5.           MBS item group 1: MRI of the knee

5.1        Items considered in this section

The items listed in Table 3 are considered in this section.

Table 3: Item descriptors

Item

Descriptor

63328

NOTE: Benefits are payable for each service included by Subgroup 12 on three occasions only in any 12 month period

MAGNETIC RESONANCE IMAGING performed under the professional supervision of an eligible provider at an eligible location where the patient is referred by a specialist or by a consultant physician - scan of musculoskeletal system for:

- derangement of knee or its supporting structures (R) 

Fee: $403.20 Benefit: 75% = $302.40 85% = $342.75

63343

NOTE: Benefits are payable for each service included by Subgroup 12 on three occasions only in any 12 month period

MAGNETIC RESONANCE IMAGING performed under the professional supervision of an eligible provider at an eligible location where the patient is referred by a specialist or by a consultant physician - scan of musculoskeletal system for:

- derangement of knee or its supporting structures (R) (NK)

Fee: $201.60 Benefit: 75% = $151.20 85% = $171.40

63513

SUBGROUP 33- MAGNETIC RESONANCE IMAGING – FOR SPECIFIED CONDITIONS – PERSON UNDER THE AGE OF 16YRS

referral by a medical practitioner (excluding a specialist or consultant physician) for a scan of knee for a patient under 16 years following radiographic examination for internal joint derangement (R) (Contrast) (Anaes.)

Fee: $403.20 Benefit: 75% = $302.40 85% = $342.75

63514

SUBGROUP 33- MAGNETIC RESONANCE IMAGING – FOR SPECIFIED CONDITIONS – PERSON UNDER THE AGE OF 16YRS

referral by a medical practitioner (excluding a specialist or consultant physician) for a scan of knee for a patient under 16 years following radiographic examination for internal joint derangement (R) (NK) (Contrast) (Anaes.)

Fee: $201.60 Benefit: 75% = $151.20 85% = $171.40

63560

SUBGROUP 34 – MAGNETIC RESONANCE IMAGING – FOR SPECIFIED CONDITIONS

referral by a medical practitioner (excluding a specialist or consultant physician) for a scan of knee following acute knee trauma for a patient 16 years or older with:

- inability to extend the knee suggesting the possibility of acute meniscal tear (R) (Contrast) (Anaes.); or

- clinical findings suggesting acute anterior cruciate ligament tear. (R) (Contrast) (Anaes.)

Fee: $403.20 Benefit: 75% = $302.40 85% = $342.75

 

63561

SUBGROUP 34 – MAGNETIC RESONANCE IMAGING – FOR SPECIFIED CONDITIONS

referral by a medical practitioner (excluding a specialist or consultant physician) for a scan of knee following acute knee trauma for a patient 16 years or older with:

- inability to extend the knee suggesting the possibility of acute meniscal tear (R) (NK) (Contrast) (Anaes.); or

- clinical findings suggesting acute anterior cruciate ligament tear. (R) (NK) (Contrast) (Anaes.)

Fee: $201.60 Benefit: 75% = $151.20 85% = $171.40

 

5.2        Issues identified

Since the introduction of GP specialist referral privileges, the proportion of total Medicare expenditure of knee MRI has increased from 17% in 2010-11 to 25% in 2014-157 of all Medicare services on MRI. Concerns were raised regarding the net health benefits of this additional expenditure, particularly in older patients where the clinical value of knee MRI has come into question.

The first items for GP-referred MRI of the knee were introduced in November 2012 for children under 16 years. A further two items were added to the MBS in November 2013 for patients aged over 16 years following an acute knee trauma, to increase patient access to MRI services. These items required that the patient show symptoms indicative of an acute meniscal tear or anterior cruciate ligament tear to be eligible for a knee MRI. This has led to a doubling in MBS-funded knee MRI, from $16 million in 2011-12 (100,000 knee MRI services performed) to $38 million in 2013-14 post implementation of all GP-referred knee MRI (approx. 180, 000 of all knee MRI services i.e. items 63513, 63328, 63560 and 63561).7

Number of services for MRI of the knee by patient's age group 2014-15

The graph shows the number of services for MRI of the knee by pateints age group for 2014-15, highlight a concern over the use of item 63560 due top the high volume performed in patients over 65.

