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 and 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. Testing for people over the age of 70 years is not currently restricted to these 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 some changes to the MBS bone densitometry items. The Government has decided, as announced on 22 June 2017 by Bruce Robinson the Taskforce Chair, to implement a number of recommended bone densitometry changes which will come into effect from 1 November 2017.
It is important to note that on 8 June 2017, the Taskforce also recommended the removal of the MBS QCT items 12309* and 12318* from the MBS. However the Taskforce’s endorsement of the Diagnostic Clinical Committee’s recommendation to delete these items has not been confirmed by Government. Should the Government, as anticipated, adopt these changes they would take effect on 1 November 2017.
What are the MBS BD changes?
The Taskforce recommended the following changes:
- replacing item 12323 for people aged 70 years and over with two time-restricted items (new items 12320 & 12322) based on patient Bone Mineral Density T scores;
- 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 (ie MBS items 12309*, 12318*, 12320 and 12322) and personally attend the patient if required;
- deleting the QCT items 12309* and 12318* from the MBS, pending the Government’s anticipated confirmation of this recommendation. Should this occur, the QCT qualification changes detailed would apply only to the two new items for bone densitometry (12320 and 12322); and
- introducing the requirement that the interpretation and report for all MBS bone densitometry services will be provided by a specialist or consultant physician.
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 from 1 November 2017 for patients aged 70 years and over?
From 1 November 2017 there will be two new MBS items for patients aged over 70 years.
Patients 70 years and over will continue to be eligible for an initial screening study. Patients assessed as having a normal study or mild osteopenia as measured by a t-score down to -1.5 will be eligible for one scan every 5 years (item 12320).
Patients with moderate to marked osteopenia as measured by a T-score of -1.5 to -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. Eligibility and time restrictions for these items will not change.
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 for item 12323 which they replace.
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
PDF version: Bone Densitometry Services under Medicare Patients Questions and Answers (PDF 39 KB)
Word version: Bone Densitometry Services under Medicare Patients Questions and Answers (Word 32 KB)
PDF version: Bone Densitometry Services under Medicare Providers Questions and Answers (PDF 37 KB)
Word version: Bone Densitometry Services under Medicare Providers Questions and Answers (Word 31 KB)
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.