9. Cardiac surgery recommendations

9.1 Cardiac Surgery Working Group membership

The Committee formed a Working Group to consider the cardiac surgical MBS items. The Cardiac Surgery Working Group included the following members:

  • ΔProfessor Paul Bannon (Chair) – Head of Department, Cardiothoracic Unit, The Royal Prince Alfred Hospital; Professorial Chair of Cardiothoracic Surgery, University of Sydney; President, Australian and New Zealand Society of Cardiac and Thoracic Surgeons.
  • 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.
  • ΔProfessor Derek Chew – Professor of Cardiology, Flinders University; Regional Director of Cardiology, Southern Adelaide Local Health Network.
  • 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.
  • ΔMr Alex Segler – Independent consumer.
  • ΔProfessor Richard Walsh – Specialist Cardiac Anaesthetist, Royal Prince Alfred Hospital, Strathfield Private Hospital and the Mater Hospital.
  • ΔProfessor David Winlaw – Professor in Paediatric Cardiac Surgery, University of Sydney; Head of Paediatric Cardiothoracic Surgery, Sydney Children’s Hospital Network (Westmead and Randwick).
  • ΔProfessor Richard Harper – Emeritus Director of Cardiology, Monash Medical Centre; Adjunct Professor of Medicine, Monash University (Ex-Officio).

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

The Committee also endorsed the recommendations unanimously.

9.2 Restructure of cardiac surgery items as complete medical services

Recommendation 38
  • ΔApply a general rule to the cardiac surgery section of the MBS specifying that the items contained therein are intended to be complete medical services. As such, these items are not to be co-claimed with services outside this section of the MBS.

Rationale

This recommendation focuses on the creation of complete medical services and is based on the following observation.

  • ΔThe Committee and the Cardiac Surgery Working Group invested significant time in restructuring the MBS to reflect contemporary practice, with each item intended (where possible) to reflect a complete medical service. It was noted that cardiothoracic surgical procedures are regularly co-claimed with items from other areas of the MBS, particularly the vascular and plastics sections. It was agreed that this makes the MBS less user-friendly, requiring providers to search for items and resulting in rebate variability among patients. For this reason, the Committee recommended incorporating current appropriate co-claiming into the restructured items, and applying a rule that limits co-claiming from other sections of the MBS. This aligns with the recommendations of other surgical committees in the MBS Review. Such a restriction would only apply within a single procedure, and would not apply if a patient required multiple procedures or re-operation on the same day. Similarly, in cases such as trauma, where there are multiple simultaneous procedures, there should be no restrictions on providers of other disciplines claiming for the services they have provided during a single operation. It is not, however, intended that an assistant or other provider number be used to circumvent this restriction during a cardiothoracic procedure.
  • ΔThe Committee is aware that the Principles and Rules Committee is considering changes to the Multiple Operations Rule. In light of the considerable work involved in formulating the recommendations outlined below, the Committee recommended exempting cardiac surgery from future changes. Implementing the recommendations below alongside other significant reforms without due consideration by cardiac surgeons could have significant negative consequences. Should other such reforms be applied to cardiac surgery items, the Committee would consider these surgical recommendations to be rescinded and recommended that it be reconvened to consider the implications of this, and to develop alternative recommendations if necessary.

9.3 Coronary artery bypass

9.3.1 Primary bypass items

Current item descriptors and MBS data from FY 2014/15

Item 38496 – Schedule fee: $623.95
Services: 2,026  Total Benefits: $379,250  Average annual growth: 0.7%

Artery harvesting (other than internal mammary), for coronary artery bypass (Anaes.) (Assist.)

Item 38497 – Schedule fee: $2047.60
Services: 582  Total Benefits: $720,403  Average annual growth: 2.9%

Coronary artery bypass with cardiopulmonary bypass, using saphenous vein graft or grafts only, including harvesting of vein graft material where performed, not being a service associated with a service to which item 38498, 38500, 38501, 38503 or 38504 apply (Anaes.) (Assist.)

Item 38498 – Schedule fee: $2047.60
Services: 11  Total Benefits: $16,125  Average annual growth: 1.9%

Coronary artery bypass with the aid of tissue stabilisers, performed without cardiopulmonary bypass, using saphenous vein graft or grafts only, including harvesting of vein graft material where performed, either via a median sternotomy or other minimally invasive technique and where a stand-by perfusionist is present, not being a service associated with a service to which items 38497, 38500, 38501, 38503, 38504 or 38600 apply (Anaes.) (Assist.)

Item 38500 – Schedule fee: $2200.00
Services: 2,661  Total Benefits: $4,207,925  Average annual growth: 2.3%

Coronary artery bypass with cardiopulmonary bypass, using single arterial graft, with or without vein graft or grafts, including harvesting of internal mammary artery or vein graft material where performed, not being a service associated with a service to which items 38497, 38498, 38501, 38503 or 38504 apply (Anaes.) (Assist.)

Item 38501 – Schedule fee: $2200.00
Services: 181  Total Benefits: $296,861  Average annual growth: -5.3%
Coronary artery bypass with the aid of tissue stabilisers, performed without cardiopulmonary bypass, using single arterial graft, with or without vein graft or grafts, including harvesting of internal mammary artery or vein graft material where performed, either via a median sternotomy or other minimally invasive technique and where a stand-by perfusionist is present, not being a service associated with a service to which items 38497, 38498, 38500, 38503, 38504 or 38600 apply (Anaes.) (Assist.)

Item 38503 – Schedule fee: $2388.70
Services: 2,241  Total Benefits: $3,889,421  Average annual growth: 1.5%

Coronary artery bypass with cardiopulmonary bypass, using 2 or more arterial grafts, with or without vein graft or grafts, including harvesting of internal mammary artery or vein graft material where performed, not being a service associated with a service to which items 38497, 38498, 38500, 38501 or 38504 apply (Anaes.) (Assist.)

Item 38504 – Schedule fee: $2388.70
Services: 184  Total Benefits: $320,731  Average annual growth: 11.2%

Coronary artery bypass with the aid of tissue stabilisers, performed without cardiopulmonary bypass, using 2 or more arterial grafts, with or without vein graft or grafts, including harvesting of internal mammary artery or vein graft material where performed, either via a median sternotomy or other minimally invasive technique and where a stand-by perfusionist is present, not being a service associated with a service to which items 38497, 38498, 38500, 38501, 38503 or 38600 apply (Anaes.) (Assist.)

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

Recommendation 39
  • ΔRestructure the items used for coronary artery graft surgery (items 38497, 38498, 38500, 38501, 38503, 38504 and 38496) to create a complete medical service, and remove the now redundant item numbers, excluding item 38588 (which will be incorporated into all relevant codes but is retained for 12months). The proposed item descriptors are provided below.

Item 38500

Coronary artery bypass including cardiopulmonary bypass, with or without retrograde cardioplegia, with or without vein graft or grafts, including harvesting of left internal mammary artery and/or vein graft material where performed.

Not being a service associated with a service to which items 38497, 38498, 38501, 38503, 38504, 38806, 11700–11702, 45503, 33824 or 18260 apply. (Anaes.) (Assist.)

Item 3850A

Artery harvesting (other than left internal mammary), for coronary artery bypass where more than one arterial graft are required. Claimed in conjunction with 38500.

Item 3850B

Coronary artery bypass with the aid of tissue stabilisers, performed without cardiopulmonary bypass. Claimed in conjunction with 38500.

Item 3850X

Creation of a graft to graft anastomosis (including Y-graft, T-graft, and graft to graft extensions) requiring micro-arterial or micro-venous anastomosis using microsurgical techniques. Claimed in conjunction with 38500.

Rationale

The recommendation focuses on the creation of complete medical services to simplify the MBS and reduce rebate variability for patients. It is based on the following observations.

