OUR LOCATIONS

Medicare Guidelines for Doctors

All examinations performed by North Coast Radiology are done so in observance of the Medicare Benefits Schedule. The Medicare Benefits Schedule provides criteria which determine if rebates offered by Medicare can be accessed by patients.

 

For a patient to be eligible for a Medicare rebate there are certain criteria that all referrals must display.

– Referrer name, provider number, contact details and signature of the referrer
– Examination requested
– All relevant clinical history

 

Click on the tab with Modality you want Medicare rule information about. If you are in Allied Health or Dentistry click here for Medicare information.

Bone Densitometry

ItemDescriptionLimitations
12306The confirmation of a presumptive diagnosis of low bone mineral density made on the basis of;
  • 1 or more fractures occurring after minimal trauma; or

  • for the monitoring of low bone mineral density proven by bone densitometry at least 12 months previously

1 service only in a period of 24 consecutive months
12312
  • prolonged glucocorticoid therapy;
  • conditions associated with excess glucocorticoid secretion;
  • male hypogonadism; or
  • female hypogonadism lasting more than 6 months before the age of 45
1 service only in a period of 12 consecutive months
12315for the diagnosis and monitoring of bone loss associated with 1 or more of the following conditions
  • primary hyperparathyroidism;
  • chronic liver disease;
  • chronic renal disease;
  • proven malabsorptive disorders;
  • rheumatoid arthritis; or
  • conditions associated with thyroxine excess.
1 service only in a period of 24 consecutive months
12320for the measurement of bone mineral density, if:
  • the patient is 70 years of age or over; and
  • either:
    1. the patient has not previously had bone densitometry; or
    2. the t score for the patient’s bone mineral density is -1.5 or more
1 service only in a 5 year period
12321for the measurement of bone density 12 months following a significant change in therapy (change in class of drugs not just dose changes) for
  • established low bone mineral density; or
  • the confirmation of a presumptive diagnosis of low bone mineral density made on the basis of 1 or more fractures occurring after minimal trauma.
1 service only in a period of 12 consecutive months
12322for the measurement of bone mineral density, if:
  • the patient is 70 years of age or over; and
  • the t score for the patient’s bone mineral density is less than -1.5 but more than -2.5
1 service only in a 2 year period
DEXAFor screening bone mineral density, which is not eligible for a Medicare rebate.

CT Colonography

ItemDescriptionLimitations
56553For exclusion or diagnosis of colorectal neoplasia in a symptomatic or high risk patient if:
  1. One [or more] of the following applies:
    • the patient has had an incomplete colonoscopy in the 3 months before the scan;
    • there is a high-grade colonic obstruction;
    • the patient is referred by a specialist or consultant physician who performs colonoscopies [in the practice of his or her speciality];
    and
  2. The service is not a service to which item 56301, 56307, 56401, 56407, 56409, 56412, 56501, 56507, 56801,56807 or 57001 applies; and
  3. The service has not been performed on the patient in the 36 months before the scan

CT Coronary Arteries

ItemDescriptionLimitations
57360performed on a minimum of a 64 slice (or equivalent) scanner, where the request is made by a specialist or consultant physician and
  1. the patient has stable symptoms consistent with coronary ischaemia, is at low to intermediate risk of coronary artery disease and would have been considered for coronary angiography; or
  2. the patient requires exclusion of coronary artery anomaly or fistula; or
  3. the patient will be undergoing non-coronary cardiac surgery

CT Spiral Angiography

ItemDescriptionLimitations
57350the service is performed for the exclusion of arterial stenosis, occlusion, aneurysm or embolism; and the service is not a study performed to image the coronary arteries1 in 12 months
57351the service is performed for the exclusion of acute or recurrent pulmonary embolism; acute symptomatic arterial occlusion; post operative complication of arterial surgery; acute ruptured aneurysm; or acute dissection of the aorta, carotid or vertebral artery; and the service is not a study performed to image the coronary arteries, and the services to which item 57350 apply have been performed on the same patient within the previous 12 months1 in 12 months

MRI for GPs

From 1 November 2013 General Practitioners are able to refer patients over 16 years of age for a small range of Medicare eligible indications, in addition to the indications awarded in 2012 for children under 16 years of age.

