defined as the transient or permanent obstruction of the coronary blood flow leading to myocardial ischaemia and infarction as a result of unstable atheromatous plaques or endothelial disruption.

Serum troponin levels must be elevated greater than the laboratory reference range or item 38306I applies.

The item number claimed should reflect the number of coronary vascular territories (Left Anterior Descending, Circumflex or Right Coronary Artery distribution) that are stented during the procedure, not the total number of stented territories the patient has received to date.

Where a multi-day staged procedure is performed, the subsequent procedures should be coded as stable (38306G–I).

Item 38306G

Percutaneous transluminal insertion of stent(s) in a single coronary vascular territory (Left Anterior Descending Artery, Circumflex Artery or Right Coronary Artery distribution) in patients: (a) with limiting stable angina or an angina equivalent or an acute coronary syndrome without an elevated troponin; and (b) who have received an adequate trial of optimal medical therapy; and (c) who fulfil at least one of the following conditions in the territory treated:

(a) Has a >90% stenosis in a proximal coronary artery; or

(b) Has myocardial ischaemia demonstrated on stress test affecting >10% of the left ventricular myocardium including the region supplied by the vascular territory to be treated; or

(c) Has a Fractional Flow Reserve (FFR) distal to the lesions that is ≤ 0.80; or

(d) A Heart Team Conference (item HTCCXX) has recommended stenting; or

(e) In single territory disease with a Duke Treadmill Score of <= -11.
Including any associated balloon dilatation, including associated angiography.
Requires documentation in the procedure report of how the indication requirements of this descriptor were met for each territory treated.
Only claimable in patients with triple vessel disease where they meet the indication requirements for item 38306I. Not claimable with any other PCI item number. (Anaes.) (Assist.)

Explanatory notes: Stable angina or angina equivalent includes chest pain, chest discomfort and/or shortness of breath due to myocardial ischaemia.

Limiting angina includes patients with symptoms that are Canadian Cardiovascular Society (CCS) class II, III or IV.

The item number claimed should reflect the number of coronary vascular territories (Left Anterior Descending, Circumflex or Right Coronary Artery distribution) that are stented during the procedure, not the total number of stented territories the patient has received to date.

Item 38306H

Percutaneous transluminal insertion of stent(s) in any two coronary vascular territories (Left Anterior Descending Artery, Circumflex Artery or Right Coronary Artery distribution) in patients: (a) with limiting stable angina or an angina equivalent or an acute coronary syndrome without an elevated troponin; and (b) who have received an adequate trial of optimal medical therapy; and (c) who fulfil at least one of the following conditions in EACH territory treated:

(a) Has a >90% stenosis in a proximal coronary artery; or

(b) Has myocardial ischaemia demonstrated on stress test affecting >10% of the left ventricular myocardium including the region supplied by the vascular territory to be treated; or

(c) Has a Fractional Flow Reserve (FFR) distal to the lesions that is ≤ 0.80; or

(d) A Heart Team Conference (item HTCCXX) has recommended stenting.
Including any associated balloon dilatation, including associated angiography.
Only claimable in patients with triple vessel disease where they meet the indication requirements for item 38306I.
Requires documentation in the procedure report of how the indication requirements of this descriptor were met for each territory treated. Not claimable with any other PCI item number. (Anaes.) (Assist.)

Explanatory notes: Stable angina or angina equivalent includes chest pain, chest discomfort and/or shortness of breath due to myocardial ischaemia.

Limiting angina includes patients with symptoms that are Canadian Cardiovascular Society (CCS) class II, III or IV.

Item 38306I

Percutaneous transluminal insertion of stent(s) in all three coronary vascular territories (Left Anterior Descending Artery, Circumflex Artery or Right Coronary Artery distribution) or left main coronary artery; in patients: (a) with limiting stable angina or an angina equivalent or an acute coronary syndrome without an elevated troponin; and (b) who have received an adequate trial of optimal medical therapy; and (c) who fulfil at least one of the following conditions:

  • (a)A Heart Team Conference (item HTCCXX) has recommended coronary stenting; or
  • (b)In a patient who does not have diabetes mellitus where both of the following are met:
    • i.EACH territory treated either:
      • A.Has a >90% stenosis in a proximal coronary artery; or
      • B.Has myocardial ischaemia demonstrated on stress test affecting >10% of the left ventricular myocardium including the region supplied by the vascular territory to be treated; or
      • C.Has a Fractional Flow Reserve (FFR) distal to the lesions that is ≤ 0.80.
    • ii.The multi-vessel coronary artery disease is non-complex, NOT involving any of:
      • A. A stenosis >50% in the left main coronary artery; or
      • B. A stenosis <90% in the proximal left anterior coronary artery; or
      • C. Bifurcation lesions involving side branches with a diameter >2.75mm; or
      • D. Chronic vessel occlusions (>3 months); or
      • E. Severely angulated or severely calcified lesions; or
      • F. SYNTAX score >23.