  • ΔThe Committee noted that one of the goals of this review is to consolidate items into complete medical services, where appropriate. This is particularly relevant to the large number of surgical MBS items, which are co-claimed in highly variable patterns. This variation has multiple implications. For instance, two patients may undergo the same medical service but receive very different rebates due to co-claim variation.
  • ΔIn general, if one service is an integral part of another service and cannot reasonably be claimed independently, both should be included within the same item number. However, if two services can be provided both separately and in combination, it is logical to retain them as separate services with separate item numbers. For this reason, it makes sense to consolidate coronary artery bypass graft (CABG) items into a complete medical service, but it does not make sense to consolidate CABG and valve replacement items. The Committee felt that some item delineation was an historical legacy and no longer reflected contemporary practice. As the Taskforce and this review encourage the modernisation of the MBS, historical idiosyncrasies should not constrain recommendations. The Committee also agreed that although there are variations between patients, developing a single item that represents a more complete medical service could reduce variation in MBS claiming practices.
  • ΔThe Committee felt that co-claimed ‘bolt-on’ items are necessary to account for the added technical difficulty and potential patient outcome benefits associated with specific approaches. Such items would be claimed in addition to the ‘base’ complete medical service item. When considering the creation of bolt-on items, the Committee considered three criteria (these applied to all restructures, not only those related to bypass):
    • 1 The element requires a significant increase in the time or complexity of the procedure, which would warrant a higher MBS rebate.
    • 2 Evidence shows that the performance of this element improves patient outcomes for at least a subset of patients, and access to this service should be retained for those patients.
    • 3 The element is not performed equally or is not able to be performed by all providers. As a result, the creation of an averaged / ‘swings and roundabouts’ item would result in some providers being overpaid for simple procedures and others being underpaid for more complex procedures. This would create a disincentive for the provision of more complex services.
  • ΔConsidering these criteria, the Committee acknowledged that off-pump coronary artery graft surgery (OPCAB) is a more technically difficult and potentially more time-consuming procedure, but noted that it can deliver equivalent cardiac outcomes with a lower stroke risk when performed by a technically proficient surgeon, particularly among elderly and high-risk patients. (The evidence is unclear regarding the comparative long-term outcomes of on- versus off-pump surgery.) The Committee also noted that cardiac surgery is currently a credentialed profession. Due to the spectrum of patients and the complexity seen in clinical practice, additional specificity in terms of the providers who are able to perform off-pump procedures would be difficult to implement and of unclear value to patients or the health system. It was felt that the additional complexity and improved patient outcomes associated with off-pump surgery support this item being added to the core bypass item.
  • ΔWhen discussing right internal mammary artery (RIMA) and other (rarely gastroepipoleic) harvesting, the Committee agreed that left internal mammary artery (LIMA) harvesting is the standard of care and does not share the complexity or time requirements of the RIMA, and that it should be incorporated into the base item. The RIMA and radial arteries are regularly used for bypass procedures, but these are more time-consuming to perform. Evidence from studies and revised guidelines in the United States shows that bilateral internal mammary grafts in ‘T’ formation are associated with better patient outcomes (6972). Bilateral internal mammary artery graft outcomes remain superior, despite the increased risk of sternal wound infection associated with this approach. The Committee acknowledged that radial and RIMA harvesting increase procedural complexity, but felt that removing this item could discourage best-practice care.
  • ΔRegarding the Y-graft conduit approach, there is evidence that the use of such approaches allows greater flexibility and makes anaortic procedures (where the aorta is not touched) achievable in more patients, which is associated with better patient outcomes (7379). This procedure is performed by only a small subset of surgeons and requires a significant amount of time and skill. Although this item could reasonably be considered best practice, it is not standard practice, and it is not performed by the majority of operators. Adding a requirement for the Y-graft approach would therefore result in access issues. For this reason, this item was retained as a bolt-on procedure. The code is derived from the currently co-claimed 45503 plastic surgery item, which is used for all arterial tree grafts. It was agreed that a similar item should be created (although with an appropriately lower schedule fee) and a restriction placed on the co-claiming of other microsurgical items.
  • ΔIn reviewing the MBS data provided, the Committee was struck by the variability in co-claiming practices, including the co-claiming of items that are clearly integral to the procedure. For example, the insertion of an intercostal catheter (item 38806) was co-claimed with over 10 per cent of item 38500 episodes in FY 2014/15 (9). Other inappropriately co-claimed items included intercostal nerve blocks (18260), thoracoscopy (38436), concomitant lung resection (38440), ECG trace and report (11700), and other items outside the cardiothoracic section of the schedule (excepting anastomosis items currently used for Y-graft procedures). The Committee strongly recommended taking steps to prevent the co-claiming of services that are clearly inherent to the procedure.
  • ΔThe Committee felt that retrograde cardioplegia (retroplegia) represents best-practice care. Although it is not appropriate for all patient populations, it is now performed in a majority of CAGS and other cardiac procedures, and there is a trend towards more frequent use. The Committee also agreed that retroplegia is not a distinct procedure that would be performed independently. For this reason, it recommended incorporating it into the relevant items (CAGS, valve and aorta-related procedures) in a cost-neutral way, ensuring that the descriptors clearly reflect that this is an optional element of the procedure, to be performed at the surgeon’s discretion in order to provide the most appropriate care for each individual patient. Once this item has been fully incorporated into the relevant procedural codes, it could be removed from the MBS; however in the short term it should be retained to ensure some indications have not be inadvertently missed.
  • ΔThe Committee acknowledged that many procedures (such as the arterial switch procedure) may be performed with or without retroplegia, particularly in paediatrics. However, it felt that creating a complete medical service specifically for this population would be difficult and of low value, given the diversity of paediatric cardiac surgery and the exceptionally low service volumes. It was agreed that although the rate of retroplegia use is lower in paediatrics, it would still be reasonable to utilise the single item for all patients. This would not result in significant disadvantage for any provider group, and it would have no impact on paediatric patient access or outcomes.

9.3.2 Patent diseased coronary artery

Current item descriptors and MBS data from FY 2014/15

Item 38637 – Schedule fee: $554.55
Services: 80  Total Benefits: $9,058  Average annual growth: -4.4%

Patent diseased coronary artery bypass vein graft or grafts, dissection, disconnection and oversewing of (Anaes.) (Assist.)

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

Recommendation 40
  • ΔRetain item 38687, despite low service volumes.

Rationale

This recommendation is based on the following observation.

  • ΔThis discrete item number is expected to phase out over time. It is currently utilised in the ‘redo’ setting, and there is clear evidence that this increases the risk of surgery. This item should be retained as an ‘add-on’ to the base procedure.

9.3.3 Coronary endarterectomy

Current item descriptors and MBS data from FY 2014/15

Item 38505 – Schedule fee: $277.25
Services: 29  Total Benefits: $1,560  Average annual growth: 5.7%

Coronary endarterectomy, by open operation, including repair with 1 or more patch grafts, each vessel (Anaes.) (Assist.)

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

Recommendation 41
  • ΔObsolete – delete item 38505 from the MBS.

Rationale

This recommendation focuses on modernising the MBS to reflect contemporary practice and is based on the following observation.

  • ΔHistorically, this item referred to the removal of the lining from the full length of the vessel. In current practice, however, this item would only be claimed as part of a bypass procedure, rather than as a discrete service. For example, if a vessel was opened for grafting at the site of a lesion, the obstructing materials would be removed. For this reason, the Committee agreed that this is not a stand-alone service, and that it is at the operator’s discretion to determine the best approach for performing a CAGS procedure. As a discrete medical service, the item is obsolete and should be removed from the MBS.

9.4 Valvular heart disease and aortic procedures

9.4.1 Primary valve-related items

Current item descriptors and MBS data from FY 2014/15

Item 38475 – Schedule fee: $831.75
Services: 21  Total Benefits: $4,211  Average annual growth: 7%

Valve annuloplasty without insertion of ring, not being a service associated with a service to which item 38480 or 38481 applies (Anaes.) (Assist.)

Item 38477 – Schedule fee: $2003.35
Services: 434  Total Benefits: $368,195  Average annual growth: 7.2%

Valve annuloplasty with insertion of ring not being a service to which item 38478 applies (Anaes.) (Assist.)

Item 38478 – Schedule fee: $970.40
Services: 710  Total Benefits: $189,812  Average annual growth: 1.9%

Valve annuloplasty with insertion of ring performed in conjunction with item 38480 or 38481 (Anaes.) (Assist.)

Item 38480 – Schedule fee: $2003.35
Services: 695  Total Benefits: $723,392  Average annual growth: 3.7%

Valve repair, 1 leaflet (Anaes.) (Assist.)

Item 38481 – Schedule fee: $2280.65
Services: 333  Total Benefits: $506,617  Average annual growth: 3.8%

Valve repair, 2 or more leaflets (Anaes.) (Assist.)

Item 38483 – Schedule fee: $1720.90
Services: 7  Total Benefits: $3,558  Average annual growth: 7%

Aortic valve leaflet or leaflets, decalcification of, not being a service to which item 38475, 38477, 38480, 38481, 38488 or 38489 applies (Anaes.) (Assist.)

Item 38485 – Schedule fee: $817.10
Services: 167  Total Benefits: $28,038  Average annual growth: 5.1%

Mitral annulus, reconstruction of, after decalcification, when performed in association with valve surgery (Anaes.) (Assist.)

Item 38487 – Schedule fee: $1720.90
Services: None  Total Benefits: None  Average annual growth: -100%

Mitral valve, open valvotomy of (Anaes.) (Assist.)

Item 38488 – Schedule fee: $1909.60
Services: 2,822  Total Benefits: $2,616,016  Average annual growth: 3.2%

Valve replacement with bioprosthesis or mechanical prosthesis (Anaes.) (Assist.)

Item 38489 – Schedule fee: $2271.05
Services: 52  Total Benefits: $61,318  Average annual growth: -6.6%

Valve replacement with allograft (subcoronary or cylindrical implant), or unstented xenograft (Anaes.) (Assist.)

