Medicare benefits are payable for:
- the diagnosis and monitoring of bone loss if a patient has certain specific medical conditions or is undergoing particular treatments likely to cause rapid bone loss;
- the confirmation of clinically suspected low bone mineral density, usually following a fracture;
- the subsequent monitoring of established low bone mineral density; and/or
- those patients aged 70 years or over.
For Medicare purposes, most bone density testing is subject to a restriction on the time interval between tests, from one every 12 to 24 months, depending on the item. This is because bone density loss is considered a relatively slow process and repeat testing within 24 months is unlikely to assist in clinical decision making.
For specific medical conditions or particular treatments that may cause more rapid bone loss, a Medicare rebate is available for repeat testing at 12 monthly intervals.
Review of Bone Densitometry
An expert, clinician-led Medicare Benefits Schedule (MBS) Review Taskforce was established in April 2015, under the Government’s Healthier Medicare initiative, to lead a programme of MBS reviews aiming to align MBS funded services with contemporary clinical evidence and improve health outcomes for patients.
The Taskforce has made a number of recommendations to date including changes to the MBS bone densitometry items. The Government has decided, as announced on 22 August 2017 by Professor Bruce Robinson the Taskforce Chair, to implement a number of recommended bone densitometry changes which will come into effect from 1 November 2017.
What are the MBS Bone Densitometry changes?
From 1 November 2017, the following changes recommended by the Taskforce will be made:
- specifying that the person performing the DEXA items (12306, 12312, 12315, 12321 and the two new items 12320 & 12322) holds a radiation license, as required by State or Territory law and the scan is performed under the supervision of an appropriate specialist or consultant physician;
- specifying that an appropriate specialist or consultant physician must be available to monitor and influence the conduct of the Quantitative Computed Tomography (QCT) scan (i.e. 12320 and 12322, when performed using QCT) and personally attend the patient if required;
- introducing the requirement that the interpretation and report for all MBS bone densitometry services will be provided by a specialist or consultant physician;
- replacing item 12323 for people aged 70 years or over with two time-restricted items (new items 12320 & 12322) based on patient bone mineral density
t-scores. Item 12320 continues to make available an initial bone densitometry service for those patients aged 70 years or over who have not already had this service; and
- deleting the QCT items 12309 and 12318 from the MBS.
From 1 November 2017, the MBS bone densitometry items with the changes outlined above, will be included in the Health (General Medical Services) Table Regulation 2017 in conjunction with their removal from the Health Insurance (Bone Densitometry) Determination 2012.
How will bone mineral density be measured for patients aged 70 years or over?
From 1 November 2017 there will be two new MBS items for patients aged 70 years or over.
Patients 70 years or over will continue to be eligible for an initial screening study (item 12320).
Patients with a bone mineral density t-score of -1.5 or above will be eligible for one scan every 5 years (item 12320).
Patients with a bone mineral density t-score of less than -1.5 and above -2.5 will be eligible for one scan every two years (item 12322).
The Taskforce considers these testing frequencies to be clinically appropriate. A testing interval of one year is not considered reliable in detecting change attributable to actual bone loss in the screening setting.
What about patients diagnosed with osteoporosis?
Patients diagnosed with osteoporosis will continue to be able to use the existing clinically appropriate bone densitometry MBS items. The Taskforce did not recommend changes to eligibility and time restrictions for these items.
Are Medicare recommended fees and benefits changing?
There are no changes to the MBS recommended fees and benefits as part of the Taskforce recommendations. The MBS schedule fees and benefits for the two new items, 12320 & 12322, will be the same as the item they replace (12323).
It remains the case that medical and health practitioners, including diagnostic imaging providers, are free to set their own fees for the services they provide and to determine their own billing practices. Consumers are responsible for any difference between the applicable Medicare benefit and the fee set by the provider. Where a provider chooses to bulk bill there should be no out-of-pocket cost.
Questions and Answers
A Fact Sheet summarising the MBS Bone Densitometry changes is available at www.mbsonline.gov.au
The official announcement regarding the Bone Densitometry changes is available on the webpage Reducing unnecessary bone densitometry testing.