Including any associated balloon dilatation, including associated angiography.
Requires documentation in the procedure report of how the indication requirements of this descriptor were met for each territory treated. Not claimable with any other PCI item number. (Anaes.) (Assist.)

Explanatory notes: Complex coronary artery disease is defined as (a) a stenosis >50% in the left main coronary artery; (b) >90% in the proximal left anterior coronary artery; (c) bifurcation lesions involving side branches with a diameter >2.75mm; (d) chronic vessel occlusions (>3 months); (e) severely angulated or severely calcified lesions; or (f) SYNTAX score >23. Such disease should only undergo PCI with a documented recommendation from a Heart Team Conference.

Stable angina or angina equivalent includes chest pain, chest discomfort and/or shortness of breath due to myocardial ischaemia.

Limiting angina includes patients with symptoms that are Canadian Cardiovascular Society (CCS) class II, III or IV.

The item number claimed should reflect the number of coronary vascular territories (Left Anterior Descending, Circumflex or Right Coronary Artery distribution) that are stented during the procedure, not the total number of stented territories the patient has received to date.

Item 38303

Percutaneous transluminal coronary balloon angioplasty to 1 or more coronary arteries.

Claimable where: (a) the territory meets the requirements for stenting under a PCI item (38306A–I); and (b) the territory is not included in the count of territories vascularised for a claim under items 38306A–I. Including associated imaging.

Procedure report to include documentation of how the indication requirements of this descriptor were met. (Anaes.) (Assist.)

Explanatory note: This item can be claimed once per patient but cannot be claimed for a territory that is claimed for a stent. For example, if 2 territories are revascularised, one by stent and the other by angioplasty, the item for single territory PCI would be claimed for the first territory and item 38303 for the second territory. This item cannot be claimed with any three territory stent items (38306C/38306F/38306I).

Item 38309

Percutaneous transluminal rotational atherectomy including balloon angioplasty of one or more coronary arteries where the target stenosis within a coronary artery is heavily calcified; and balloon angioplasty with or without stenting is not feasible without rotational atherectomy. Including associated imaging.

Claimed in association with one of items 38306A–I. (Anaes.) (Assist.)

Explanatory note: Percutaneous transluminal coronary rotational atherectomy is suitable for revascularisation of stenoses in heavily calcified coronary artery in the absence of significant lesion angulation or vessel tortuosity in patients for whom coronary artery bypass graft surgery is not indicated.

Item 38309 describes an episode of service and can only be claimed once in a single episode.

Rationale

The recommendation focuses on quality of care and is based on the following observations.

  • ΔDespite relatively clear indications for percutaneous coronary intervention—including appropriateness criteria published by the ACC, the AHA and the Society for Coronary Angiography and Intervention (44)—substantial variation persists across Australia with NSW performing nearly twice as many PCI per population as SA (Figure 19).
Figure 19: Geographical variation in PCI services
Figure 19 depicts bar graphs that show the geographical variation in PCI services per 100,000 population. There are two bar graphs, one that depicts state-based variation and another for rurality based variation. State-based variations shows that NSW the highest at 139 services per 100,000 population, followed by VIC, QLD, WA, TAS and ACT between 98-104. SA and NT 77 and 26 services per 100,000 population..Rurality-based variations shows that major cities, inner regional and outer regional areas have between 110 and 121 services per 100,000 population. Remote and very remote areas show 72 and 37, respectively.

PCI item 38306.
Unpublished data for services in 2014-15 by date of service extracted on 20 June 2016. (Department of Health). Remoteness Area classes are based on ARIA. Reference: ASGS: Volume 5 – Remoteness Structure Australia July 2011, 1270.0.55.005. The patient postcode is linked to the Remoteness Area Concordance file.