ItemDescriptionLimitations
63551 HeadReferral by a medical practitioner (excluding a specialist or consultant physician) for a scan of the head for any of the following:
  • Unexplained seizure(s)
  • Unexplained chronic headache with suspected intracranial pathology
Person over age 16 years
63554 C-SpineReferral by a medical practitioner (excluding a specialist or consultant physician) for a scan of the spine for suspected:
  • Cervical radiculopathy
Person over age 16 years
63557 C-SpineReferral by a medical practitioner (excluding a specialist or consultant physician) for a scan of the spine for suspected:
  • Cervical spine trauma
Person over age 16 years
63560 KneeReferral by a medical practitioner (excluding a specialist or consultant physician) for a scan of the knee following acute knee trauma with:
  • Inability to extend the knee suggesting the possibility of acute meniscal tear or;
  • Clinical findings suggesting acute anterior cruciate ligament tear
Person 16 years to 49 years old
63508 HeadReferral by a medical practitioner (excluding a specialist or consultant physician) for a scan of the head for any of the following:
  • Unexplained seizure
  • Unexplained headache where significant pathology is suspected
  • Paranasal sinus pathology which has not responded to conservative therapy.
Person over age 16 years
63511 Full SpineReferral by a medical practitioner (excluding a specialist or consultant physician) for a scan of the spine following radiographic examination for any of the following:
  • Significant trauma
  • Unexplained neck or back pain with associated neurological signs
  • Unexplained back pain where significant pathology is suspected
Person underage 16 years - must have x-ray first
63514 KneeReferral by a medical practitioner (excluding a specialist or consultant physician) for a scan of the knee following radiographic examination for internal joint derangement.Person underage 16 years
63517 HipReferral by a medical practitioner (excluding a specialist or consultant physician) for a scan of the hip following radiographic examination for any of the following:
  • Suspected septic arthritis
  • Suspected slipped capital femoral epiphysis
  • Suspected perthes disease
Person underage 16 years - must have x-ray first
63520 ElbowReferral by a medical practitioner (excluding a specialist or consultant physician) for a scan of the elbow following radiographic examination where a significant fracture or avulsion injury is suspected.Person underage 16 years - must have x-ray first
63523 WristReferral by a medical practitioner (excluding a specialist or consultant physician) for a scan of the wrist following radiographic examination where a scaphoid fracture is suspected.Person underage 16 years - must have x-ray first

Mammography

If you want a 3D examination (where possible e.g. Grafton and Lismore) please write 3D or Tomography onto the referral.

ItemDescriptionLimitations
59300

2D Mammography Bilateral Breasts

Where there is a reason to suspect the presence of malignancy because of:

     
  1. the past occurrence of breast malignancy in the patient or members of the patient’s family (blood relative); or
  2. symptoms or indications of malignancy found on an examination of the patient by a medical practitioner
 


Symptoms or indications of malignancy include: localised mass, localised lumps, localised pain, localised tenderness. For previous history of malignancy in patient or family member please provide relevant history. It is helpful to include any relevant clinical information such as past history of breast surgery, breast reduction or augmentation and specific information relating to the area of interest, including the side, size and location within the breast.

Only 2D
59303

2D Mammography Breast

Where there is reason to suspect the presence of malignancy because of:

     
  1. the past occurrence of breast malignancy in the patient or members of the patient’s family; or
  2. symptoms or indications of malignancy found on an examination of the patient by a medical practitioner.
 


Symptoms or indications of malignancy include: localised mass, localised lumps, localised pain, localised tenderness. For previous history of malignancy in patient or family member please provide relevant history. It is helpful to include any relevant clinical information such as past history of breast surgery, breast reduction or augmentation and specific information relating to the area of interest, including the side, size and location within the breast.