Item 38490 – Schedule fee: $554.55
Services: 308  Total Benefits: $39,394  Average annual growth: 4.9%

Sub-valvular structures, reconstruction and re-implantation of, associated with mitral and tricuspid valve replacement (Anaes.) (Assist.)

Item 38493 – Schedule fee: $1957.60
Services: 114  Total Benefits: $102,311  Average annual growth: 2.9%

Operative management of acute infective endocarditis, in association with heart valve surgery (Anaes.) (Assist.)

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

Recommendation 42.1
  • ΔRestructure the items used for valve surgery to create more complete medical services, and remove the redundant item numbers, including item 38588 (which will be incorporated into all relevant codes).
Recommendation 42.2
  • ΔThe proposed changes for valve replacement items are as follows:
  • – Item 38487: Leave this item unchanged.
  • – Item 38488: Delete this item, which will be replaced by items 3848A and 3848B.
  • – Item 38489: Delete this item, which will be replaced by items 3848A and 3848B.
  • – Item 38490: Leave this item unchanged, only claimable with item 3848B.
  • – Item 38485: Leave this item unchanged.
  • – Create the following items:

Item 3848A

Aortic or pulmonary valve replacement with bioprosthesis or mechanical prosthesis. Including retrograde cardioplegia, where performed. (Anaes.) (Assist.)

Item 3848B

Mitral or tricuspid valve replacement with bioprosthesis or mechanical prosthesis. Including retrograde cardioplegia, where performed. (Anaes.) (Assist.)

Item 3848C

Valve explant of a previous prosthesis performed during valve replacement (3848A/3848B). . (Anaes.) (Assist.)

Recommendation 42.3
  • ΔThe proposed changes for valve repair items are as follows:
  • – Item 38480: Delete this item, which is now included in item 3848E.
  • – Item 38481: Delete this item, which is now included in item 3848F.
  • – Item 38475: Delete this item, which has been replaced by items 3848E and 3848F.
  • – Item 38477: Leave this item unchanged, but add the following explanatory note: “For congenital surgery, alternative dissolvable options may be used instead of the insertion of permanent fixed rings which may result in negative long term outcomes.”
  • – Item 38478: Delete this item, which has been replaced by items 3848E and 3848F.
  • – Item 38493: Leave this item unchanged.
  • – Item 38483: Obsolete – delete from the MBS.
  • – Create the following items:

Item 3848E

Simple valve repair, with or without annuloplasty, including quadrangular resection, cleft closure, or Alfieri. Including retrograde cardioplegia, where performed. (Anaes.) (Assist.)

Item 3848F

Complex valve repair, with or without annuloplasty, involving one of

  • (a) Neochords; or
  • (b) Chordal transfer; or
  • (c) Patch augmentation; or
  • (d) Multiple leaflets.

Including retrograde cardioplegia, where performed. (Anaes.) (Assist.)

Item 38477

Valve annuloplasty with insertion of ring, not being a service to which item 3848E or 3848F applies (Anaes.) (Assist.)

Explanatory note: For congenital surgery, alternative dissolvable options may be used instead of the insertion of permanent fixed rings which may result in negative long term outcomes

Recommendation 42.4
  • ΔPrevent inappropriate co-claiming of services inherent to the relevant procedures for all valve surgery items in this section, both new and amended, including items 38806, 38418, 11700–11702, 33824 and 18260.

Rationale

These recommendations focus on simplifying the MBS and creating complete medical services. They are based on the following observations.

Valve replacement

  • ΔThe Committee agreed that there was an opportunity to modernise the valve procedure items under the MBS, and that these should be constructed as complete medical services, where possible. It was agreed that item 38487 (mitral valvotomy) should remain on the MBS, with no changes required. This item is most commonly performed in Indigenous populations and in some migrant or refugee populations, almost exclusively in public hospitals. Over the last 10 years, 1–10 services have been claimed each year. The Committee agreed that this is a discrete and appropriate service for the relevant patient groups and should be retained.
  • ΔThe Committee agreed that items 38488 and 38489 should be modernised so that they are no longer demarcated by technology. It was noted that some of the technologies listed in the descriptors are no longer available in Australia.
  • ΔIt was agreed that valve replacement items should be demarcated by the valve that is replaced (items 3848A and 3848B). This provides greater transparency for tracking and compliance purposes, particularly where multiple valves are replaced in the same episode of care. This change is complementary with item 38490 for reconstruction of sub-valvular structures.
  • ΔThe Committee noted that there is currently no item or service for valve explant procedures. The removal of a previously inserted bioprosthesis or mechanical prosthesis is complex and increases the duration of a valve replacement by approximately one hour. The Committee agreed that this service is currently under-remunerated, and it recommended that this change should not be cost-neutral, acknowledging that this may entail an expedited MSAC review (the service is not new). This MSAC application would be most appropriately sponsored by The Australian and New Zealand Society of Cardiac and Thoracic Surgeons.
  • ΔThe Committee recommended retaining item 38490 as a discrete item as this is not currently standard practice and there may be patients for whom an alternative approach is more appropriate. There is evidence that preserving the subvalvular apparatus may improve short- and long-term outcomes, but this is relatively uncommon in surgical practice. This ‘bolt on’ item should be retained to incentivise this emerging best practice.
  • ΔThe Committee acknowledged that allografts can be very complex procedures. However, they are likely to be co-claimed with the relevant aortic/aortic root procedures, and the Committee agreed that this is a reasonable approach.
  • ΔIt was acknowledged that although paediatric surgeons generally operate under the paediatric section of the MBS, these revised items would not disadvantage them.

Valve repair

  • ΔRegarding leaflet repair items 38480 and 38481, the Committee agreed that there was a significant difference between the two procedures. A two-leaflet repair is a more technically complicated procedure, and the Committee was surprised to note that these accounted for approximately 30 per cent of claims in FY 2014/15. The Committee agreed that full valve repair has better outcomes for patients compared with valve replacement. Higher performing facilities will do more complete repairs including the anterior leaflet, and this has better patient outcomes.
  • ΔThe Committee discussed the lack of clarity in the current item descriptors—and the MBS more broadly—regarding the claiming of attempted services. For example, a repair was attempted in a patient who was then taken off heart lung bypass. The repair was unsuccessful, and a second repair was attempted. The patient was again taken off bypass, but the repair was again found to be unsuccessful. The procedure then progressed to a valve replacement. Both the repair and replacement items were claimed (with the lesser item subject to the multiple services rule). The Committee noted that there is an item for procedures that are aborted for medical reasons, but it did not believe this was appropriate on this occasion. Specifically, it was suggested that this MBS item is intended for procedures that are cancelled prior to commencement. The Department clarified that this is not the intent of the abortive item, as the MBS does not provide funding for cancelled procedures.
  • ΔThe Committee agreed that in the case of valve repair, clinicians would never intend to do both a repair and a replacement in a single session. For this reason, it felt that there were situations in which co-claiming repair and replacement items would be appropriate, and that this would encourage clinicians to attempt a repair (where appropriate), which may improve patient outcomes. However, it acknowledged that there are also situations in which co-claiming would be considered fraudulent, including attempting a repair for an inadequate amount of time. Providers who have high rates of co-claiming should be subject to compliance measures and audit.
  • ΔThe Committee agreed that the schedule fees for items 38480 and 38481 are not appropriately distributed and should be reviewed in light of the time and skill required for each procedure. It also felt that there is overlap with the annuloplasty items, and that differentiation by number of leaflets is a poor indication of complexity. (For example, the Alferi procedure involves a suture between two leaflets and is relatively simple, but it attracts the higher rebate for item 38481.) The Committee recommended restructuring the items to create items for simple and complex valve replacements, retaining some additional related items.
  • ΔThe Committee agreed that performing an annuloplasty with valve repairs represents best practice, although there are instances where this may not be true, particularly in paediatric practice. It agreed that annuloplasty should be consolidated into the new repair items (items 3848E and 3848F), but as a ‘with or without’ option, performed at the discretion of the surgeon
  • ΔThe Committee felt that item 38477 (annuloplasty with ring) should be retained as an appropriate discrete service. The explanatory notes should clarify that alternatives (including dissolvable rings or compression bands) may be used instead of permanent fixed rings for congenital surgery in order to improve long-term outcomes, as these procedures are performed in hearts that are still growing.
  • ΔThe Committee agreed that item 38483 no longer reflects contemporary clinical practice and has been replaced by items 38480 and 38481. The item was therefore considered obsolete, as there is minimal evidence for aortic valve leaflet repair. If this procedure is performed, it can be claimed under the other valve leaflet repair items. The item is not used in the paediatric population.
  • ΔThe Committee agreed that item 38493 should remain a discrete service. Although it is not performed in isolation, it is uncommon and is infrequently co-claimed. It is also a significantly more complex and time-consuming procedure.