Proposed structure

  • ΔThe current item numbers have been rebuilt to capture the clinical complexity of treating patients with ACS (compared to treating stable CAD), as well as the complexity of multi-territory PCI during the same procedure (compared to the staged procedures). These descriptors were designed to reflect the best available evidence, and they are intended to reduce procedures that do not align with clinical best practice (7).
  • ΔThe PCI item numbers have been divided into three broad indications:
  •  – STEMI, within the context of an acute reperfusion strategy (targeting a door-to-balloon time of less than 60 minutes), among patients with chest pain presenting within 12 hours.
  •  – Troponin positive ACS (and STEMI outside of 60-minute door-to-balloon time).
  •  – Stable CAD with evidence of ongoing ischaemia, despite optimal medical management documented on functional testing or FFR. (Note that involvement of the Heart Team in decision-making is advocated.)
  • ΔAlthough compliance with STEMI revascularisation guidelines has been improving, the Committee noted that rates are still below the target level of 75 per cent of patients being re-perfused within 60 minutes of first medical contact. Data from the 2015 Victorian Cardiac Outcomes Registry (VCOR) shows a median door-to-balloon time of 72 minutes, with only four out of 23 hospitals achieving the current target of 75 per cent of reperfusions occurring within 90 minutes (VCOR targets are set at 90 minutes DTB not 60 minutes)(45). It was also suggested by members that some centres, particularly in non-metro areas, do not provide STEMI services.
  • ΔThe Committee felt that a financial incentive may improve compliance with best practice in this area, although some members expressed disappointment that financial incentives were necessary for standards of care to be followed. It was suggested that patients in Australia already receive high standards of reperfusion, as noted above, but all improvements in time to reperfusion help, and this may incentivise faster responses. One of the objectives of the Review is to support best-practice care, and the additional data capture would be valuable for monitoring best-practice care and access to timely revascularisation. This change would be cost-neutral, with the higher schedule fee offset by a reduction in the stable PCI fee.
  • ΔA concern was raised that this may set a precedent for other services to implement loadings based on guideline compliance. The Committee felt that this was unlikely but could be a positive outcome for the health system. If there are services or procedures with level 1A evidence in Australian and international guidelines that improve patient outcomes and can be encouraged in a cost-neutral way, this would provide additional value for patients and the health system. It was also noted that performing PCI for STEMI is more complex than elective PCI as patients are usually more unwell, which further reduces the likelihood of similar approaches being used elsewhere.
  • ΔEach of the clinical indications is divided into one, two and three territory interventions to recognise the increased procedural complexity associated with multi-vessel intervention, and to allow for staged revascularisation over multiple days where clinically indicated. It was noted that the current PCI items allow each stent to be billed separately, which creates perverse incentives—for example, to deploy two short stents rather than one long stent, or to stent additional lesions, in order to obtain a higher rebate. A single averaged item may also create perverse incentives to stage procedures, as the incremental value would be higher. This option would also disadvantage providers who have a more complex casemix. Differentiating the clinical indications into one, two and three territory interventions also allows for improved data capture over time, which may be useful for research and tracking purposes. At present, the MBS does not capture territory data, so VCOR data was used to estimate the proportion of patients likely to fall into each acuity/territory category. When considering the spectrum of solutions, the Committee considered the acceptability of each option to the profession, although it was agreed that this should never compromise patient care.
  • ΔThe proposed solution still provides a higher rebate for more territories, but it also incorporates numerous other checks and balances to counter the financial incentives, primarily the requirement that each territory meets guideline-based indications for revascularisation. The indications for all PCI items align with the current evidence and international guidelines, as well as the findings of the PCI Review Report (7,43,46,47). This should ensure that providers do not perform inappropriate PCI, as long as they comply with the descriptors.
  • ΔThe Committee discussed the role of PCI in stable CAD. The PCI Review Report noted that there is limited evidence to support routine revascularisation by PCI rather than OMT in patients with chronic stable angina, in terms of reducing death or recurrent myocardial infarction. The PCI Working Group (formed prior to the MBS Review, which then came under the auspices of the CAD Working Group) agreed with this assessment. Revascularisation with PCI may be appropriate for patients who remain symptomatic despite OMT, providing there is objective evidence of ischaemia related to the lesion(s) being considered for treatment. However, although the evidence shows improved quality of life over the short term (less than 12 months), no difference is seen in the longer term. There was no significant difference between PCI and OMT for any of the late efficacy outcomes assessed in this review (43).
  • ΔExamination of the cost-effectiveness of PCI in addition to OMT found that PCI is not cost-effective in patients with stable CAD (43). The PCI Review Report identified two studies examining the COURAGE randomised control trial data, which found that this was not cost-effective in patients with stable CAD, with incremental cost-effectiveness ratios in excess of $150,000/quality adjusted life year (48,49). Two additional observational studies have suggested otherwise, however, particularly in patients with severe symptoms (50,51). The PCI Review Working Group, the CAD Working Group and the Committee agreed that these findings are based on international studies, which limits their applicability in the Australian context. As a result, it was agreed that without Australian cost-effectiveness analysis, PCI should not be restricted from use in stable CAD.
  • ΔThe Committee discussed at length the indications for PCI in stable multi vessel disease. Concern was raised by some members about ‘ad hoc’ PCI (where the decision to perform PCI is made during a diagnostic ICA) and the appropriateness of patient consent in these situations. It was noted—and emphasised by the consumer representative—that it is not appropriate to seek informed consent during a conversation that takes place while the patient is on the table undergoing ICA, particularly with sedation. Informed consent should be obtained prior to the procedure, with various potential outcomes discussed. The Committee considered whether a Heart Team conference should be required prior to PCI in any patient with stable triple vessel disease. It was agreed that the Heart Team should be involved for the majority of patients, although there was debate about the role of the Heart Team for the small group of patients who have non-complex non-diabetic triple vessel disease. In this group, the current evidence shows clinical equipoise between PCI and CABG. While a Heart Team may be valuable and may provide for more informed consent, it was decided that this was an expensive undertaking, particularly as the Committee felt (anecdotally) that most patients choose PCI when given the option. The Committee agreed that fully informed consent was part of the basic standard of care expected from all providers for all patients, and noted that even when not required, a Heart Team can be involved to provide additional input during this process.
  • ΔThe implications for patients with triple vessel disease are as follows. In patients where CABG and PCI have clinically equivalent outcomes (those that meet 38306I descriptor indication (ii) for non-diabetic, non-complex disease), it was felt that with informed consent, patients will most likely choose PCI, which means that requiring a Heart Team conference is not a high-value use of resources. All other patients with triple vessel disease need a Heart Team recommendation in order to proceed to PCI under 38306I indication (i). For patients in the (i) category, many would have better long-term outcomes from CABG over PCI, but they may not be suitable for surgery or may still prefer PCI once fully informed. The Heart Team is not intended to ensure that these patients have CABG, but to prompt a dialogue between surgeon and interventional cardiologist, as well as the patient, his/her family, the GP and other providers, to determine the best option for the patient.

