How To Write A Level C

Transcription

1 Appropriate use of skin cancer item numbers a guide for primary care skin cancer doctors Disclaimer: This document reflects the personal views of the authors based on their own experience and is not the official opinion of SCCANZ. It is meant to draw attention to areas of Medicare and the MBS that may not be fully understood by primary care practitioners. Issues regarding the appropriate use of MBS item number should be referred to Medicare Australia for definitive ruling As you may be aware, in the last budget, the Federal Government allocated a large amount of money for Medicare to increase the number of practice audits. Skin cancer will almost certainly be in their sights. It is therefore very important for doctors working in primary care skin cancer medicine to document their consultations and procedures fully, making sure that what is recorded satisfies the descriptor and explanatory notes for the item number charged. Medicare Australia appears to see the Medicare Benefits Schedule as purely a billing system rather than appropriate guidelines for clinical medicine or patient care. It is therefore very important that the patient notes not only reflect the clinically relevant details of the consultation and management plan but also support the billing descriptors for the services charged. Recently Medicare has been targeting the inappropriate billing of Level B and Level C consultations; Full skin check NAD does not satisfy the descriptor for a Level B consultation, as you need to document taking a selective history, examining the patient, and formulating a management plan. Medicare is particularly concerned when consultations are charged in association with procedures or when sutures are removed i.e. aftercare. It is acceptable to charge a consultation in these situations provided there is documentation supporting the content of the Medicare descriptor for a consultation involving a history, examination and management plan. For example, a routine skin check could be documented as follows: Patient presents for skin check concerned re risk of skin cancers from previous sun exposure History of sun burns in childhood and previous solar keratoses Full skin check performed, Occasional small symmetrical naevi on back No other clinically suspicious lesions seen Sun protection advice discussed with patient Patent advised to return for skin check in 1 year or if new or changing lesions noted. This may seem to be a little over-inclusive but we need to make sure the patient notes fulfill the billing descriptors. The Level C descriptor is even harder to satisfy as it requires taking a detailed history, examination of multiple systems, arranging any necessary investigations, implementing a management plan and duration of at least 20 minutes. Just because the consult is greater than 20 minutes, it does not necessarily qualify to be charged as a Level C, unless the other requirements are also fulfilled and documented.

2 With procedures, it is important to document: the type and size of the lesion, (the size is the average diameter of the lesion before excision, i.e. add the length and width of the lesion and divide by 2). The size does not refer to the size of the specimen, just the actual lesion the reason for biopsying it or removing it the amount and concentration of local anesthetic used the type of wound and method of closure the number, gauge and type of any sutures used Item numbers 30202, 30203, 30196, and the excision numbers require histological proof of the lesion prior to billing. The descriptor in the Medicare Benefits Schedule (MBS) states: - that the lesion must be histologically proven to be a BCC / SCC, or that a similar lesion in the same anatomical region, must be proven by histology to be a BCC / SCC before we can charge a for treating one lesion or a for treating 10 or more similar lesions in the same anatomical region. It also states: - that the lesion must be treated with repeat freeze / thaw cycles of cryotherapy (for / 30203) - and repeat cycles of curettage and cautery for serial curettage. (30196 / 30197) In a recent edition of the MBS, a couple of years ago, the definition of an anatomical region was tightened up and the trunk, limbs and face were divided into multiple small areas thus making it much more difficult for us to charge the multiple lesion treatment numbers (30203 / 30197). There is no mention in the descriptor or explanatory notes as to how recent the histological proof must be, or that the histology must have been obtained from a lesion treated by the same practitioner. Recently however, the HIC advisors have been maintaining that we need recent histological proof (whatever recent means) and that if the previous histology was from another doctor at a different practice, this was not sufficient to charge the numbers. Even though these requirements are not stated in the MBS, the HIC s bottom line is that whatever we do must be reasonable to a jury of our peers. On the basis of this rather arbitrary interpretation of the MBS descriptor, the HIC Advisors have demanded repayment of previously paid rebates, with the only redress for the doctor being through a formal peer review process. Given this, it is advised that the doctor should have obtained a positive histology result within the last three months for a relevant lesion in the same anatomical region to be charged as a / or a / 30197). Everyone should reread the descriptors and explanatory notes for these item numbers and make sure that your practice notes complies with them. It is also very important that the use of repeat freeze / thaw cycles be recorded in the patient notes as these are the legal record of what treatment was provided and thus its eligibility for Medicare Benefits. If everyone takes care to ensure that their notes adequately fulfill the descriptors then the Medicare Auditors will have the confirmation they require that we are billing appropriately within the Medicare system. Note: below is a copy of the relevant Medicare Item number descriptors and associated explanatory notes for the most frequently performed skin cancer procedures