Only 2D
59302

3D Tomosynthesis Bilateral Breasts

Where there is a reason to suspect the presence of malignancy because of:

     
  1. the past occurrence of breast malignancy in the patient or members of the patient’s family (blood relative); or
  2. symptoms or indications of malignancy found on an examination of the patient by a medical practitioner
 


Symptoms or indications of malignancy include: localised mass, localised lumps, localised pain, localised tenderness. For previous history of malignancy in patient or family member please provide relevant history. It is helpful to include any relevant clinical information such as past history of breast surgery, breast reduction or augmentation and specific information relating to the area of interest, including the side, size and location within the breast.

Only 3D
59305

3D Tomosynthesis Breast

Where there is reason to suspect the presence of malignancy because of:

     
  1. the past occurrence of breast malignancy in the patient or members of the patient’s family; or
  2. symptoms or indications of malignancy found on an examination of the patient by a medical practitioner.
 


Symptoms or indications of malignancy include: localised mass, localised lumps, localised pain, localised tenderness. For previous history of malignancy in patient or family member please provide relevant history. It is helpful to include any relevant clinical information such as past history of breast surgery, breast reduction or augmentation and specific information relating to the area of interest, including the side, size and location within the breast.

Only 3D

Ultrasound – Obstetrics & Nuchael Translucency

To be eligible for a Medicare rebate, patients must meet one of the following criteria, and that criteria must be indicated on the referral. Here is a link to a single page PDF summary that can be printed Obstetric and Nuchal Translucency Medicare Criteria.pdf
ItemDescriptionLimitations
57700The pregnancy (as confirmed by ultrasound) is dated by a crown rump length of 45 to 84mm; and nuchal translucency measurement is performed to assess the risk of fetal abnormality; and one or more of the following conditions are present:
     
  1. hyperemesis gravidarum;
  2. diabetes mellitus;
  3. hypertension;
  4. toxaemia of pregnancy;
  5. liver or renal disease;
  6. autoimmune disease;
  7. cardiac disease;
  8. alloimmunisation;
  9. maternal infection;
  10. inflammatory bowel disease;
  11. bowel stoma;
  12. abdominal wall scarring;
  13. previous spinal or pelvic trauma or disease;
  14. drug dependency;
  15. thrombophilia;
  16. significant maternal obesity;
  17. advanced maternal age;
  18. abdominal pain or mass;
  19. uncertain dates;
  20. high risk pregnancy;
  21. previous post dates delivery;
  22. previous caesarean section;
  23. poor obstetric history;
  24. suspicion of ectopic pregnancy;
  25. risk of miscarriage;
  26. diminished symptoms of pregnancy;
  27. suspected or known cervical incompetence;
  28. suspected or known uterine abnormality;
  29. pregnancy after assisted reproduction;
  30. risk of fetal abnormality
Pregnancy < 12 weeks only
57707the pregnancy (as confirmed by ultrasound) is dated by a crown rump length of 45 to 84mm; and nuchal translucency measurement is performed to assess the risk of fetal abnormality; and one or more of the following conditions are present:
     
  1. hyperemesis gravidarum;
  2. diabetes mellitus;
  3. hypertension;
  4. toxaemia of pregnancy;
  5. liver or renal disease;
  6. autoimmune disease;
  7. cardiac disease;
  8. alloimmunisation;
  9. maternal infection;
  10. inflammatory bowel disease;
  11. bowel stoma;
  12. abdominal wall scarring;
  13. previous spinal or pelvic trauma or disease;
  14. drug dependency;
  15. thrombophilia;
  16. significant maternal obesity;
  17. advanced maternal age;
  18. abdominal pain or mass;
  19. uncertain dates;
  20. high risk pregnancy;
  21. previous post dates delivery;
  22. previous caesarean section;
  23. poor obstetric history;
  24. suspicion of ectopic pregnancy;
  25. risk of miscarriage;
  26. diminished symptoms of pregnancy;
  27. suspected or known cervical incompetence;
  28. suspected or known uterine abnormality;
  29. pregnancy after assisted reproduction;
  30. risk of fetal abnormality
Pregnancy nuchal translucency only
55704PELVIS or ABDOMEN dating of the pregnancy (by ultrasound) is 12 - 16 weeks and one or more of the following conditions are present:
     