Co-claiming

  • ΔThe Committee noted that current co-claiming patterns (Table 14 and Table 15) were not surprising, and that the Review should attempt to reduce this variability through the creation of complete medical services. To this end, the proposed PCI items are intended to provide complete services (including, for example, set-up shots and ECGs). The Committee agreed, however, that if an ICA is performed prior to PCI, a repeat service should not be claimed. For this reason, ICA should not be included in these items and should be claimed only if a diagnostic study has not previously been performed. The Committee agreed that consultations should only be co-claimed where appropriate, as discussed for ICA above.

Table 14: Top 9 items co-claimed with PCI services

Item number and truncated descriptor Episodes(#) Episodes(%)

38246: Selective coronary angiography, …with right or left heart catheterisation or both, or aortography …

970

69%

59925: Selective coronary arteriography and angiocardiography...

876

62%

116: Professional attendance by a consultant physician subsequent to the first in a single course of treatment.

721

51%

11700: Twelve-lead electrocardiography, tracing and report

634

45%

110: Professional attendance by a consultant physician, initial attendance in a single course of treatment

429

30%

59912: Selective coronary arteriography…

429

30%

38243: Placement of catheter(s) and injection of opaque material into any coronary vessel(s) or graft(s)…

353

25%

38218: Selective coronary angiography, with right or left heart catheterisation or both, or aortography…

45

3%

38240: Selective coronary angiography, … right or left heart catheterisation … aortography … injection … into free coronary graft(s) attached to the aorta … injection … into direct internal mammary artery graft(s) to one or more coronary arteries …

30

2%



Table 15: Top 10 most frequently claimed item combinations

Co-claimed items Episodes (%)

