In making clear which number to use for excising suspicious skin lesions, Medicare may have muddied the water even further.
Under new Medicare rules, removal of a clinically suspected melanoma may attract a slightly lower rebate than removing a benign skin lesion.
The new rules, which kick in tomorrow (1 November), were designed to provide clarity on which item number to bill for excision of a suspicious skin lesions.
Historically, there have been two sets of item numbers for skin lesion removals: one for benign moles and one for histologically confirmed melanomas.
Often, doctors will wait until the pathology comes back to confirm which item number is most appropriate to bill.
“All of the Medicare billing is dependent on the histology report,” Adjunct Associate Professor Jeremy Hudson, chair of the RACGP dermatology specific interest group, told The Medical Republic.
“It’s either going to come back as benign, or it’s going to come back as a melanoma or a non-melanoma cancer.
“There’s been a lot of poor clarity from Medicare for years about whether or not that first excision, if it turns out to be a melanoma, should be billed as a melanoma [excision] or not.”
Confirmed melanomas can often require a second excision.
TMR understands that Medicare itself has given conflicting advice as to whether it’s appropriate to bill the melanoma item number twice.
“One of the ways out of that [was that Medicare] said, ‘well, look, let’s create a new item number for if you cut it out and it’s a melanoma, but it’s not a definitive, curative excision,’” Professor Hudson said.
“And there’s been a lot of back and forth about the rebate for this.”
Essentially, seven new item numbers have been added which remunerate doctors for the initial excision of a clinically suspected melanoma.
These will be items 31377 through to 31383.
Additionally, there will be amendments to the existing melanoma excision item numbers of 31371 through to 31376 to add “including excision of the primary tumour bed” to all item descriptions.
There is no indication in the fact sheets released by Medicare that the remuneration for these item numbers will change.
No changes are being made to item numbers covering the removal of benign lesions, i.e. 31357, 31360, 31362, 31364, 31366, 31368 and 31370.
At time of writing, there are fears that removal of a benign lesion will attract a higher patient rebate than removal of a clinically suspected melanoma.
Removing a non-malignant skin lesion of 6mm or more on the face or neck, for example, attracts an 85% benefit of $151.05, whereas removing a clinically suspected melanoma of 6mm or more from the same site would attract an 85% benefit of $148.60.
The full fees listed on the MBS are $177.65 and $174.85, respectively.
Removing the primary tumour bed of a malignant melanoma 6mm or larger from the face or neck will still have a full fee of $377.40 and 85% benefit of $320.80.
Professor Hudson said the disparity “made no sense”, and that he felt it was a clerical error on Medicare’s part.
“Someone must have made a mistake and it must have slipped through to the final draft,” he said.
“We’re all sensible people and basically, what we said is that it makes no sense from a training, risk or management perspective to have a melanoma [cost] less than a benign lesion.”
He is confident that the disparity will be addressed within the next few days.
Australian Society of General Practice president Dr Chris Irwin, who also has a special interest in skin medicine, was similarly perplexed.
“It’s bizarre that the patient would get a smaller rebate from the government for you to diagnose and start treatment for a melanoma, as opposed to knowingly cutting off a harmless mole,” he told TMR.
It is especially vexing, Dr Irwin said, given that there won’t be many scenarios in which it would be clinically necessary for a doctor to knowingly remove a benign lesion.
“Why is anyone cutting out benign moles, apart from cosmetics?” he said.
“It’s always more complicated than that – there will be instances in which there’s a large mole that’s rubbing under the breast or causing recurrent infections in an area through ulceration.”
While the actual difference between rebates for the two procedures is relatively small, Dr Irwin said it quickly stacks up over time.
“These numbers aren’t massive, [it’s] maybe a 5% cut, but in the context of a year in which now we’re getting towards 8% … real headline inflation … it really equates to a significant cut to the viability of any bulk-billed service,” he said.
TMR reached out to the Department of Health for comment on whether the rebates are final.