3 Skin Cancer Item Numbers and Explanatory Notes Item number 53 Standard Consult of more than 5 minutes duration but not more than 25 minutes duration. Fee: $21.00 Benefit: 100% = $21.00 Item number 54 Long Consult of more than 25 minutes duration but not more than 45 minutes duration Fee: $38.00 Benefit: 100% = $38.00 Item number 23 Level 'B'. Professional attendance involving taking a selective history, examination of the patient with implementation of a management plan in relation to 1 or more problems, OR a professional attendance of less than 20 minutes duration involving components of a service to which item 36, 37, 38, 40, 43, 44, 47, 48, 50 or 51 applies. Surgery Consultation (Professional attendance at consulting rooms). Fee: $32.10 Benefit: 100% = $32.10 Item number 36 Level 'C'. Professional attendance involving taking a detailed history, an examination of multiple systems, arranging any necessary investigations and implementing a management plan in relation to 1 or more problems, and lasting at least 20 minutes, OR a professional attendance of less than 40 minutes duration involving components of a service to which item 44, 47, 48, 50 or 51 applies. Surgery Consultation (Professional attendance at consulting rooms) Fee: $60.95 Benefit: 100% = $60.95 Level B The descriptions of these items introduce the words 'selective history' and 'implementation of a management plan in relation to one or more problems'. In this context a 'selective history' means a history relating to a specific problem or condition; and 'implementation of a management plan' includes formulation of the decision or plan of management and any immediate action necessary such as advising or counseling the patient, ordering tests, or referring the patient to a specialist medical practitioner or other allied health professional. The essential difference between Levels A and B relate not to time but to complexity. Example: Otitis media presenting as earache.

4 Level C Further levels of complexity are implied in these items by the introduction of 'taking a detailed history' and 'examination of multiple systems'. A physical attendance of at least 20 minutes is necessary to qualify for a Level C attendance. The words following 'OR' in the items for Levels B and C allow for the situation where an attendance involves some components of a more complex level but the time taken is less than specified in the higher level. Benefit is claimable at the appropriate lower level. For example, if an attendance involved a detailed history and examination of multiple systems, arranging investigations and implementing a management plan, but the time taken was less than 20 minutes, it would constitute a Level B attendance. Example: Essential hypertension presenting as headache. Item number Diagnostic biopsy of skin or mucous membrane, as an independent procedure, where the biopsy specimen is sent for pathological examination. Fee: $46.15 Benefit: 85% = $39.25 Biopsy for diagnostic purposes (item ) needle aspiration biopsy attracts benefits on an attendance basis and not under item item should be used when a biopsy (including shave) of a lesion is required to confirm a diagnosis and would facilitate the appropriate management of that lesion. If the shave biopsy results in a definitive excision of the lesion, only can be claimed. items require that the specimen be sent for pathological examination. the aftercare period for item is 2 days rather than the standard aftercare period for skin excision of 10 days. Item number Premalignant skin lesions (including solar keratoses), treatment of, by ablative technique (10 or more lesions) Fee: $35.00 Benefit: 85% = $29.75

5 Item number Benign neoplasm of skin, other than viral verrucae (common warts) seborrheic keratoses, cysts and skin tags, treatment by electrosurgical destruction, simple curettage or shave excision, or laser photocoagulation, not being a service to which item 30196, 30197, 30202, or applies (1 or more lesions). Fee: $56.10 Benefit: 85% = $47.70 Therapeutic procedures Treatment of keratoses, warts etc (items & 36815) treatment of seborrheic keratoses by any means, attracts benefits on an attendance basis only. treatment of fewer than 10 solar keratoses by ablative techniques such as cryotherapy attracts benefits on an attendance basis only. Where 10 or more solar keratoses are treated by ablative techniques, benefits are payable under item Where one or more solar keratoses are treated by electrosurgical destruction, simple curettage or shave excision, benefits are payable under item warts and molluscum contagiosum where treated by any means attract benefits on an attendance basis except where: (a) admission for treatment in an operating theatre of an accredited day surgery facility or hospital is required. In this circumstance, benefits are paid under item where a definitive removal of the wart or molluscum contagiosum is to be undertaken. (b) benefits have been paid under item 30189, and recurrence occurs. (c) definitive removal of palmar or plantar warts is undertaken. In these circumstances, where less than 10 palmar or plantar warts are treated, by methods other than ablative techniques alone, benefits are paid under item 30186, with fees progressively reducing as for multi operations, and where 10 or more palmar or plantar warts are treated, by methods other than ablative techniques alone, benefits are paid as a flat fee under item (d) palmar and plantar warts are treated by laser and require treatment in an operating theatre of an accredited day surgery facility or hospital. In this circumstance, benefits are paid under item ablative techniques include cryotherapy and chemical removal. Item number Malignant neoplasm of skin or mucous membrane proven by histopathology or confirmed by specialist opinion, removal of, by serial curettage or carbon dioxide laser or erbium laser excision-ablation, including any associated cryotherapy or diathermy, not being a service to which item applies.