  1. hyperemesis gravidarum;
  2. diabetes mellitus;
  3. hypertension;
  4. toxaemia of pregnancy;
  5. liver or renal disease;
  6. autoimmune disease;
  7. cardiac disease;
  8. alloimmunisation;
  9. maternal infection;
  10. inflammatory bowel disease;
  11. bowel stoma;
  12. abdominal wall scarring;
  13. previous spinal or pelvic trauma or disease;
  14. drug dependency;
  15. thrombophilia;
  16. significant maternal obesity;
  17. advanced maternal age;
  18. abdominal pain or mass;
  19. uncertain dates;
  20. high risk pregnancy;
  21. previous post dates delivery;
  22. previous caesarean section;
  23. poor obstetric history;
  24. suspicion of ectopic pregnancy;
  25. risk of miscarriage;
  26. diminished symptoms of pregnancy;
  27. suspected or known cervical incompetence;
  28. suspected or known uterine abnormality;
  29. pregnancy after assisted reproduction;
  30. risk of fetal abnormality
Pregnancy 12-16 weeks only
55706PELVIS or ABDOMEN pregnancy related or pregnancy complication, fetal development and anatomy, ultrasound scan of, by any or all approaches, with measurement of all parameters for dating purposes, where
     
  1. the patient is referred by a medical practitioner; and
  2. the dating for the pregnancy (as confirmed by ultrasound) is 17 to 22 weeks of gestation; and
  3. the service is not associated with a service to which an item in Subgroup 2 or 3 of this group applies; and
  4. the referring practitioner is not a member of a group of practitioners of which the providing practitioner is a member; and
  5. the service is not performed in the same pregnancy as item 55709
Pregnancy 17-22 weeks only and only 1 per pregnancy
55712

Specialist Referral Only

PELVIS or ABDOMEN, pregnancy related or pregnancy complication, fetal development and anatomy, ultrasound scan of, by any or all approaches, with measurement of all parameters for dating purposes, where:
     
  1. the patient is referred by a medical practitioner who is a Member or a Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists or who has a Diploma of Obstetrics or has a qualification recognised by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists as being equivalent to a Diploma of Obstetrics or has obstetric privileges at a non-metropolitan hospital; and
  2. the dating of the pregnancy (as confirmed by ultrasound) is 17 to 22 weeks of gestation; and
  3. the service is not associated with a service to which an item in Subgroup 2 or 3 of this group applies; and
  4. the referring practitioner is not a member of a group of practitioners of which the providing practitioner is a member; and
  5. further examination is clinically indicated in the same pregnancy to which item 55706 applies
Pregnancy 17-22 weeks only
55718PELVIS or ABDOMEN, pregnancy related or pregnancy complication, fetal development and anatomy, ultrasound scan of, by any or all approaches, where:
     
  1. the patient is referred by a medical practitioner; and
  2. the dating of the pregnancy (as confirmed by ultrasound) is after 22 weeks of gestation; and
  3. the service is not associated with a service to which an item in Subgroup 2 or 3 of this group applies; and
  4. the referring practitioner is not a member of a group of practitioners of which the providing practitioner is a member; and
  5. the service is not performed in the same pregnancy as item 55723; and
  6. one or more of the following conditions are present:
       
    1. known or suspected fetal abnormality or fetal cardiac arrhythmia;
    2. fetal anatomy (late booking or incomplete mid-trimester scan);
    3. malpresentation;
    4. cervical assessment;
    5. clinical suspicion of amniotic fluid abnormality;
    6. clinical suspicion of placental or umbilical cord abnormality;
    7. previous complicated delivery;
    8. uterine scar assessment;
    9. uterine fibroid;
    10. previous fetal death in utero or neonatal death;
    11. antepartum haemorrhage;
    12. clinical suspicion of intrauterine growth retardation;
    13. clinical suspicion of macrosomia;
    14. reduced fetal movements;
    15. suspected fetal death;
    16. abnormal cardiotocography;
    17. prolonged pregnancy;
    18. premature labour;
    19. fetal infection;
    20. pregnancy after assisted reproduction;
    21. trauma;
    22. diabetes mellitus;
    23. hypertension;
    24. toxaemia of pregnancy;
    25. liver or renal disease;
    26. autoimmune disease;
    27. cardiac disease;
    28. alloimmunisation;
    29. maternal infection;
    30. inflammatory bowel disease;
    31. bowel stoma;
    32. abdominal wall scarring;
    33. previous spinal or pelvic trauma or disease;
    34. drug dependency;
    35. thrombophilia;
    36. significant maternal obesity;
    37. advanced maternal age;
    38. abdominal pain or mass
Pregnancy >22 weeks only and only 1 per pregnancy
55721