Figure 1: Number of services for MRI of the knee by item by patient’s age group 2014-157

5.3        Recommendation 1 – MRI Items 63328, 63343, 63513, 63514

 Leave 63328 and 63343 item descriptors unchanged.

 For items 63513 and 63514, remove the current requirement of mandatory plain radiography before an MRI in patients under the age of 16 years.

Table 4: Current and proposed item descriptor

Current item descriptor

Proposed new item descriptor

SUBGROUP 33- MAGNETIC RESONANCE IMAGING – FOR SPECIFIED CONDITIONS – PERSON UNDER THE AGE OF 16YRS

referral by a medical practitioner (excluding a specialist or consultant physician) for a scan of knee for a patient under 16 years following radiographic examination for internal joint derangement

SUBGROUP 33- MAGNETIC RESONANCE IMAGING – FOR SPECIFIED CONDITIONS – PERSON UNDER THE AGE OF 16YRS

referral by a medical practitioner (excluding a specialist or consultant physician) for a scan of knee for a patient under 16 years

5.3.1        Rationale

The recommendation for the removal of mandatory radiographic examination is to avoid radiation exposure and associated radiography costs, particularly in the setting of suspected acute anterior cruciate ligament or meniscal injury in children who do not require preliminary plain radiography (x-rays) before MRI.

 

5.4        Recommendation 2 – MRI Items 63560, 63561

5.4.1        Recommendation 2

 Introduction of the principal of an additional age cut-off for knee MRI referrals (N.B. segregation into over and under 16 years of age is currently part of the MBS) to provide separate descriptors and/or restrictions for patients under and over 50 years.

 Restrict the number of GP-referred MRIs to three per annum.

 An intensive education program for GPs, radiologists, and consumers on the Medicare item descriptors and clinical indications for knee imaging.

 Review and audit activities for GPs and radiologists 12 months post implementation to ensure the criteria for knee imaging are met.

5.4.2        Rationale for the Introduction of the principal of an age cut off for knee MRI referrals

 Remove the ability for a GP to request MRIs for patients ≥ 50 years of age from the MBS, but retain specialist requesting for any age group.

There is a concern about inappropriate use of item 63560 as there is a high volume performed in patients over 65 (Figure 1) who often have coexistent symptoms of osteoarthritis that can be difficult to distinguish from those of meniscal tear and incidental meniscal tears which are common in elderly patients with osteoarthritis. This can lead to the erroneous assumption that the meniscal tear revealed by MRI in an older person with knee osteoarthritis symptoms is responsible for the patient’s symptoms, when this is not the case.

The Committee considered two options to address the principal of an additional age cut-off for knee MRI referrals.

1. To retain the MBS item for patients ≥ 50 with the descriptor to state:

Referral by a medical practitioner (excluding a specialist consultant or physician) for a patient 50 years or older with suspected meniscal tear or ACL injury, if surgery is being considered in consultation with a specialist who is not a radiologist.

OR

2. To remove the ability for a GP to request MRIs for patients ≥ 50 from the MBS schedule.

 

The Committee was unable to decide between the two options.  The Taskforce’s preference is for a specific recommendation for public consultation, rather than two options.  Following consideration of the options the Taskforce made the following recommendation:

To remove the ability for a GP to request MRIs for patients ≥ 50 years of age from the MBS, but retain specialist requesting for any age group.

 

5.4.3        Recommendation 2.1

5.4.4        Restrict the number of GP-referred MRIs to three per annum

 It was noted that currently there is no restriction on the number of MRI of the knee that a GP can request, and that specialists are currently restricted to three referrals per annum per patient. In attempt to promote appropriate utilisation of GP requested MRI of the knee, it was recommended that GP referred MRI be restricted to three referrals per annum per patient. Any further MRI should be requested by a specialist if the referral falls within the 12 month period after the initial GP referred MRI.