6 Fee: $ Benefit: 85% = $94.90 Item number Malignant neoplasm of skin or mucous membrane proven by histopathology or confirmed by specialist opinion, removal of, by serial curettage or carbon dioxide laser excisionablation, including any associated cryotherapy or diathermy, (10 or more lesions). Fee: $ Benefit: 85% = $ Item number Malignant neoplasm of skin or mucous membrane proven by histopathology or confirmed by specialist opinion, removal of, by liquid nitrogen cryotherapy using repeat freeze-thaw cycles, not being a service to which item applies. Fee: $42.70 Benefit: 85% = $36.30 Item number Malignant neoplasm of skin or mucous membrane proven by histopathology or confirmed by specialist opinion, removal of, by liquid nitrogen cryotherapy using repeat freeze-thaw cycles (10 or more lesions). Fee: $ Benefit: 85% = $ Cryotherapy and serial curettage excision (items ) in items and 30197, serial curettage excision, as opposed to simple curettage, refers to the technique where the margin having been defined, the lesion is carefully excised by a skin curette using a series of dissections and cauterisations so that all extensions and infiltrations of the lesion are removed. for the purposes of items to (inclusive), the requirement for histopathological proof of malignancy is satisfied where multiple lesions are to be removed from the one anatomical region if a single lesion from that region is histologically tested and proven for malignancy. for the purposes of items to (inclusive), an anatomical region is defined as: hand, forearm, upper arm, shoulder, upper trunk or chest (anterior and posterior), lower trunk (anterior or posterior) or abdomen (anterior lower trunk), buttock, genital area/perineum, upper leg, lower leg and foot, neck, face (six sections: left/right lower, left/right mid and left/right upper third) and scalp. Related items: 30196, 30197, 30202, 30203

7 Item number Basal cell carcinoma or squamous cell carcinoma (including keratocanthoma), removal from areas of the body not covered by items and 31265, tumour size up to and including 10mm in diameter and where removal is by therapeutic surgical excision (other than by shave excision) and suture, where the initial specimen removed is sent for histological examination and malignancy confirmed, and any subsequently excised specimen is sent for histological examination. Fee: $ Benefit: 85% = $ Item number Basal cell carcinoma or squamous cell carcinoma (including keratocanthoma), removal from face, neck, (anterior to the sternomastoid muscles) or lower leg (mid calf to ankle), tumour size up to and including 10mm in diameter and where removal is by therapeutic surgical excision (other than by shave excision) and suture, where the initial specimen removed is sent for histological examination and malignancy confirmed, and any subsequently excised specimen is sent for histological examination. Fee: $ Benefit: 85% = $ Item number Basal cell carcinoma or squamous cell carcinoma (including keratocanthoma), removal from nose, eyelid, lip, ear, digit or genitalia, tumour size up to and including 10mm in diameter - where removal is by therapeutic surgical excision (other than by shave excision) and suture and where the initial specimen removed is sent for histological examination and malignancy confirmed, and any subsequently excised specimen is sent for histological examination. Fee: $ Benefit: 85% = $ Removal of skin lesions (31200 to 31355) the excision of warts and seborrheic keratoses attracts benefits on an attendance basis with the exceptions outlined below. Excision of pre-malignant lesions including solar keratoses where clinically indicated are covered by items to the excision of suspicious pigmented lesions for diagnostic purposes attract benefits under items to Only if a further more extensive excision is undertaken should the items covering excision of malignancies be used. items and do not require the specimen to be sent for histological confirmation. Items to and require that the specimen be sent for histological examination. Items to require that a specimen has been sent for histological confirmation of malignancy, and any subsequent specimens are sent for histological examination. Confirmation of malignancy must be received before itemisation of accounts for Medicare benefits purposes.