59925: Angiography, 38306: PCI, 38246: Angiography & 116: Consult

12%

59925: Angiography 38306: PCI, 38246: Angiography 11700: ECG & 116: Consult

11%

59925: Angiography 38306: PCI & 38246: Angio

7%

59925: Angiography 38306: PCI, 38246: Angiography & 110: Initial consult

7%

59925: Angiography 38306: PCI, 38246: Angiography 11700: ECG & 110: Initial consult

5%

59912: Angiography 38306: PCI, 38243: Angiography 11700: ECG & 116: Consult

5%

59912: Angiography 38306: PCI, & 38243: Angiography

3%

59912: Angiography 38306: PCI, 38243: Angiography & 116: Consult

2%

59912: Angiography 38306: PCI, 38246: Angiography 11700: ECG & 110: Initial consult

2%

59912: Angiography 38306: PCI, 38246: Angiography & 116: Consult

2%

Tables 14 and 15 relate to services by date of service performed between 1 July 2014 and 30 June 2015 processed to 30 June 2016.

  • ΔAdditional codes for angioplasty and rotational atherectomy have been retained. Stand-alone angioplasty is uncommon, but it remains a clinically acceptable treatment option for patients who are not suitable for stenting. Rotational atherectomy is not routinely performed and is not performed by all providers. Patients who are known to have highly calcified lesions may be referred to a provider proficient in rotational atherectomy for their revascularisation. The inclusion of this service as part of a standard PCI would therefore result in inequitable remuneration that does not reflect the additional time and expertise required for rotational atherectomy. Such a change may result in fewer providers performing the service and subsequent access issues for patients.

Aftercare

  • ΔThe Committee noted that PCI is one of the few procedures on the MBS that is exempt from the inclusion of aftercare. The Committee received guidance from the Chair of the Taskforce that the Principles and Rules Committee is reviewing the rules regarding aftercare, and that the updated rules are intended to be applied to all procedures without exception. The Committee discussed this matter at length and accepted that the challenges faced by cardiologists providing emergency PCI were similar to those of other proceduralists and surgeons providing emergency services. However, on reviewing the draft recommendations of the Principles and Rules Committee, the Committee had significant concerns about the application of these to PCI, and to other surgical and procedure items. These concerns have been conveyed to the Principles and Rules Committee for consideration alongside feedback from public consultation.

6.4 CTCA

Current item descriptors and MBS data from FY 2014/15

Item 57360 – Schedule fee: $700.00
Services: 44,974  Total Benefits: $29,224,450  Average annual growth: N/A

Computed tomography of the coronary arteries performed on a minimum of a 64 slice (or equivalent) scanner, where the request is made by a specialist or consultant physician, and: the patient has stable symptoms consistent with coronary ischaemia, is at low to intermediate risk of coronary artery disease and would have been considered for coronary angiography; or the patient requires exclusion of coronary artery anomaly or fistula; or the patient will be undergoing non-coronary cardiac surgery (r) (k) (Anaes.)



Recommendation 14
  • ΔSplit item 57360 into three items: item 57360A for structured access for GPs for the investigation of CAD in a specific population; item 57360B for specialist investigation of CAD; and item 57360C for specialist use for non-CAD related indications. Proposed descriptors for these items are outlined below.
  • ΔThe MSAC should review this recommendation prior to implementation.

Item 57360A

COMPUTED TOMOGRAPHY OF THE CORONARY ARTERIES performed on a minimum of a 64 slice (or equivalent) scanner, for a patient that: (a) is not known to have coronary artery disease (CAD); and (b) has stable atypical symptoms (suggesting low or intermediate risk of CAD); and (c) has a 5 year Australian Absolute risk of cardiovascular event of ≥10%.

Requested using a form that provides at least the information required on the MBS structured CTCA request form. Formal report to include documentation of how the indication requirements of this descriptor were met.

Not claimable within 5 years following a CTCA that detected no coronary artery disease. (R) (K). (Anaes.)

Explanatory note: Patients with typical angina symptoms or known coronary artery disease should be referred for functional testing and/or referred to a cardiologist or consultant physician for management.

Patients with atypical symptoms and an Australian Absolute risk score of <10% over 5 years should be considered for exercise stress testing.

Heart rate during CTCA should be less than 65 beats per minute wherever possible, and sublingual GTN should be administered immediately prior to scanning where clinically appropriate.

