Medicare MBS Item Codes for Plastic Surgery went into effect on the 1st of November, potentially impacting patient surgery costs. MBS item numbers can also impact your private health fund rebate. This article 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 the 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 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)
- Combinations of some surgical 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 meet the NEWLY UPDATED MBS criteria for plastic surgery.
- Contact us for an updated quote by phoning 038849 1444.
If you are still eligible for an 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 upfront
- 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).
Why did these Medicare changes to the MBS come into effect?
- These changes are made by government-directed Medicare Code reviews by MBSR officials, advisory panels and healthcare budget advisors.
- In brief, the Medicare Claims Review Panel was dissolved and MBS changes relate to amendments to MCRP and MBS items for Plastic & Reconstructive Surgery.
- Source: Medicare MBS Code Changes – Plastic Surgery Updates MCRP MBS changes Fact Sheet, updated Oct-2018.
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.
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 Trabeculoplasty 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 Ophthalmologist
- 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.