8 where histological results are available at the time of issuing accounts, the histological diagnosis will decide the appropriate itemisation. If the histological report shows the lesion to be benign, items to should be used. Malignant tumours are covered by items to a practitioner providing the first treatment episode for a primary BCC / SCC must use the appropriate item from the following: 31255; 31260; 31265; 31270; 31275; 31280; 31285; or where residual BCC / SCC remains following an initial excision of a primary lesion and the same practitioner is excising that residual BCC / SCC then the appropriate item must be claimed from the following: 31256; 31261; 31266; 31271; 31276; 31281; or where residual BCC / SCC remains following an initial excision of a primary lesion and a practitioner other than the practitioner that performed the previous excision is excising that residual BCC / SCC then the appropriate item must be claimed from the following: 31257; 31262; 31267; 31272; 31277; 31282; or where a BCC / SCC was removed and complete excision of the lesion was confirmed, but a BCC / SCC has recurred at the primary site, then the items providing for recurrent BCC / SCC would usually apply. a practitioner excising a recurrent BCC / SCC of the head or neck and who is a specialist in the practice of his or her specialty or a practitioner other than the practitioner who provided previous treatment (where the lesion was removed by previous surgery, serial cautery and curettage, radiotherapy or two prolonged freeze/thaw cycles of liquid nitrogen therapy) must use item a practitioner excising a recurrent BCC / SCC from an area other than the head or neck or who otherwise does not meet the criteria as described under item must use the appropriate item from the following 31258; 31263; 31268; 31273; 31278; 31283; or for the purpose of these items, the tumour/lesion size should be determined by the macroscopic measurement of the surface diameter of the tumour/lesion or, for elliptical tumours/lesions, by the average surface diameter. The relevant size of the lesion relates to that measured in situ before excision. Suture of wound following surgical excision also includes closure by tissue adhesive resin, clips or similar. definitive surgical excision for items to is defined as surgical removal with an adequate margin and, as a result, no further surgery is indicated at the site of the primary tumour. it will be necessary for practitioners to retain copies of histological reports. items and do not cover shave excision. Removal of skin lesion from face (items , , ) for the purposes of these items, the face is defined as that portion of the head anterior to the hairline and above the jaw line.

9 Item number Skin flap surgery (note: see explanatory notes to this category for definition of "local skin flap"). Single stage local flap, where indicated to repair 1 defect, simple and small, excluding flap for male pattern baldness and excluding h-flap or double advancement flap. Fee: $ Benefit: 85% = $ Item number Single Stage Local Flap, where indicated to repair 1 defect, complicated or large, excluding flap for male pattern baldness and excluding H-flap or double advancement flap. Fee: $ Benefit: 85% = $ Item number Single Stage Local Flap where indicated to repair 1 defect, on eyelid, nose, lip, ear, neck, hand, thumb, finger or genitals, and excluding H-flap or double advancement flap. Fee: $ Benefit: 85% = $ Item number H-flap or double advancement flap where indicated to repair 1 defect, on eyelid, eyebrow or forehead. Fee: $ Benefit: 85% = $ Local skin flap - definition Medicare benefits for flaps are only payable when clinically appropriate. Clinically appropriate in this instance means that the flap or graft is required to close the defect because the defect cannot be closed directly, or because the flap is required to adapt scar position optimally with regard to skin creases or landmarks, maintain contour on the face or neck, or prevent distortion of adjacent structures or apertures. a local skin flap is an area of skin and subcutaneous tissue designed to be elevated from the skin adjoining a defect requiring closure. The flap remains partially attached by its pedicle and is moved into the defect by

10 rotation, advancement or transposition, or a combination of these manoeuvres. A benefit is only payable when the flap is required for adequate wound closure. A secondary defect will be created which may be closed by direct suture, skin grafting or sometimes a further local skin flap. This later procedure will also attract benefit if closed by graft or flap repair but not when closed by direct suture. by definition, direct wound closure (e.g. by suture) does not constitute skin flap repair. Similarly, angled, curved or trapdoor incisions which are used for exposure and which are sutured back in the same position relative to the adjacent tissues are not skin flap repairs. Undermining of the edges of a wound prior to suturing is considered a normal part of wound closure and is not considered a skin flap repair. a "z" plasty is a particular type of transposition flap repair. Although 2 flaps are created, benefit will be paid on the basis of items 45200, or once only. items where benefit for local skin flap repair (if indicated as above) is payable, include: 30023; 30180; 30186; 30269; ; 45030; 45033; ; 45512; Note: this list is not all - inclusive and there are circumstances where other services might involve flap repair. The following items are examples of where local flap repair would usually not be payable. If further advice is required, Medicare Australia should be contacted ; ; ; 31200; 45520; 45522; ; 45587; ; 45659; 45662;