Item 57360B

COMPUTED TOMOGRAPHY OF THE CORONARY ARTERIES performed on a minimum of a 64 slice (or equivalent) scanner, where the request is made by a specialist or consultant physician, for a patient that has stable or acute symptoms consistent with coronary ischaemia, is not known to have coronary artery disease, and is at low to intermediate risk (no cardiac biomarker elevation/no ECG changes indicating ischaemia) of an acute coronary event.

Requested using a form that provides at least the information required on the MBS structured CTCA request form. Formal report to include documentation of how the indication requirements of this descriptor were met.

Not claimable within 5 years following a CTCA that detected no coronary artery disease. (R) (K). (Anaes.)

Explanatory notes: Heart rate during CTCA should be less than 65 beats per minute wherever possible, and sublingual GTN should be administered immediately prior to scanning where clinically appropriate.

Item 57360C

COMPUTED TOMOGRAPHY OF THE CORONARY ARTERIES performed on a minimum of a 64 slice (or equivalent) scanner, where the request is made by a specialist or consultant physician, and:

  1. The patient has stable symptoms and newly recognised LV systolic dysfunction with unknown aetiology; or
  2. The patient requires exclusion of coronary artery anomaly or fistula; or
  3. The patient will be undergoing non-coronary cardiac surgery; or
  4. Coronary arteries or bypass graft have been unable to be delineated on a recent ICA.

Requested using a form that provides at least the information required on the MBS structured CTCA request form. Formal report to include documentation of how the indication requirements of this descriptor were met. (R) (K). (Anaes.)

Explanatory notes: Heart rate during CTCA should be less than 65 beats per minute wherever possible, and sublingual GTN should be administered immediately prior to scanning where clinically appropriate.

Rationale

The recommendations focus on best practice care and are based on the following observations.