Specialist Referral Only

PELVIS or ABDOMEN, pregnancy related or pregnancy complication, fetal development and anatomy, ultrasound scan of by any or all approaches, where:
     
  1. the patient is referred by a medical practitioner who is a Member or a Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists or who has a Diploma of Obstetrics or has qualifications recognised by the Royal Australian and New Zealand College of Obstericians and Gynaecologists as being equivalent to a Diploma of obstetrics or has obstetric privileges at a non-metropolitan hospital; and
  2. the dating of the pregnancy (as confirmed by ultrasound) is after 22 weeks of gestation; and
  3. the service is not associated with a service to which an item in Subgroup 2 or 3 of this group applies; and
  4. the referring practitioner is not a member of a group of practitioners of which the providing practitioner is a member; and
  5. further examination is clinically indicated in the same pregnancy to which item 55718 applies
Pregnancy >22 weeks only
55759PELVIS or ABDOMEN, pregnancy related or pregnancy complication, fetal development and anatomy, ultrasound scan of, by any or all approaches, with measurement of all parameters for dating purposes, where:
     
  1. the patient is referred by a medical practitioner; and
  2. ultrasound of the same pregnancy confirms a multiple pregnancy; and
  3. the dating of the pregnancy (as confirmed by ultrasound) is 17 to 22 weeks gestation; and
  4. the service is not associated with a service to which an item in Subgroup 2 or 3 of this group applies; and
  5. the referring practitioner is not a member of a group of practitioners to which the providing practitioner is a member; and
  6. the service is not performed in conjunction with item 55706 or 55712 during the same pregnancy
Multiple Pregnancy 17-22 weeks only and only 1 per pregnancy
55764

Specialist Referral Only

PELVIS or ABDOMEN, pregnancy related or pregnancy complication, fetal development and anatomy, ultrasound scan of, by any or all approaches, with measurement of all parameters for dating purposes, where:
     
  1. the patient is referred by a medical practitioner who is a Member or Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists or who has a Diploma of Obstetrics or has a qualification recognised by the Royal Australian and New Zealand College of Obstericians and Gynaecologists as equivalent to a Diploma of obstetrics or has obstetric privileges at a non-metropolitan hospital; and
  2. ultrasound of the same pregnancy confirms a multiple pregnancy; and
  3. the dating of the pregnancy (as confirmed by ultrasound) is 17 to 22 weeks gestation; and
  4. the service is not associated with a service to which an item in Subgroup 2 or 3 of this group applies; and
  5. the referring practitioner is not a member of a group of practitioners to which the providing practitioner is a member; and
  6. further examination is clinically indicated in the same pregnancy to which item 55759 has been performed; and
  7. not performed in conjunction with item 55706 or 55712 during the same pregnancy
Multiple Pregnancy 17-22 weeks only
57768PELVIS or ABDOMEN, pregnancy related or pregnancy complication, fetal development and anatomy, ultrasound scan of, by any or all approaches, where:
     
  1. dating of the pregnancy (as confirmed by ultrasound) is after 22 weeks of gestation; and
  2. the ultrasound confirms a multiple pregnancy; and
  3. the patient is referred by a medical practitioner; and
  4. the service is not performed in the same pregnancy as item 55770; and
  5. the service is not associated with a service to which an item in Subgroups 2 or 3 of this group applies; and
  6. the referring practitioner is not a member of a group of practitioners of which the providing practitioner is a member; and
  7. the service is not performed in conjunction with item 55718 or 55721 during the same pregnancy
Multiple Pregnancy >22 weeks only and only 1 per pregnancy
55772