Co-claiming

  • ΔThe Committee noted that 14 per cent of valve-related services were co-claimed with one of three items for thoracotomy or sternotomy involving division of adhesions (9). It suggested that this reflects the adoption of minimally invasive approaches for valve procedures via thoracotomy, as opposed to the standard approach via sternotomy. The Committee determined that as with other evolutions in surgical technique (such as the move to laparoscopic procedures), the access required for the procedure is part of the primary item. The surgeon should choose the most appropriate approach for the patient, and additional items should not be claimed to account for specific approach decisions. For example, it is inappropriate to co-claim an item 38418 (exploratory thoracotomy) simply because a cardiac procedure is conducted using a thoracotomy approach instead of sternotomy.
  • ΔThe Committee noted that closure of atrial septal defect (ASD) services were co-claimed with up to 33 per cent of some valve procedures—well above the expected level (which is 15 per cent, based on anecdotal evidence). The Committee considered including this item in the complete medical services for other valve procedures. However, it ultimately decided that it should be retained as a discrete item because the procedure should not be performed in the majority of cases, and because it requires additional time and specific planning to perform. The Committee also recommended a review of co-claiming patterns for ASD procedures, particularly where rates are significantly greater than 15 per cent.
  • ΔThe Committee considered including items for the division of accessory pathways into the complete services, but it agreed that this is a discrete service that may be performed at the same time. It also noted that there is evidence that it may improve survival over time. The Committee agreed that the current co-claiming rate of 20 per cent aligned with members’ experience, although this is expected to increase over time as more providers become convinced by the increasing weight of international evidence regarding the merits of this combination. The generational shift in surgeons also means that more young surgeons will be trained in the procedure, which will further increase uptake.
  • ΔThe Committee noted that some inappropriate co-claiming of items (such as insertion of an intercostal catheter) was occurring with valve-related procedures. Steps should be taken by the MBS to prevent the co-claiming of these items (items 38806, 11700–11702, 33824 and 18260).
  • ΔThe Committee recommended incorporating retroplegia into the valve replacement and repair services, as described for CAGS.
  • ΔThe Committee agreed that routine CAGs and valve procedures should not be co-claimed with the vascular surgical codes for the repair of major vessels, such as items 33815, 33818 and 33824. It felt that co-claiming these services for true major intraoperative complications would be rare, and not in the order of 10–24 per cent evident in the MBS data. It was noted that these items may be claimed for transcatheter aortic valve implantation (TAVI) procedures to account for wound closure. This would be low volume and should cease with the creation of TAVI items, should they be listed by the MSAC.

9.4.2 Ascending thoracic aorta

Current item descriptors and MBS data from FY 2014/15

Item 38550 – Schedule fee: $2146.15
Services: 89  Total Benefits: $115,184  Average annual growth: 8.6%

Ascending thoracic aorta, repair or replacement of, not involving valve replacement or repair or coronary artery implantation (Anaes.) (Assist.)

Item 38553 – Schedule fee: $2719.75
Services: 564  Total Benefits: $1,139,648  Average annual growth: 12.1%

Ascending thoracic aorta, repair or replacement of, with aortic valve replacement or repair, without implantation of coronary arteries (Anaes.) (Assist.)

Item 38556 – Schedule fee: $3104.70
Services: 314  Total Benefits: $723,880  Average annual growth: 7.5%

Ascending thoracic aorta, repair or replacement of, with aortic valve replacement or repair, and implantation of coronary arteries (Anaes.) (Assist.)

Item 38572 – Schedule fee: $1987.05
Services: 115  Total Benefits: $83,733  Average annual growth: 15.1%

Operative management of acute rupture or dissection, in conjunction with procedures on the thoracic aorta (Anaes.) (Assist.)

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

Recommendation 43.1
  • ΔCreate an item for valve-sparing aortic root surgery, using the following proposed descriptor:

Item 385XXA

Valve sparing aortic root surgery with reimplantation of aortic valve and coronary arteries and with replacement of the ascending aorta. Including cardiopulmonary bypass, and including retrograde cardioplegia, where performed. (Anaes.) (Assist.)

Recommendation 43.2
  • ΔLeave the descriptors for items 38550, 38553, 38556 and 38572 unchanged, except as described below.
Recommendation 43.3
  • ΔCreate complete services by including appropriate and necessary procedures in all items in this section, such as vascular anastomoses and retroplegia.
Recommendation 43.4
  • ΔPrevent inappropriate co-claiming of services inherent to the relevant procedures (such as intercostal catheter insertion), including items 38806, 38418, 11700–11702, 33824 and 18260.

Rationale

These recommendations focus on the creation of complete medical services and modernising the MBS to reflect contemporary practice. They are based on the following observations.

  • ΔThe Committee agreed that there is scope for simplifying aortic procedure codes, and that structuring under the themes of ascending, descending and arch-related would provide clear distinctions. It considered a revised structure suggested by one of its members and felt that this provided an appropriate update to the MBS, reflecting contemporary surgical practice.
  • ΔTo create complete medical services, the Committee recommended a new item (item 385XA) for valve-sparing aortic root surgery. This is only performed by a few surgeons in Australia and is a complex and time-consuming procedure. For this reason, multiple items are often co-claimed (for example, item 38556 with a two-leaflet valve repair, with or without an aortic arch procedure). There would be no expected increase in overall volume or MBS benefits paid, although the fee for this item should be commensurate with the complexity of the procedure. The Committee agreed that retroplegia should be included in these services, and that vascular anastomoses are integral to performing this procedure and should also be incorporated.
  • ΔThe Committee agreed that item 38572 should be retained as a ‘bolt on’ item for aortic procedures to reflect the significant time, complexity and risk associated with such procedures.
  • ΔIt is inappropriate to co-claim certain services (such as the insertion of an intercostal catheter) as they are already included in the schedule fee for the service. Such co-claiming should be prevented.
  • ΔIt was highlighted that the items for paediatric aortic surgery (items 38706–38712) are significantly limited, and that the same items are used to cover services ranging from 45 minutes to five hours. The current wording of adult items precludes their use in paediatric populations. The proposed wording (in addition to the recommended changes to the paediatric items outlined in Section 9.4.5) will ensure that the MBS more accurately describes the procedures being performed.

9.4.3 Descending thoracic aorta

Current item descriptors and MBS data from FY 2014/15

Item 38568 – Schedule fee: $1862.95
Services: 24  Total Benefits: $23,010  Average annual growth: 3.7%

Descending thoracic aorta repair or replacement of, without shunt or cardiopulmonary bypass, by open exposure, percutaneous or endovascular means (Anaes.) (Assist.)

Item 38571 – Schedule fee: $2051.75
Services: 19  Total Benefits: $15,291  Average annual growth: 3.5%

Descending thoracic aorta, repair or replacement of, using shunt or cardiopulmonary bypass (Anaes.) (Assist.)

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

Recommendation 44.1
  • ΔLeave the descriptors of items 38568 and 38571 unchanged.
Recommendation 44.2
  • ΔRestrict inappropriate co-claiming of services inherent to the relevant procedures (such as intercostal catheter insertion and thoracotomy approach), including items 38806, 38418, 11700–11702, 33824 and 18260.
Recommendation 44.3
  • ΔThe Committee also recommended that the Vascular Clinical Committee consider the most appropriate construction of complete medical services.

Rationale

The recommendations focus on modernising the MBS. They are based on the following observation.

  • ΔThe Committee felt that these items were sufficiently simple. However, steps could be taken to promote a more complete medical service and reduce patient rebate variability, as with the creation of complete medical services for vascular procedures. The Committee agreed that the co-claiming of item 38571 with items 33818 and 38603 was likely to be related to the endoluminal stenting of descending aortic aneurysms. Although the Committee agreed that closure of vascular access for a transluminal procedure should be included in the primary procedure code and not co-claimed, it recommended that the Vascular Clinical Committee consider the most appropriate construction of complete vascular services.

9.4.4 Aortic arch

Current item descriptors and MBS data from FY 2014/15

Item 38559 – Schedule fee: $2531.00
Services: 55  Total Benefits: $100,676  Average annual growth: 3.2%

Aortic arch and ascending thoracic aorta, repair or replacement of, not involving valve replacement or repair or coronary artery implantation (Anaes.) (Assist.)

Item 38562 – Schedule fee: $3104.70
Services: 98  Total Benefits: $224,468  Average annual growth: 17.4%

Aortic arch and ascending thoracic aorta, repair or replacement of, with aortic valve replacement or repair, without implantation of coronary arteries (Anaes.) (Assist.)

Item 38565 – Schedule fee: $3482.25
Services: 109  Total Benefits: $283,144  Average annual growth: 9.3%

Aortic arch and ascending thoracic aorta, repair or replacement of, with aortic valve replacement or repair, and implantation of coronary arteries (Anaes.) (Assist.)

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

Recommendation 45
  • ΔIn conjunction with the changes made to ascending aorta items, consolidate items 38565, 38559 and 38562 into two items for simple and complex procedures. The proposed item descriptors are provided below.