Table 5: Current and proposed item descriptor for items 63560 and 63561

Current item descriptor

Proposed new item descriptor

referral by a medical practitioner (excluding a specialist consultant or physician) for a scan of knee following acute knee trauma for a patient 16 years or older with:

inability to extend the knee suggesting possibility of acute meniscal tear (R)/(NK) (Contrast) (Anaes); or

clinical findings suggesting acute anterior cruciate ligament tear. (R)/(NK) (Contrast) (Anaes).

NOTE: Benefits are payable for each service included on three occasions only in any 12 month period

referral by a medical practitioner (excluding a specialist consultant or physician) for a scan of knee following acute knee trauma for a patient 16–49 years old with:

inability to extend the knee suggesting possibility of acute meniscal tear (R) (NK) (Contrast) (Anaes); or

clinical findings suggesting acute anterior cruciate ligament tear. (R) (NK) (Contrast) (Anaes).

 

5.4.5        Summary of governance and education of practitioners, patients and the public

 More intensive programs to educate GPs and patients regarding the specific circumstances in which GPs may refer a patient for knee MRI.

 Greater penetration of educational strategies already undertaken by RACGP and RANZCR relating to history and examination findings in patients with acute ACL and meniscal tears are required to improve adherence to evidence-based referral item descriptors.

 Electronic decision support at the point of care (when the referral is generated) that is a seamless part of the test requesting process in addition to points 1, 2, and 3 above would support appropriate referrals.

 While test substitution by radiology practices (i.e. MRI instead of ultrasound for patients with suspected ACL or meniscal injuries) could reduce inappropriate use of low-utility tests, correct test choice in the first place, by the referrer themselves, is likely to be more efficient and more acceptable to patients, and thus should be the preferred option.

An educational program funded by the Commonwealth and delivered by NPS is required regarding:

 the low utility of MRI for the specific purpose of identifying a symptomatic meniscal tear in an older patient with symptomatic knee osteoarthritis;

 the increasing frequency of ‘incidental’ meniscal tears and meniscal degeneration with advancing age. Such tears and degeneration are not necessarily symptomatic or the cause of knee pain when pain is present.

5.4.6        Review and audit activities for GPs and radiologists

 More frequent and extensive auditing of the clinical indication for GP-referred knee MRI. Feedback from such audits, i.e. consistency of the referral with Medicare rules, should be provided to both the referrer and the radiology practice.

5.4.7        Rationale

The recommendations on governance and education of practitioners, patients and the public and review and audit activities for GPs and radiologists, focus on improving the value of diagnostic knee MRI performed by GPs in accordance to current evidence and encouraging best practice.  The recommendations attempt to reduce the utilisation of inappropriate use of GP requested knee MRI in older patients. They are based on the following observations:

 MRI is a highly accurate and high-utility test for diagnosing or excluding acute meniscal tear and/or anterior cruciate ligament rupture in younger patients.

 A high volume of GP-referred knee MRI services was observed (approximately 12,000 in patients >70 years and 66,000 services in patients > 50 years)7

 Annual growth in non-GP specialist referred MRI for 2010 –11 and 2011 – 2012 was 4% for the under 50 age group and 7% for the over 50 age group. 7

 For adult patients (aged over 16 but under 50) growth in GP referred MRI (extrapolating from data for 2013-14 half year growth) was 32% p.a. for patients under 50 and 35% for over 50 age group. 7 This growth rate is very high, particularly in the over 50 age group where the utility of MRI diminishes with age. 

 GP referred knee MRI was introduced in November 2013 to increase patient access to MRI under certain requisites such as age over 16 and clinical evidence suggesting anterior cruciate ligament and/or meniscal tear. Medicare data showed that approximately 22,000 non-GP specialist referred MRIs were prevented by performing 91,953 GP specialist - referred MRIs in patients under 50 years, and 14,000 non-GP specialist referred MRIs would have been prevented performing 65,931 GP specialist - referred MRIs in patients  in the 2014-15 financial year7.