  • ΔCTCA item numbers have been modified to reflect the expanding role of this test in the assessment of acute chest pain and stable CAD. The Committee agreed that the investigation was becoming more common as evidence builds of its effectiveness. The Committee agreed that it should be forward-looking in terms of making recommendations to improve the MBS, without overreaching.
  • ΔThe Committee agreed that the items for specialist access to CTCA for CAD were appropriate and should remain, with the addition of reasonable restrictions on repeats. The Committee felt that a discrete item for specialist access to CTCA for indications other than the investigation of suspected CAD should be created to allow for tracking, however. It recommended the addition of an indication where “coronary arteries of bypass graft have been unable to be delineated on ICA” which is an increase in scope and was agreed to be appropriate in the expert opinion of the Committee.
  • ΔThe Committee discussed at length the recommendation for GP access to CTCA under certain circumstances. The remainder of the rationale pertains to the recommended new item 57360A which has been created in line with current guidelines(44,52).
  • ΔThe Committee agreed that CTCA is a robust test with a very strong negative predictive value in terms of outcomes. However, the CTCA item with limited GP access carries the risk of considerable uptake (as the Department noted had occurred with GP access to knee MRI). This risk is expected to be mitigated (to some extent) for the following reasons: (i) many CTCAs ordered by a GP would otherwise have been ordered by a cardiologist; (ii) the test can only be ordered following Absolute risk assessment; and (iii) the test cannot be repeated in patients in whom the result is positive, or within five years of a negative result. Nonetheless, the Committee acknowledged this risk and recommended that the MSAC reviews these changes prior to implementation.
  • ΔIf the item is not well defined, there is a risk that poorly informed providers will use the test for screening, or for other low-value indications due to pressure from patients. This would result in significant health costs and a flood of patients with low risk or no symptoms, as well as indeterminate findings on CTCA, who are seeking reassurance or advice from specialists or emergency departments.
  • ΔSpecialist use of CTCA is already increasing rapidly, and a concern was raised about the potential risk of GP overuse of this item leading to significant volume increases, similar to past experiences noted by the Department with GP access to services such as knee MRI. Ensuring GPs and providers strictly comply with the indications for the test is intended to avoid over-usage of the test. To this end, the Committee recommended designing a structured request form to facilitate GP compliance, containing all the descriptor requirements, including information needed to calculate an Australian Absolute risk score. Education of GPs regarding the most appropriate management plan (based on the results of the test) will be critical to obtaining maximum clinical benefit from the investigation. A completely normal study suggests an excellent prognosis with no further cardiac testing required. A test that reveals coronary atherosclerosis but no major obstructive disease (i.e., no lesion greater than 50 per cent) in most instances requires risk factor modification and standard cardio-protective therapy. If symptoms persist, functional testing can be considered to see if symptoms relate to ischaemia, and referral to a cardiologist can be considered at any stage. If the test suggests significant obstructive disease, or if the severity of the obstructive disease cannot be accurately determined, referral to a cardiologist is recommended. In most instances, such patients will then undergo functional testing to determine the presence and extent of ischaemia. Depending on the result and the response to medical therapy, such patients may undergo ICA with a view to revascularisation.
  • ΔThe Committee agreed that a targeted GP education program should be implemented. Education for GPs, whether provided by professional bodies or the Department, may improve the effectiveness of GPs as gatekeepers and custodians of health system resources. It was also suggested that the ability to refer for the new GP-access CTCA item could be made dependent on the completion of an education module.
  • ΔThe Committee noted that there is a lack of evidence linking CTCA findings to management decisions, particularly for mild to moderate non-obstructive disease. For example, it is unclear what level of disease warrants the commencement of statins. It was stated that work is underway to develop a consistent CTCA grading system, and evidence is expected to emerge in the near future regarding the use of CTCA results. It was suggested that the current lower rate of follow-up investigations after CTCA in Australia may be an early-use phenomenon. In the United States, for example, there is evidence that the rate of ICA is up to 50 per cent higher post-CTCA (12.2 per cent for the CTCA group versus 8.1 per cent for the functional-testing group) (53,54).
  • ΔThe Committee discussed the potential outcome benefits that may result from a diagnosis of atherosclerosis by CTCA, as well as the associated impact on patient compliance and behaviour change. However, it did not feel that there was sufficient evidence to warrant broadening the proposed scope.
  • ΔThe Committee discussed the role of ICA post-CTCA. Unless the CAD is obviously very severe (e.g. left main disease) ICA will generally only be indicated for patients where CTCA suggests significant obstructive CAD, ischaemia is demonstrated on a functional test and the patient has limiting symptoms despite optimal medical therapy. It noted that it would not be appropriate to perform an ICA on a patient with a positive CTCA in a setting not capable of revascularisation with an interventional cardiologist. Although it was suggested that a negative CTCA should exclude ICA, low quality studies should not be considered normal.
  • ΔThe Committee agreed that the role of CTCA is to exclude disease. For this reason, it is not currently indicated for patients with known CAD or typical chest pain with a high probability of CAD. It was noted that the MSAC recommendation specifically intended to exclude patients with significant disease, with MSAC taking the view that these patients should proceed directly to a trial of optimal medical therapy as the CTCA is unlikely to change management. If this fails, this population should proceed to ICA as it is highly likely that they will require revascularisation. Due to the high cost of CTCA and associated radiation burden, the Committee agreed that CTCA should not be used in patients who have an Australian Absolute risk of cardiovascular event of less than 10 per cent over 5 years (Australian Absolute risk calculator). The Committee agreed that in a population with atypical pain, low to intermediate risk of CAD and a low Absolute risk of cardiovascular event, an EST was a more appropriate first-line investigation. This may change as additional evidence for CTCA emerges and technological advancements reduce the cost of services.
  • ΔThe Committee agreed that no repeat CTCA should be performed within five years in patients who have received a high-quality study that shows no CAD. As the item is only indicated for patients with no known disease, there should be no repeat studies within five years, as those with an abnormal study will have some evidence of known disease and thus no longer qualify. The Committee felt that this was appropriate, and noted that symptomatic patients with known CAD should generally have functional testing, which is not currently possible with CTCA.
  • ΔThe Committee agreed that this recommendation for limited GP access to CTCA, even with a specific and restrictive indication, has a risk of cost implications. It therefore recommended referring the issue to the MSAC for consideration for a health technology assessment (HTA), and suggested that The Royal Australian College of General Practitioners and Australian College of Rural and Remote Medicine may be the most appropriate sponsors, with support from CSANZ and The Royal Australian and New Zealand College of Radiologists. The Department also provided advice that a 12-month pilot, with a subsequent impact audit, may be acceptable. Although the Department has limited resources and currently performs a limited number of audits, this may be an appropriate instance in which to conduct one.
  • ΔThe Committee considered specific recommendations to improve the quality of CTCA studies. Specific rules around heart rate were not applied, noting that a patient’s heart rate may fluctuate during a study (e.g., if they become anxious). Such studies are often diagnostic, and the Committee did not want to create an incentive for repeat scanning in order to obtain a rebate, particularly given the radiation exposure. The Committee also noted that newer scanners are able to provide high-quality services at higher heart rates. The Committee recognised that there has been considerable improvement in scanners over recent years, and considered if it would be reasonable for 128-slice to become the minimum standard for MBS rebatable services. However, the Committee also noted that 64-slice scanners are able to provide high quality imaging at low radiation doses. Radiation dose is not dependent on slice thickness or number, but is more dependent of factors such as iterative reconstruction and ability to provide prospective and retrospective acquisition. It was also noted that the DIST already contains provisions to ensure that safe, high-quality services are provided. For this reason, the Committee did not recommend a specific requirement for 128-slice scanners for CTCA.
  • ΔOne member of the Working Group, Dr Forge, disagreed that the role of CTCA is only to exclude disease and requested this be noted. He suggested that patients with a high probability of CAD on the basis of history and functional testing should have CTCA to guide therapy by confirming the diagnosis, excluding left main disease and establishing plaque burden, prior to the commencement of lifetime medical therapy.