Item 385XXB

Simple replacement or repair of aortic arch including deep hypothermic circulatory arrest, peripheral cannulation for cardiopulmonary bypass, and antegrade or retrograde cerebral perfusion, where performed. Claimable in association with items 38550, 38553, 38556, 385XA, 38568 and 38571.

Item 385XXC

Complex replacement or repair of aortic arch involving debranching and reimplantation of head and neck vessels. Including deep hypothermic circulatory arrest, peripheral cannulation for cardiopulmonary bypass, and antegrade or retrograde cerebral perfusion, where performed. Claimable in association with items 38550, 38553, 38556, 385XA, 38568 and 38571.

Rationale

The recommendation focuses on modernising and simplifying the MBS and is based on the following observations.

  • ΔThe Committee agreed that alongside the changes made to the ascending aorta items, it was appropriate to consolidate aortic arch items into two items, including deep hypothermic circulatory arrest with antegrade or retrograde cerebral perfusion and other relevant items. This would be claimable in addition to the relevant repair item. It was suggested that a separate item should be created for procedures involving debranching and the reimplantation of head and neck vessels as this significantly increases the complexity of the procedure.
  • ΔThe Committee also noted that retrograde cerebral perfusion is no longer best practice, and that many of the 70 services covered by item 38588 would likely involve anterograde perfusion. Furthermore, other anterograde services may be claimed under peripheral cannulation (femoral/axillary item 38603). Given that the proposed aortic arch item includes retrograde or antegrade cerebral perfusion, the item for retrograde perfusion will no longer be required however the Committee recommended it be retained for 12 months to identify any unexpected uses which it can be incorporated into prior to deletion.
  • ΔIt was noted that there is a risk of indication drift based on aortic size, with providers performing procedures in patients with minimal dilation. However, it was agreed that this is a small risk, and the Committee felt that it was inappropriate to define indications, given the fluid nature of current guidelines.
  • ΔThe Committee agreed that it was reasonable for hemi-arch procedures to fall under the scope of item 385XXB.
  • ΔAs with other items, services such as the insertion of an intercostal catheter are included in the base item and should not be inappropriately co-claimed.

9.4.5 Aortic repair (congenital)

Current item descriptors and MBS data from FY 2014/15

Item 38706 – Schedule fee: $1822.40
Services: 24  Total Benefits: $32,120  Average annual growth: -1.6%

Aorta, anastomosis or repair of, without cardiopulmonary bypass, for congenital heart disease (Anaes.) (Assist.)

Item 38709 – Schedule fee: $2134.50
Services: 29  Total Benefits: $36,420  Average annual growth: 3%

Aorta, anastomosis or repair of, with cardiopulmonary bypass, for congenital heart disease (Anaes.) (Assist.)

Item 38712 – Schedule fee: $2563.15
Services: 2  Total Benefits: $2,884  Average annual growth: -27.5%

Aortic interruption, repair of, for congenital heart disease (Anaes.) (Assist.)

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

Recommendation 46.1
  • ΔLeave items 38706 and 38709 unchanged.
Recommendation 46.2
  • ΔDelete item 38712 from the MBS and replace it with item 387XXA, with the following proposed descriptor:

Item 387XXA

Aortic repair involving augmentation of hypoplastic or interrupted aortic arch including use of antegrade cerebral perfusion or deep hypothermic circulatory arrest and associated myocardial preservation including retrograde cardioplegia. Performed in a neonate.

Rationale

The recommendations focus on modernising the MBS and are based on the following observations.

  • ΔThere was clinical consensus that no changes were required for items 38706 and 38709.
  • ΔItem 38712 should be deleted as it no longer reflects contemporary practice and is specifically confined to aortic interruption, which is a rare presentation.
  • ΔThe paediatric cardiac surgery component of the MBS has not been revised in some time, and there have been important changes in practice that are now widely adopted across Australia, particularly in centres that perform high volumes of neonatal work (Sydney, Melbourne and Brisbane). These include:
    • – A drive to definitive repair during the neonatal period, if possible. For example, coarctation with ventricular septal defect is now often fixed as a single procedure as a neonate, rather than coarctation repair with pulmonary artery banding, followed by a second procedure at 6 to 18 months of age for debanding and VSD closure.
    • – A drive to improve the quality of aortic arch repair in order to reduce the need for re-intervention, as well as the incidence or severity of later hypertension. This strategy includes a preference for primary repair of aortic interruption, rather than placing interposition grafts and repair of the aorta via sternotomy with cardiopulmonary bypass, to better address hypoplasia of the transverse aortic arch.
  • ΔWorking on the neonatal aorta via sternotomy on bypass is a skill set that is now standard for surgeons trained in the last 10–15 years. Older surgeons may prefer more conservative approaches. The newer approaches involve bigger and more complex operations, but the long-term outcomes are believed to be superior.
  • ΔThe proposed descriptor for the item captures the work described for this small subset of patients—estimated at less than 60 per year nationally—and would include patients undergoing two ventricle repairs, as well as first-stage single ventricle operations. Use of the word “augmentation” restricts use of the item to larger operations where best practice requires sternotomy and augmentation with homograft or other tissues. It is unlikely that the new item would incentivise inappropriate use of this approach as it covers a four- to six-hour operation with substantially larger post-operative care requirements, compared to an operation lasting 1.5 hours.
  • ΔThe descriptor distinguishes these operations from ‘lesser’ operations to repair aortic coarctation, not requiring formal augmentation, which would still be claimed as item 38709 (repair of aorta, on bypass). Item 38709 volumes currently include operations that would move to item 387XXA, as this is currently the only item that can be used for more complex aortic repairs.
  • ΔThis new item should be listed in the congenital section of the MBS, and could be restricted to neonates (first 30 days of life) to reduce the risk (albeit low) of misuse.
  • ΔAs this is a novel item, the Committee noted that item 38565 is an analogous adult procedure that does not require valve replacement but involves augmentation of the ascending aorta, arch and descending aorta. This item could be considered when determining the appropriate schedule fee for item 387XXA.

9.5 Other cardiac surgical items

9.5.1 Thoracotomy/sternotomy

Current item descriptors and MBS data from FY 2014/15

Item 38640 – Schedule fee: $958.40
Services: 115  Total Benefits: $42,241  Average annual growth: -0.8%

Re-operation via median sternotomy, for any procedure, including any divisions of adhesions where the time taken to divide the adhesions is 45 minutes or less (Anaes.) (Assist.)

Item 38643 – Schedule fee: $1067.40
Services: 999  Total Benefits: $377,450  Average annual growth: 6.7%

Thoracotomy or sternotomy involving division of adhesions where the time taken to divide the adhesions exceeds 45 minutes (Anaes.) (Assist.)

Item 38647 – Schedule fee: $2134.50
Services: 751  Total Benefits: $957,977  Average annual growth: 7.8%

Thoracotomy or sternotomy involving division of extensive adhesions where the time taken to divide the adhesions exceeds 2 hours (Anaes.) (Assist.)

Item 38656 – Schedule fee: $958.40
Services: 345  Total Benefits: $227,000  Average annual growth: -0.6%

Thoracotomy or median sternotomy for post-operative bleeding (Anaes.) (Assist.)

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

Recommendation 47.1
  • ΔConsolidate items 38640, 38643 and 38647 into a single item, with the following descriptor:

Item 38643

Re-operation via thoracotomy or sternotomy involving the division of adhesions, where the time taken to divide the adhesions exceeds 30 minutes. (Anaes.) (Assist.)

Recommendation 47.2
  • ΔLeave item 38656 unchanged.

Rationale

The recommendations focus on simplifying the MBS and are based on the following observations.

  • ΔThe Committee noted that the growth trends for these items follow the trends for similar items across the MBS, with volumes shifting to longer and higher rebated procedures. The five-year growth rates for items 38643 and 38647 were 7 per cent and 8 per cent, respectively, compared with -1 per cent for item 38640. These growth rates are contrary to the expectation that procedures will become more efficient over time. The Committee also noted that the proportion of services claimed under item 38647 was higher than expected.
  • ΔThe Committee felt that all three items should be consolidated into item 38643 in a cost-neutral manner. It felt that such a change would be unlikely to significantly affect volumes or costs, as the majority of services are already claimed under the higher value, long-duration division items.
  • ΔThe Committee agreed that no change was required for item 38656.

9.5.2 Circulatory support

Current item descriptors and MBS data from FY 2014/15

Item 38577 – Schedule fee: $554.55
Services: 70  Total Benefits: $8,631  Average annual growth: 9.2%

Cannulation for, and supervision and monitoring of, the administration of retrograde cerebral perfusion during deep hypothermic arrest (Assist.)

Item 38588 – Schedule fee: $416.05
Services: 6,882  Total Benefits: $841,880  Average annual growth: 3.2%

Cannulation of the coronary sinus for and supervision of, the retrograde administration of blood or crystalloid for cardioplegia, including pressure monitoring (Assist.)