 Therefore, the number of GP – referred knee MRI services that are required to “prevent” one non GP specialist MR service is similar in the over and under 50 year old age group and is between 4.2 and 4.6 GP referred knee MRI services.

 Expansion of referral privileges to GP specialists has been associated with reduction in non-GP specialist referrals and the reduction per GP referral is much greater for the under 50 age group. However, this reduction has been insufficient to prevent overall growth in referrals of adults and children for knee MRI.

 Medicare data reflected that patients over 50 are more likely to see an orthopaedic surgeon after GP referred MRI (> 50: 66.9% vs <50:46.9%) but are somewhat less likely to receive arthroscopy than patients under 50 (> 50: 35% vs <50:41%)7.

 The Royal Australian College of General Practitioners (RACGP) guidelines for referral for MRI state:

- MRI is indicated in the assessment of anterior cruciate ligament (ACL) injuries, but is not always necessary if the clinical diagnosis is clear.

- MRI is indicated for assessment of meniscal tears, but is not always necessary if a clear clinical diagnosis of meniscal tear has been made.

- Use MRI particularly in situations where there is doubt about diagnosis or patient management.

- Do not use MRI for the diagnosis of isolated medial collateral ligament injuries, except where there is concern about alternative pathology or if symptoms fail to settle after 6–8 weeks.

- Further testing is not immediately needed in patients with knee injury who have negative physical examination findings, although close follow-up is required.

 MRI has low utility with regard to subsequent clinical decision making in patients who are thought to have symptomatic knee osteoarthritis. Therefore, potential reason for unnecessary knee MRI derives from the incorrect attribution of knee symptoms to meniscal tear in patients with symptomatic knee osteoarthritis, particularly in older adults.

 MRI does identify meniscal tears in older adults. These may be asymptomatic or may not be a significant contributor to knee pain in older individuals with knee pain. Where osteoarthritis may also be present in cases of acute trauma and symptomatic meniscal tears of the knee, including an age cut-off in the item descriptor will require GPs to follow a structured process to determine whether osteoarthritis is present for patients aged ≥ 50. This may have a significant positive effect on improving the cost-effectiveness of current practice.

 Age cut-off of 50 years was recommended on the basis that GPs would see more patients older than 50 presenting with knee pain than patients under 50; and the test is less useful for preventing referrals in patients over 50 than under 50 in whom ‘incidental knee pain’ (such as that due to osteoarthritis) is less common.

 Most meniscal tears in adults are not preceded by an identifiable incident of acute trauma. The standard care approach to symptoms due to possible meniscal tear in this situation is initially to provide non-operative care depending on age group, then surgery if required. It is appropriate to undertake watchful waiting for some patients with suspected meniscal tears, depending on their symptoms and signs and then refer them for MRI if required. Reference to ‘acute symptoms’ in the descriptor for MRI in patients > 50 years old may lead GPs to request MRI in the first instance, bypassing the watchful wait stage, making it counterproductive.

 Introducing the requirement of a specialist consultation, where consultation and collaboration with specialists can be done in regard to discussing the clinical history of a patient may result in more appropriate GP-referred knee MRI in patients over 50 and further promote the quality use of this test.

 An electronic MBS item requesting system is likely to direct GPs to state the relevant condition because of the requirement to complete mandatory fields of an electronic request.

 Providing education to consumers about the specific conditions covered by the Medicare rebate for GP referred knee MRI may reduce GP pressure for knee MRI requests from patients.

5.5        Recommendations impact statement

Changes to items 63513 and 63514 to remove the requirement of a plain radiography before MRI is expected to have a positive impact on patients. This is likely to minimise radiation exposure.

Including an upper-limit age restriction will minimise unnecessary requests for MRI of the knee in patients who do not have a meniscal tear or ACL injury.

Education should be delivered to providers, as these changes also have an impact on provider behaviour change in clinical practice.