WHAT YOU NEED TO KNOW WITH MEDICARE
|NEW CHANGES IN MEDICARE BILLING AND REBATES|
On November 1, 2018, the Australian Government-directed Medicare Claims Review Panel revised the Medicare Benefits Schedule [MBS] for plastic surgery code items and introduced a series of rebate restrictions on multiple plastic surgery procedures — a process that now either limits or no longer provides a rebate to patients undergoing plastic surgery.
HOW WILL THIS AFFECT YOU?
Patients are required to meet Medicare’s new MBS Item Code criteria or incur the full surgical costs including Dr Chang’s fees, the anaesthetist’s fees and the hospital stay if the surgery is not eligible for a Medicare rebate.
The MBS Item Codes that were removed include, as follows:
- 11222 – Computerised Perimetry (Eyes)
- 11225 – Ocular Perimetry (Eyes)
- 30214 – Starburst vessels (Head & neck)
- 32501 – Varicose Veins
- 42783 – Laser Trobeculoplasty for Glaucoma
- 42786 – Laser Iridology
- 42789 – Laser Capsulotomy (Eye)
- 42792 – Laser Vitreolysis
- 45020 – Deep Chemical Face Peel
- 45559 – Tuberous Breast -Masto/Aug (new 45060/45061/45062)
- 45586 – Liposuction for Buffalo hump
- 45638 – Rhinoplasty
- 45639 – Rhinoplasty
Though some of the changes will affect a small percentage of patients, most cosmetic procedures are primarily performed as elective surgeries [for aesthetic purposes].
For patients who remain eligible for a rebate, Medicare will pay for the surgeon and the anaesthetist. If you have private medical insurance, your fund will also cover the hospital fees. However, the new Medicare criteria will require patients to submit extensive pre-surgery tests, medical documents that certify the necessity of the surgery and accompanying photographic evidence [including before, during and after images].
The procedures include, as follows:
Blepharoplasty (eyelids): An optometrist or ophthalmologist will be required to confirm that the skin you’re removing from your eyelids obstruct your vision. You will also have to provide a series of photographic evidence to support the claim.
- 45617 – Upper Eye Reduction
Rhinoplasty [nose]: a nose scale survey will be required.
- 45632 – Rhinoplasty Partial – Lateral/Alar cartridges
- 45635 – Rhinoplasty Partial – Bony Vault only
- 45641 – Rhinoplasty Total – External Nose
- 45644 – Rhinoplasty Total – External Nose with Graft
- 45650 – Rhinoplasty Revision
Breast Lifts and Reductions: Rebates for breast lifts, implant replacements and reductions must include anterior, left and right and side photos that reveal the IMF position (must be two-thirds below IMF and nipple at lowest point).
- 45554 – Removal and replacement breast implant – Requirement > 50% capsule removed
- 45553 – Removal and replacement of breast implant
- 45051 – Breast Cancer Reconstruction
- 45060 – Breast Asymmetry including mastopexy or implants
- 45061 – Breast Asymmetry stage 1
- 45062 – Breast Asymmetry stage 2
- 45528 – Breast Reconstruction
- 45556 – Unilateral Mastopexy for Breast Ptosis
- 45558 – Bilateral Mastopexy for Breast Ptosis
Otoplasty (Ears): The cost of otoplasty will increase if you do not have it completed before the age of 18.
- 45659 – Photos of the year and patients under 18 years of age are only eligible
Additionally, the payment and rebate structure for plastic surgery has likewise changed. Patients will, as follows:
- be required to pay upfront for any surgical procedure
- be permitted to only undergo a single lipectomy procedure [abdominoplasty, thigh reduction, arm reduction, etc] if they wish to meet the criteria and apply for a rebate. Both Medicare and your private health provider will not provide a rebate or cover your hospital fees if lipectomy procedures such as a tummy tuck or an arm reduction are performed together as a combined procedure.
- now have to apply for a Medicare and private health fund after the surgery has been completed.
- be aware that there is no guarantee that you will meet Medicare’s criteria even with the supporting documents
- be aware that any health fund will only cover plastic surgery if there’s an accompanying MBS Item number.
Please view the Medicare link for further information and discuss your surgical costs with Jane Luong, Practice Manager along with your health fund provider.
We look forward to supporting you on your COSMETIC JOURNEY.