Item 38600 – Schedule fee: $1532.00
Services: 10  Total Benefits: $9,287  Average annual growth: 0%

Central cannulation for cardiopulmonary bypass excluding post-operative management, not being a service associated with a service to which another item in this Subgroup applies (Anaes.) (Assist.)

Item 38603 – Schedule fee: $958.40
Services: 706  Total Benefits: $169,936  Average annual growth: 9.8%

Peripheral cannulation for cardiopulmonary bypass excluding post-operative management (Anaes.) (Assist.)

Item 38609 – Schedule fee: $479.15
Services: 57  Total Benefits: $8,491  Average annual growth: -3.5%

Intra-aortic balloon pump, insertion of, by arteriotomy (Anaes.) (Assist.)

Item 38612 – Schedule fee: $537.10
Services: 16  Total Benefits: $4,434  Average annual growth: 0%

Intra-aortic balloon pump, removal of, with closure of artery by direct suture (Anaes.) (Assist.)

Item 38613 – Schedule fee: $674.05
Services: None  Total Benefits: None  Average annual growth: N/A

Intra-aortic balloon pump, removal of, with closure of artery by patch graft (Anaes.) (Assist.)

Item 38627 – Schedule fee: $669.60
Services: 31  Total Benefits: $9,542  Average annual growth: 14.1%

Extra-corporeal membrane oxygenation, bypass or ventricular assist device cannulae, adjustment and re-positioning of, by open operation, in patients supported by these devices (Anaes.) (Assist.)

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

Recommendation 48.1
  • ΔDelete item 38577 and incorporate the procedure into the aortic arch procedures.
Recommendation 48.2
  • ΔReview item 38588 for potential deletion 12 months after implementation of the recommendations in this report.
Recommendation 48.3
  • ΔChange the descriptor for item 38603 to read:

Item 38603

Peripheral cannulation for cardiopulmonary bypass excluding post-operative management. Not claimable where peripheral cannulation is used in preference over central cannulation for valve or coronary artery bypass procedures, or as part of a service to which item 385XXB or 38572 applies. (Anaes.) (Assist.)

Recommendation 48.4
  • ΔLeave items 38600, 38609, 38612 and 38627 unchanged.
Recommendation 48.5
  • ΔDelete item 38613 as item 38612 renders it redundant.

Rationale

The recommendations focus on simplifying the MBS and are based on the following observations.

  • ΔItem 38577 is not a stand-alone service and is therefore now included in the items for aortic arch repair and replacement, including retrograde and antegrade cerebral protection.
  • ΔItem 38588 is not a stand-alone service, but there was significant discussion around including this item in complete medical services. Although there are a number of instances where the co-claiming of this item is inappropriate, the Committee agreed that the item should be retained and potentially reviewed in 12 months. It felt that excluding routine CAGS and valve procedures, or aortic arch and dissection-related procedures, would significantly reduce the remaining volumes, and it may be appropriate to consider removal at that time. The Committee also noted that there are certain complicated redo procedures where peripheral access can improve patient outcomes, and the retention of an incentive for this may be beneficial.
  • ΔGiven that aortic arch items now include antegrade cerebral perfusion, item 38603 is now used for femoral access only.
  • ΔThe Committee noted that item 38613 had exceedingly low service volumes, with just three services provided over the last 10 years. For this reason, it felt that the item should be removed, with item 38612 remaining to ensure that there are no access issues.

9.5.3 Transoesphageal echocardiography

Current item descriptors and MBS data from FY 2014/15

Item 55118 – Schedule fee: $275.50
Services: 15,151  Total Benefits: $3,156,428  Average annual growth: 6.6%

Heart, two-dimensional real time transoesophageal examination of, from at least 2 levels, and in more than1 plane at each level: (a) with: (i) real time colour flow mapping and, if indicated, pulsed wave doppler examination; and (ii) recordings on video tape or digital medium; and (b) not being an intra-operative service or a service associated with a service to which an item in Subgroup 1 (except item 55054) or 3 applies (R)(Anaes.) (Anaes.)

Item 55130 – Schedule fee: $170.00
Services: 744  Total Benefits: $92,738  Average annual growth: -13%

Intra-operative 2 dimensional real time transoesophageal echocardiography incorporating doppler techniques with colour flow mapping and recording onto video tape or digital medium, performed during cardiac surgery incorporating sequential assessment of cardiac function before and after the surgical procedure, not being a service associated with a service to which item 55135 applies (R)(Anaes.) (Anaes.)

Item 55135 – Schedule fee: $353.60
Services: 3,387  Total Benefits: $888,818  Average annual growth: 4%

Intra-operative 2 dimensional real time transoesophageal echocardiography incorporating doppler techniques with colour flow mapping and recording onto video tape or digital medium, performed during cardiac valve surgery (replacement or repair) incorporating sequential assessment of cardiac function and valve competence before and after the surgical procedure, not being a service associated with a service to which item 55130 applies (R)(Anaes.) (Anaes.)

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

Recommendation 49.1
  • ΔRemove the words “video tape or” from all echocardiogram item descriptors.
Recommendation 49.2
  • ΔUpdate the payment restrictions for items 55135 to reflect the new valve procedure item structure, and specify the new item numbers for valvular surgery, with which this can be claimed.

Rationale

These recommendations focus on modernising the MBS and are based on the following observations.

  • ΔThe Committee agreed that “video tape” is an historical reference and should be removed.
  • ΔIn light of the changes to items 55135 and 55136, the restrictions should be updated.

9.5.4 Ablation and division of pathways

Current item descriptors and MBS data from FY 2014/15

Item 38512 – Schedule fee: $2098.45
Services: 483  Total Benefits: $490,426  Average annual growth: 25%

Division of accessory pathway, isolation procedure, procedure on atrioventricular node or perinodal tissues involving 1 atrial chamber only (Anaes.) (Assist.)

Item 38515 – Schedule fee: $2671.95
Services: 295  Total Benefits: $548,398  Average annual growth: 2.8%

Division of accessory pathway, isolation procedure, procedure on atrioventricular node or perinodal tissues involving both atrial chambers and including curative surgery for atrial fibrillation (Anaes.) (Assist.)

Item 38518 – Schedule fee: $2868.05
Services: 2  Total Benefits: $2,933  Average annual growth: 0%

Ventricular arrhythmia with mapping and muscle ablation, with or without aneurysmeotomy (Anaes.) (Assist.)

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

Recommendation 50
  • ΔLeave items 38512, 38515 and 38518 unchanged.

Rationale

This recommendation is based on the following observation.

  • ΔThese items were referred from the AECG and Electrophysiology Working Group for surgical input. It was the strong consensus of the Committee that these reflect contemporary practice and are under-utilised. For this reason, these items should remain, and there is an expectation that volumes will continue to increase over time.

9.5.5 Cardiac tumour

Current item descriptors and MBS data from FY 2014/15

Item 38670 – Schedule fee: $1909.20
Services: 47  Total Benefits: $34,008  Average annual growth: 10.9%

Cardiac tumour, excision of, involving the wall of the atrium or inter-atrial septum, without patch or conduit reconstruction (Anaes.) (Assist.)

Item 38673 – Schedule fee: $2148.85
Services: 27  Total Benefits: $39,485  Average annual growth: 1.6%

Cardiac tumour, excision of, involving the wall of the atrium or inter-atrial septum, requiring reconstruction with patch or conduit (Anaes.) (Assist.)

Item 38677 – Schedule fee: $2010.35
Services: 12  Total Benefits: $13,570  Average annual growth: 19.1%

Cardiac tumour arising from ventricular myocardium, partial thickness excision of (Anaes.) (Assist.)

Item 38680 – Schedule fee: $2384.55
Services: None  Total Benefits: None  Average annual growth: -100%

Cardiac tumour arising from ventricular myocardium, full thickness excision of including repair or reconstruction (Anaes.) (Assist.)

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

Recommendation 51
  • ΔLeave items 38670, 38673, 38677 and 38680 unchanged.

Rationale

This recommendation is based on the following observation.

  • ΔThese are very low-volume items with specific indications, and no obvious concerns were identified.

9.5.6 Pacemaker insertion

Current item descriptors and MBS data from FY 2014/15

Item 38470 – Schedule fee: $958.40
Services: 136  Total Benefits: $42,137  Average annual growth: 1.1%

Permanent myocardial electrode, insertion of, by thoracotomy or sternotomy (Anaes.) (Assist.)

Item 38473 – Schedule fee: $573.70
Services: 18  Total Benefits: $3,587  Average annual growth: -4.8%

Permanent pacemaker electrode, insertion by open surgical approach (Anaes.) (Assist.)

