Medicare MBS Item Code Changes for Plastic Surgery – Rebate Criteria

health-insurance-policy-hospital-cover-surgery-bupa-medibank

Medicare MBS Item Code Changes for Plastic Surgery went into effect on the 1st of November 2018, potentially impacting patient surgery costs. MBS changes also impact your private health fund. This article, last updated 13 November 2018, overviews rebate criteria changes and new MBS Item Code rules impacting Medicare rebate eligibility and Private Health Fund coverage for Plastic Surgery (operations).

Is my Plastic Surgery still covered by Medicare or Private Health Insurance?

  • There have been some major changes to Medicare rebates, MBS Item Codes and Health Fund coverage for plastic surgery procedures.
  • Changed MBS Item Numbers and new rules for Plastic Surgery went into immediate effect on 1 November 2018.
  • This article helps you understand if YOUR plastic surgery plans will be affected.

Which plastic surgery procedures were impacted by latest MBS changes?

  • Some MBS Item numbers have been completely removed as of 1 November 2018.
  • Medicare surgery criteria for rebates has also changed, making eligibility difficult or narrower in scope.
  • Documentation, new assessments and photographic evidence may now be required.
  • These Medicare rule changes to Plastic Surgery MBS Items were made because the Government believes some Item numbers were previously used for ‘cosmetic’ surgery purposes rather than medically indicated procedures.

Plastic Surgery Procedures most affected by new MBS rules and Medicare changes:

  • Breast Reduction
  • Mastopexy (Breast Lift)
  • Removal and replacement of breast implants
  • Breast Asymmetry and Tuberous
  • Septoplasty/rhinoplasty (nose)
  • Blepharoplasty (eyelids)
  • Otoplasty (Ears)
  • Labiaplasty
  • Combinations of some surgery procedures are also subject to revised limitations per new MBS multiple-procedure rules and condition criteria changes

Plastic Surgery MBS Rule Changes: Surgery Prices and Costs

Medicare MBS Changes for Plastic Surgery – What impact will new MBS rule changes have on what patient’s pay for surgery?

Will I pay more for my operation now that Medicare codes have changed?

  • It depends IF the MBS Item Code allocated to you was impacted by recent changes AND
  • It depends IF your current medical condition and Plastic Surgery operation meets the NEWLY UPDATED MBS criteria for plastic surgery.
  • Contact us for an updated quote by phoning 038849 1444.

 

If you ARE still eligible for a MBS rebate for Plastic Surgery:

You may be required to:

  • attend additional pre-surgery evaluations or tests
  • provide more extensive documentation including proof of surgery necessity 
  • understand rebate eligibility for Plastic Surgery is NOT guaranteed
  • extensive proof may be required – such as photographic evidence before, during and after surgery

If you remain eligible for MBS rebates and satisfy documentation requirements, you will be granted rebates post-surgery.

Payment for Plastic Surgery for any procedure now requires:

  • paying for your surgery entirely up front
  • applying for any rebates from Medicare and your Health Fund AFTER your Plastic Surgery operation is complete
  • understanding there is no guarantee you’ll satisfy eligibility / documentation requirements
  • understanding your Health Fund (such as BUPA) will only cover Plastic Surgery IF there is an MBS Item Code.

 

What happens if my Plastic Surgery Item Code was removed from the MBS?

  • You will need to pay for your plastic surgery entirely out of pocket (no Medicare rebates apply)
  • No private Health Fund/Health Insurance rebates will apply (no PHI coverage).

Do I need a NEW surgery PRICE QUOTE for my Plastic Surgery procedure?

  • This will impact on anyone who has a procedure after the 1st November 2018.
  • If you have a procedure booked after 1st November 2018, please contact us on 8849 1444 or enquiries@plasticsurgeons.com.au to discuss if these changes will impact on your costs.

 

Why did these Medicare changes to the MBS come into effect?


Reminder about Medicare, Cosmetic Surgery, Plastic Surgery and Health Funds

  • Cosmetic Surgery is never covered by Medicare or health funds, so the current changes do not apply.
  • Plastic Surgery, medically-indicated procedures that originally met criteria for a Medicare rebate are impacted by these changes.