6.5 Other items

Current item descriptors and MBS data from FY 2014/15

Item 38270 – Schedule fee: $912.30
Services: 500  Total Benefits: $339,007  Average annual growth: 25.3%

Balloon valvuloplasty or isolated atrial septostomy, including cardiac catheterisations before and after balloon dilatation (Anaes.) (Assist.)

Item 38272 – Schedule fee: $912.30
Services: 379  Total Benefits: $254,333  Average annual growth: 0.9%

Atrial septal defect closure, with septal occluder or other similar device, by transcatheter approach (Anaes.) (Assist.)

Item 38273 – Schedule fee: $912.30
Services: 11  Total Benefits: $7,185  Average annual growth: N/A

Patent ductus arteriosus, transcatheter closure of, including cardiac catheterisation and any imaging associated with the service (Anaes.) (Assist.)

Item 38274 – Schedule fee: $912.30
Services: None  Total Benefits: None  Average annual growth: N/A

Ventricular septal defect, transcatheter closure of, with imaging and cardiac catheterisation (Anaes.) (Assist.)

Item 38275 – Schedule fee: $298.20
Services: 203  Total Benefits: $38,925  Average annual growth: 21.1%

Myocardial biopsy, by cardiac catheterisation (Anaes.)

Item 38359 – Schedule fee: $133.55
Services: 136  Total Benefits: $11,986  Average annual growth: 9.1%

Pericardium, paracentesis of (excluding aftercare) (Anaes.)

Item 38362 – Schedule fee: $384.95
Services: 302  Total Benefits: $42,616  Average annual growth: 0%

Intra-aortic balloon pump, percutaneous insertion of (Anaes.)

Public data from 2014-15 (Department of Human Services).

Recommendation 15.1
  • ΔAmend item 38274 to exclude “with imaging.”
Recommendation 15.2
  • ΔAmend item 38272 to read:

Item 38272

Atrial septal defect closure, with septal occluder or other similar device, by transcatheter approach, including right and or left heart catheterisation, for congenital heart disease in a patient with documented evidence of right heart overload or paradoxical embolism. (Anaes.) (Assist.)

Explanatory note: This item may be claimed without evidence of right heart overload in highly rare paediatric conditions such as abnormal development of the right heart. Additionally, in patients under 16 years old, risk of paradoxical embolism is sufficient.

Recommendation 15.3
  • ΔLeave items 38270, 38273, 38275, 38359 and 38362 unchanged.

Rationale

These recommendations are based on the following observations.

  • ΔThe Committee noted that for item 38274, a second provider is required to perform the imaging services. It therefore felt that it was appropriate for these services to be billed separately. This is a new item, and a fee review may be appropriate if the current fee was set with the expectation that imaging services would be included.
  • ΔRegarding item 38272 for atrial septal defect closure, the Committee agreed that this service may be frequently used for the closure of asymptomatic patent foramen ovale (PFO). There is no evidence to support this practice, and it should therefore only be claimable for patients with evidence of right heart overload or paradoxical embolism. The Committee noted that there are unique cases in paediatrics, however, and recommended an explanatory note to clarify that this item is available where clinically appropriate in paediatrics. This item should include associated heart catheterisation whether left, right or both sides of the heart are catheterised.


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