Item 38654 – Schedule fee: $1224.60
Services: 46  Total Benefits: $29,598  Average annual growth: -2.4%

Permanent left ventricular electrode, insertion, removal or replacement of via open thoracotomy, for the purpose of cardiac resynchronisation therapy, for a patient who:(a) has:(i) moderate to severe chronic heart failure (New York Heart Association (nyha) class iii or iv) despite optimised medical therapy; and (ii) sinus rhythm; and (iii) a left ventricular ejection fraction of less than or equal to 35%; and (iv) a qrs duration greater than or equal to 120 ms; or(b) has:(i) mild chronic heart failure nyha class ii) despite optimised medical therapy; and (ii) sinus rhythm; and (iii) a left ventricular ejection fraction of less than or equal to 35%; and (iv) a qrs duration greater than or equal to 150 ms; or (c) satisfied the requirements mentioned in paragraph (a) or (b) immediately before the insertion of a cardiac resynchronisation therapy device and transvenous left ventricle electrode (Anaes.) (Assist.)

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

Recommendation 52
  • ΔConsolidate items 38473 and 38654 into item 38470, with the following descriptor:

Item 38470

Permanent myocardial electrode, insertion, removal or replacement of, by open surgical approach. (Anaes.) (Assist.)

Rationale

This recommendation focuses on simplifying the MBS and is based on the following observations.

  • ΔThe Committee felt that having two low-volume items for this procedure was unnecessary, and that it was reasonable to consolidate these items into item 38470, with a revised descriptor that includes all approaches.
  • ΔThe Committee agreed that the descriptor for item 38470 allows for all instances covered by item 38654, and that these should be consolidated to simplify the MBS. Both procedures are performed almost entirely by cardiothoracic surgeons.

9.5.7 Ventricular assist devices

Current item descriptors and MBS data from FY 2014/15

Item 38615 – Schedule fee: $1532.00
Services: 12  Total Benefits: $8,325  Average annual growth: -3%

Insertion of a left or right ventricular assist device, for use as:(a) a bridge to cardiac transplantation in patients with refractory heart failure who are: (i) currently on a heart transplant waiting list, or (ii) expected to be suitable candidates for cardiac transplantation following a period of support on the ventricular assist device; or (b) acute post cardiotomy support for failure to wean from cardiopulmonary transplantation; or (c) cardio-respiratory support for acute cardiac failure which is likely to recover with short term support of less than 6 weeks; not being a service associated with the use of a ventricular assist device as destination therapy in the management of patients with heart failure who are not expected to be suitable candidates for cardiac transplantation (Anaes.) (Assist.)

Item 38618 – Schedule fee: $1909.60
Services: 20  Total Benefits: $21,098  Average annual growth: 3.3%

Insertion of a left and right ventricular assist device, for use as:(a) a bridge to cardiac transplantation in patients with refractory heart failure who are: (i) currently on a heart transplant waiting list, or (ii) expected to be suitable candidates for cardiac transplantation following a period of support on the ventricular assist device; or (b) acute post cardiotomy support for failure to wean from cardiopulmonary transplantation; or (c) cardio-respiratory support for acute cardiac failure which is likely to recover with short term support of less than 6 weeks; not being a service associated with the use of a ventricular assist device as destination therapy in the management of patients with heart failure who are not expected to be suitable candidates for cardiac transplantation (Anaes.) (Assist.)

Item 38621 – Schedule fee: $762.35
Services: 3  Total Benefits: $1,287  Average annual growth: -9.7%

Left or right ventricular assist device, removal of, as an independent procedure (Anaes.) (Assist.)

Item 38624 – Schedule fee: $856.65
Services: 3  Total Benefits: $1,515  Average annual growth: -15.6%

Left and right ventricular assist device, removal of, as an independent procedure (Anaes.) (Assist.)

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

Recommendation 53
  • ΔLeave items 38615, 38618, 38621 and 38624 unchanged.

Rationale

This recommendation is based on the following observation.

  • ΔThese items were recently reviewed (prior to the MBS Review) and are therefore beyond the scope of this review.

9.5.8 Intrathoracic vessels

Current item descriptors and MBS data from FY 2014/15

Item 38727 – Schedule fee: $1495.80
Services: 22  Total Benefits: $18,601  Average annual growth: 19.6%

Intrathoracic vessels, anastomosis or repair of, without cardiopulmonary bypass, not being a service to which item 38700, 38703, 38706, 38709, 38712, 38715, 38718, 38721 or 38724 applies, for congenital heart disease (Anaes.) (Assist.)

Item 38730 – Schedule fee: $2134.50
Services: 12  Total Benefits: $12,407  Average annual growth: -15.6%

Intrathoracic vessels, anastomosis or repair of, with cardiopulmonary bypass, not being a service to which item 38700, 38703, 38706, 38709, 38712, 38715, 38718, 38721 or 38724 applies, for congenital heart disease (Anaes.) (Assist.)

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

Recommendation 54.1
  • ΔImplement a sunset clause and review on items 38727 and 38730 to determine their ongoing need to remain on the MBS, with descriptors amended to read:

Item 38727

Intrathoracic vessels, anastomosis or repair of, without cardiopulmonary bypass, performed as a primary procedure not as an integral component of another procedure.

Not being a service to which item 38700, 38703, 38706, 38709, 38712, 38715, 38718, 38721 or 38724 applies, for congenital heart disease. (Anaes.) (Assist.)

Item 38730

Intrathoracic vessels, anastomosis or repair of, with cardiopulmonary bypass, performed as a primary procedure not as an integral component of another procedure.

Not being a service to which item 38700, 38703, 38706, 38709, 38712, 38715, 38718, 38721 or 38724 applies, for congenital heart disease. (Anaes.) (Assist.)

Recommendation 54.2
  • ΔCreate a new item with the following descriptor:

Item 387XXB

Branch pulmonary arteries – left and or right, repair, augmentation or replacement, with cardiopulmonary bypass, for congenital heart disease.

Rationale

The recommendation is based on the following observations.

  • ΔThe Committee proposed a new item (387XXB) for the augmentation or replacement of branch pulmonary arteries, acknowledging that this procedure can be very time-consuming, and that it is materially different to item 38718. Given the complexity of the procedure, a commensurate fee for consideration would be the fee for item 38730. It is estimated that 50 to 70 operations would be performed annually.
  • ΔRepair or replacement of pulmonary arteries is an important part of paediatric practice. It is particularly necessary in single ventricle operations, where normal development of the intrapulmonary vessels is needed to allow the Fontan circulation (end circulation for single ventricle patients) to work effectively. This can only occur if the conduit vessels—that is, the branch pulmonary arteries (between the main pulmonary artery and the hilum of each lung)—are of satisfactory size. Branch pulmonary arteries can be small for many reasons. For example, they may be congenitally small (asymmetry is common), scarred by previous surgery (e.g., at the site of insertion of shunts or RV-PA conduits) or compressed by the reconstructed aorta.
  • ΔAt present, there is no immediately obvious route for reimbursement for the significant time required, because item 38730 cannot be claimed with preceding items in the group. However, most operations where branch pulmonary artery augmentation or replacement is required are likely to involve major work and the preceding items. It seems that some surgeons simply use item 38718, although this is specifically described as main (rather than branch) pulmonary artery repair.
  • ΔThe Committee considered items 38727 and 38730 and felt that they were unlikely to represent discrete medical services, except for the isolated repair of a pulmonary artery, which is an uncommon operation. Co-claiming data showed that 90-95 per cent of these services were co-claimed with other items, however the Committee was not certain that legitimate standalone uses for this procedure did not exist. For this reason, and in light of the addition of item 387XXB, the Committee recommended that the descriptors be amended to clarify that this item should not be claimed when performed as part of another procedure, but only when it is a primary procedure of itself. A subsequent review may find that volumes have dropped to zero at which point the items should be deleted.

9.5.9 Congenital heart disease (atrial septum)

Current item descriptors and MBS data from FY 2014/15

Item 38739 – Schedule fee: $1924.10
Services: 26  Total Benefits: $13,124  Average annual growth: 5.4%

Atrial septectomy, with or without cardiopulmonary bypass, for congenital heart disease (Anaes.) (Assist.)

Item 38742 – Schedule fee: $1924.10
Services: 511  Total Benefits: $353,576  Average annual growth: 5.3%

Atrial septal defect, closure by open exposure direct suture or patch, for congenital heart disease (Anaes.) (Assist.)

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

Recommendation 55
  • ΔUpdate the descriptor for item 38742 as outlined below.
  • ΔLeave item 38739 unchanged.

Item 38742

Atrial septal defect, closure by open exposure direct suture or patch, 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.

Rationale

This recommendation focuses on improving the value of the MBS and is based on the following observations.

  • ΔThe Committee agreed that the rates of co-claiming for item 38472 suggested that a significant proportion of these services are being claimed for the closure of a PFO. It was agreed that routine PFO closure without symptoms or clinical indication should be restricted. PFO closure during a procedure is usually quick and simple to perform and would not warrant a specific item for co-claiming, however there are cases where the defect is significant and considerable time is required to close it (80,81). The Committee agreed that the proposed changes would not restrict appropriate access to this item where clinically indicated.
  • ΔThere was clinical consensus that item 38739 did not require revision.