Summary of changes to the Medicare / MBS codes for Plastic Surgery (effective immediately)

  • MBS changes became effective immediately (1 Nov 2018)
  • Some MBS Item Codes and rebate criteria were changed and others were removed entirely
  • Eligibility documentation and photographic evidence has become more extensive
  • Impacted patients need to request a new quote by phoning (03)88491444.

See our original article in September 2018 warning of these pending changes.


Patient Steps

  • First, review your existing QUOTE in relation to specific MBS ITEM CODE changes for Plastic Surgery, listed below.
  • If your QUOTE includes one of these codes, or you have a question about MBS or Health Fund pricing changes, please contact our office immediately for advice on getting a new price/cost quote. Phone us today on 0388491444. Thank you.

MBS Item Codes Removed

Plastic Surgery MBS Item Codes REMOVED from MEDICARE MBS effective 1 November 2018.

  • 45559 – Tuberous Breast -Masto/Aug (new 45060/45061/45062)
  • 45586 – Liposuction for Buffalo hump
  • 45638 – Rhinoplasty
  • 45639 – Rhinoplasty
  • 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

Plastic Surgery MBS Item Codes and/or Criteria Changes

Intra-Operative Photos Required for MBS Item Code Eligibility Review (effective 1 November 2018)

  • 45554 – Removal and replacement breast implant  – Requirement > 50% capsule removed
  • 45553 – Removal and replacement breast implant

Increased Documentation and Changed Photographic Submissions Required (Photo Evidence)

Nose Surgery – Rhinoplasty MBS Code Changes – Photo evidence PLUS NOSE Scale survey

  • 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 Surgery – MBS Code Changes for Breast Reduction, Breast Lift for Ptosis, Asymmetry and Reconstruction

Photos required: Anterior, Left and Right Side photos – showing IMF position (must be 2/3 below IMF and nipple at lowest point).

  • 45051 – Breast Cancer reconstruction
  • 45060 – Breast Asymm incl masto or implants (volume diff)
  • 45061 – Breast Asymm stage 1
  • 45062 – Breast Asymm stage 2
  • 45528 – Breast recon
  • 45556 – Unilateral Mastopexy for Breast Ptosis
  • 45558 – Bilateral Mastopexy for Breast Ptosis

Changed MBS Requirements for Liposuction and Medicare: Photos Required for MBS Rebate Documentation

Note that cosmetic liposuction is NEVER covered or eligible for a rebate from Medicare or your Private Health Fund.

  • 45584 – Liposuction for post-traumatic Pseudolipoma
  • 45585 – Liposuction for special cases
  • 45587 – Meloplasty for facial asymmetry
  • 45588 – Meloplasty congenital condition

Breast Surgery and Medicare – VOLUME Requirements

Changed MBS Requirement for Breast Surgery: DOCUMENTED VOLUMETRIC ANALYSIS OF BREAST

(Difference of 10% tuberous or 20% for normal)

  • 45060/45061/45062 – Breast Asymm
  • 45551 – Removal only of breast implant and half capsule
  • 45524 – Mammaplasty Augmentation performed after cancer or abnormality

OTHER KEY MBS CHANGES effective immediately (1 November 2018)

  • 30176 – LIPECTOMY – Must have had an abdominal tumour
  • 35534 – LABIOPLASTY/LABIAPLASTY – must be > 18 and have > 8cm
  • 45659 – EAR – Photo & Under < 18 only
  • 45617 – UPPER EYE Reduction – must be confirmed by Opthamologist

Remember, Cosmetic Surgery procedures are never covered by Medicare/MBS nor by Private Health Fund plans.

 

Phone us on 03 8849 1444 with questions or to request a new price quote.

 

Dr Richard Sackelariou - MBBS, FRACS, FRCS
Dr Richard Sackelariou, MBBS, FRACS/FRCS, is a leading Sydney Specialist Plastic, Cosmetic & Reconstructive Surgeon who sees patients in two locations: Double Bay, Sydney and Melbourne VIC (Australia). Dr Sackelariou offers extensive experience in attaining natural-looking, excellent surgical results for patients of all ages. Graduate of Sydney University, FRACS, Plastic and Reconstructive Surgery plus additional training in Cosmetic Surgery in Paris at the Clinique Turin in 1994.BIO PAGE: Click here