Specialist Referral Only

PELVIS or ABDOMEN, pregnancy related or pregnancy complication, fetal development and anatomy, ultrasound scan of, by any or all approaches, where:
     
  1. dating of the pregnancy as confirmed by ultrasound is after 22 weeks of gestation; and
  2. the patient is referred by a medical practitioner who is a Member or Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists or who has a Diploma of Obstetrics or has a qualification recognised by the Royal Australian and New Zealand College of Obstericians and Gynaecologists as equivalent to a Diploma of obstetrics or has obstetric privileges at a non-metropolitan hospital; and
  3. further examination is clinically indicated in the same pregnancy to which item 55768 or 55770 has been performed; and
  4. the pregnancy as confirmed by ultrasound is a multiple pregnancy; and
  5. the service is not associated with a service to which an item in Subgroups 2 or 3 of this group applies; and
  6. the referring practitioner is not a member of a group of practitioners of which the providing practitioner is a member; and
  7. the service is not performed in conjunction with item 55718 or 55721 during the same pregnancy
Multiple Pregnancy >22 weeks only

Ultrasound

 

Musculoskeletal Ultrasound

The applicable criteria must be written on the referral for the patient to be eligible for rebate or Bulk Billed.

 

Shoulder / Upper Arm

Benefits are NOT payable when referred for non-specific PAIN alone.

 

Rebatable Criteria:

  • Evaluation of injury to tendon, muscle or muscle/tendon junction; or
  • Rotator cuff tear/calcification/tendinosis (biceps, subscapular, supraspinatus, infraspinatus); or
  • Biceps subluxation; or
  • Capsulitis and bursitis; or
  • Evaluation of mass including ganglion; or
  • Occult fracture; or
  • Acromioclavicular joint pathology

 

Knee

Benefits are NOT payable when referred for non-specific knee PAIN alone or other knee condition including:

  • Meniscal and cruciate ligament tears
  • Assessment of chondral surfaces

 

Rebatable Criteria:

  • Abnormality of tendons orbursae about the knee; or
  • Meniscal cyst, popliteal fossa cyst, mass; or
  • Pseudomass; or
  • Nerve entrapment, nerve or nerve sheath tumour; or
  • Injury of collateral ligaments

 

General Ultrasound

Medicare will NOT rebate the second examination when performed on the same day.

  • Ultrasound Doppler with Ultrasound Musculoskeletal or General or Pregnancy
  • Ultrasound Abdomen with Ultrasound Pelvis
  • Ultrasound Abdomen with Ultrasound Renal
  • Ultrasound Pelvis with Ultrasound Renal
  • Ultrasound Renal with Ultrasound Abdomen
  • Ultrasound Musculoskeletal Bilateral

 

For a signle page PDF version of the above details that can be printed please click here.

ItemDescriptionLimitations
55808where the service is provided, for the assessment of one or more of the following conditions or suspected conditions:
     
  • evaluation of injury to tendon, muscle or muscle/tendon junction; or
  • rotator cuff tear/calcification/tendinosis (biceps, subscapular, suspraspinatus, infraspinatus); or
  • biceps subluxation; or
  • capsulitis and bursitis; or
  • evaluation of mass including ganglion; or
  • occult fracture; or
  • acromioclavicular joint pathology
  •  


    Benefits are not payable when referred for non-specific pain alone

Shoulder or upper arm 1 or both sides
55828where the service is provided for the assessment of one or more of the following conditions or suspected conditions:
     
  • abnormality of tendons or bursae about the knee; or
  • meniscal cyst, popliteal fossa cyst, mass or pseudomass; or
  • nerve entrapment, nerve or nerve sheath tumour; or
  • injury of collateral ligaments
  •  


    Benefits are not payable when referred for non-specific pain alone and including meniscal or cruciate ligament tears and assessment of chondral surfaces

Knees 1 or both sides