9.5.10 Congenital heart disease (Ventricular septum)

Current item descriptors and MBS data from FY 2014/15

Item 38748 – Schedule fee: $2134.50
Services: 5  Total Benefits: $4,403  Average annual growth: 10.8%

Ventricular septectomy, for congenital heart disease (Anaes.) (Assist.)

Item 38751 – Schedule fee: $2134.50
Services: 81  Total Benefits: $95,514  Average annual growth: 4.8%

Ventricular septal defect, closure by direct suture or patch (Anaes.) (Assist.)

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

Recommendation 56
  • ΔLeave items38748 and 38751 unchanged.

Rationale

This recommendation is based on clinical consensus.

9.5.11 Baffles

Current item descriptors and MBS data from FY 2014/15

Item 38745 – Schedule fee: $2134.50
Services: 40  Total Benefits: $37,322  Average annual growth: -3.2%

Intra-atrial baffle, insertion of, for congenital heart disease (Anaes.) (Assist.)

Item 38754 – Schedule fee: $2671.95
Services: 17  Total Benefits: $29,036  Average annual growth: -6.7%

Intraventricular baffle or conduit, insertion of, for congenital heart disease (Anaes.) (Assist.)

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

Recommendation 57
  • ΔLeave items 38745 and 38754 unchanged.

Rationale

This recommendation is based on clinical consensus.

9.5.12 Patent ductus arteriosus

Current item descriptors and MBS data from FY 2014/15

Item 38700 – Schedule fee: $1067.40
Services: 48  Total Benefits: $27,220  Average annual growth: 4.8%

Patent ductus arteriosus, shunt, collateral or other single large vessel, division or ligation of, without cardiopulmonary bypass, for congenital heart disease (Anaes.) (Assist.)

Item 38703 – Schedule fee: $1924.10
Services: 79  Total Benefits: $41,521  Average annual growth: 7.5%

Patent ductus arteriosus, shunt, collateral or other single large vessel, division or ligation of, with cardiopulmonary bypass, for congenital heart disease (Anaes.) (Assist.)

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

Recommendation 58
  • ΔLeave items 38700 and 38703 unchanged.

Rationale

This recommendation is based on clinical consensus.

9.5.13 Main pulmonary artery

Current item descriptors and MBS data from FY 2014/15

Item 38715 – Schedule fee: $1706.30
Services: 13  Total Benefits: $14,397  Average annual growth: 10.2%

Main pulmonary artery, banding, debanding or repair of, without cardiopulmonary bypass, for congenital heart disease (Anaes.) (Assist.)

Item 38718 – Schedule fee: $2134.50
Services: 90  Total Benefits: $94,337  Average annual growth: 2.1%

Main pulmonary artery, banding, debanding or repair of, with cardiopulmonary bypass, for congenital heart disease (Anaes.) (Assist.)

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

Recommendation 59
  • ΔLeave items 38715 and 38718 unchanged.

Rationale

This recommendation is based on clinical consensus.

9.5.14 Vena cava

Current item descriptors and MBS data from FY 2014/15

Item 38721 – Schedule fee: $1495.80
Services: 8  Total Benefits: $7,108  Average annual growth: 32%

Vena cava, anastomosis or repair of, without cardiopulmonary bypass, for congenital heart disease (Anaes.) (Assist.)

Item 38724 – Schedule fee: $2134.50
Services: 37  Total Benefits: $42,062  Average annual growth: 14.3%

Vena cava, anastomosis or repair of, with cardiopulmonary bypass, for congenital heart disease (Anaes.) (Assist.)

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

Recommendation 60
  • ΔLeave items 38721 and 38724 unchanged.

Rationale

This recommendation is based on clinical consensus.

9.5.15 Ventricular surgery

Current item descriptors and MBS data from FY 2014/15

Item 38506 – Schedule fee: $1626.25
Services: 9  Total Benefits: $5,512  Average annual growth: -2.1%

Left ventricular aneurysm, plication of (Anaes.) (Assist.)

Item 38507 – Schedule fee: $1909.20
Services: 3  Total Benefits: $1,432  Average annual growth: -15.6%

Left ventricular aneurysm resection with primary repair (Anaes.) (Assist.)

Item 38508 – Schedule fee: $2388.70
Services: 14  Total Benefits: $21,778  Average annual growth: 7%

Left ventricular aneurysm resection with patch reconstruction of the left ventricle (Anaes.) (Assist.)

Item 38509 – Schedule fee: $2388.70
Services: 8  Total Benefits: $13,437  Average annual growth: 2.7%

Ischaemic ventricular septal rupture repair of (Anaes.) (Assist.)

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

Recommendation 61
  • ΔConsolidate items 38506, 38507 and 38508 into a single item for left ventricular aneurysm repair. The proposed descriptor is as follows:

Item 38508

Left ventricular aneurysm repair or reconstruction including plication, resection, primary and patch repairs. (Anaes.) (Assist.)

Recommendation 62
  • ΔLeave item 38509 unchanged.

Rationale

These recommendations focus on simplifying the MBS and are based on the following observations.

  • ΔThe Committee felt that these items had very low volumes, and that the redundancy of the items could be addressed by recommending a cost-neutral consolidation of the three LV items. The new item descriptor also incorporates changing techniques, which have developed due to shifts in cardiac pathologies over time. However, it was noted that a patch reconstruction is generally the best-practice approach.
  • ΔThe Committee agreed that item 38509 was a materially different procedure and should be retained.

9.5.16 Pulmonary shunts

Current item descriptors and MBS data from FY 2014/15

Item 38733 – Schedule fee: $1495.80
Services: 6  Total Benefits: $6,170  Average annual growth: -11.4%

Systemic pulmonary or cavo-pulmonary shunt, creation of, without cardiopulmonary bypass, for congenital heart disease (Anaes.) (Assist.)

Item 38736 – Schedule fee: $2134.50
Services: 39  Total Benefits: $31,483  Average annual growth: 14.3%

Systemic pulmonary or cavo-pulmonary shunt, creation of, with cardiopulmonary bypass, for congenital heart disease (Anaes.) (Assist.)

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

Recommendation 63
  • ΔLeave items 38733 and 38736 unchanged.

Rationale

This recommendation is based on clinical consensus.

9.5.17 Extracardiac conduit

Current item descriptors and MBS data from FY 2014/15

Item 38757 – Schedule fee: $2134.50
Services: 19  Total Benefits: $11,827  Average annual growth: 3.5%

Extracardiac conduit, insertion of, for congenital heart disease (Anaes.) (Assist.)

Item 38760 – Schedule fee: $2134.50
Services: 12  Total Benefits: $12,184  Average annual growth: 1.8%

Extracardiac conduit, replacement of, for congenital heart disease (Anaes.) (Assist.)

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

Recommendation 64
  • ΔLeave items 38757 and 38760 unchanged.

Rationale

This recommendation is based on clinical consensus.

9.5.18 Other ungrouped surgical items

Current item descriptors and MBS data from FY 2014/15

Item 38763 – Schedule fee: $2134.50
Services: 79  Total Benefits: $57,013  Average annual growth: 1.9%

Ventricular myectomy, for relief of ventricular obstruction, right or left, for congenital heart disease (Anaes.) (Assist.)

Item 38766 – Schedule fee: $2134.50
Services: 51  Total Benefits: $24,345  Average annual growth: -0.8%

Ventricular augmentation, right or left, for congenital heart disease (Anaes.) (Assist.)

Item 38650 – Schedule fee: $1909.60
Services: 113  Total Benefits: $67,070  Average annual growth: 9.7%

Myomectomy or myotomy for hypertrophic obstructive cardiomyopathy (Anaes.) (Assist.)

Item 38653 – Schedule fee: $1909.60
Services: 380  Total Benefits: $211,793  Average annual growth: 18.2%

Open heart surgery, not being a service to which another item in this Group applies (Anaes.) (Assist.)

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

Recommendation 65.1
  • ΔConsolidate item 38650 into item 38763 with the proposed descriptor as follows:

Item 38763

Ventricular myectomy, for relief of ventricular obstruction, right or left. (Anaes.) (Assist.)

Recommendation 65.2
  • ΔLeave item 38653 unchanged, although compliance should follow up on known co-claiming.
  • ΔLeave item 38766 unchanged.

Rationale

The recommendations focus on simplifying the MBS and are based on the following observation.

  • ΔThe Committee felt that a single item for myomectomy was appropriate, given the low volumes of use for the services. The wording of the descriptor was discussed, and the Committee agreed that reference to hypertrophic obstructive cardiomyopathy in item 38650 did not reflect contemporary practice, as Committee members had treated patients without hypertrophic obstructive cardiomyopathy with evidence of outflow track obstruction. The Committee agreed that retaining the indication “for relief of ventricular obstruction” would mean that there was a very low risk of volume shifts or scope creep. This is not a procedure undertaken lightly.


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