Current EMSN caps on ART and Obstetrics

The EMSN caps for ART and Obstetrics items did not change on 1 November 2012.

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Extended Medicare Safety Net and EMSN capping
ART and obstetrics items

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Why do some services have an EMSN cap?

Following an announcement in the 2009-2010 Budget, on 1 January 2010 some Medicare items were capped after they were identified as areas of concern in the Extended Medicare Safety Net Review Report 2009 (the Review report). The Review report showed that for some services, such as obstetrics and assisted reproductive technology (ART), specialists felt fewer competitive pressures knowing that their patients would receive 80 per cent of their out of pocket costs reimbursed through the government. This has implications for people that have not qualified for the EMSN, as well as the long term sustainability of the program.

Since 1 January 2010 a number of MBS services have been listed on the MBS with EMSN benefit caps in place. These services have been capped to maintain consistency with the existing capped items, or as a result of recommendations made by the Medical Services Advisory Committee (MSAC) regarding cost effectiveness.

From 1 November 2012, EMSN benefit caps apply for all consultation items, 38 procedural items and one ultrasound item. The changes have been made to support the long term sustainability of the EMSN. There has been no change to the current caps on ART, obstetrics or selected items listed in this fact sheet.

Changes to Obstetrics and Assisted Reproductive Technology on 1 January 2010

With the introduction of EMSN capping on 1 January 2010, a number of structural changes were made to obstetrics and ART services, including the introduction of new items, changes to Medicare rebates and item descriptors. Some of these changes are outlined below:

Obstetrics

On 1 January 2010 two items for consultations relating to pregnancy, 16401 and 16404, were introduced into the obstetrics section of the MBS. These items have the same fee as specialist attendance items 104 and 105, but they carry an EMSN benefit cap. These items continue to be restricted to specialists.

The item for the planning and management of a pregnancy was split into two items. Item 16590 is claimable for planning and managing pregnancy that has progressed beyond 20 weeks where the practitioner intends to perform the labour and delivery. Item 16591 is claimable for planning and managing pregnancy that has progressed beyond 20 weeks where the practitioner does not intend to perform the labour and delivery.

With the introduction of capping the base Medicare rebates for 15 obstetric items was increased at a cost of $157.6 million over four years. The Medicare rebates for obstetric attendance items and labour and delivery items were increased by 10 per cent and 30 per cent respectively. In addition the Medicare rebate for item 16590 — planning and management of a pregnancy — was increased significantly. This is of particular benefit to those women that do not qualify for EMSN benefits.

Assisted Reproductive Technology (ART)

In addition to the EMSN capping the basic Medicare rebate for a typical IVF cycle was increased by approximately $1,000 and the Medicare items for ART services were restructured to ensure that benefits were directed to the more technical and ‘expensive’ services. These changes were done in consultation with the medical profession and consumers.

Assisted Reproductive Technology

Item number	Description	2013 EMSN benefit cap ($)
13200	ART services - superovulated treatment cycle proceeding to oocyte retrieval – initial cycle in a calendar year	1,675.50
13201	ART services – superovulated treatment cycle proceeding to oocyte retrieval – subsequent cycle in a calendar year	2,432.15
13202	ART services – superovulated cycle that is cancelled prior to oocyte retrieval	64.95
13203	Ovulation monitoring services for artificial insemination	108.15
13206	ART services – natural treatment cycle or treatment cycle where oocyte growth & development is induced using oral medication only	64.95
13209	Planning and management of an ART treatment cycle	10.90
13210	Initiation of a professional attendance via videoconference, where that service relates to item 13209	5.30
13212	Oocyte retrieval	70.35
13215	Transfer of embryos to the female reproductive system	48.70
13218	Preparation of frozen or donated embryos	702.65
13221	Preparation of semen for artificial insemination	21.70
13251	Intracytoplasmic sperm injection	108.15

#Note: Actual EMSN benefit received depends on the out-of-pocket cost incurred by a patient.

Obstetric services

Item number	Description	2013 EMSN benefit cap ($)
16399	Initiation of a professional attendance via videoconference, where that service relates to item 16401, 16404, 16406, 16500, 16590 or 16591	24.10
16400	Antenatal attendance by a nurse or midwife on the behalf of a medical practitioner	11.05
16401	Initial specialist attendance by a practitioner in the practice of obstetrics	54.90
16404	Subsequent specialist attendance by a practitioner in the practice of obstetrics	32.95
16406	32 to 36 week obstetric visit - Antenatal professional attendance, as part of a single course of treatment, at 32-36 weeks of the patient's pregnancy when the patient is referred by a participating midwife. Payable only once for a pregnancy.	108.15
16500	Antenatal attendance	32.95
16501	External cephalic version for breech presentation, after 36 Weeks	65.90
16502	Attendance for treatment of polyhydramnios, unstable lie, multiple pregnancy, pregnancy complicated by diabetes or anaemia, threatened premature labour treated by bed rest only or oral medication	22.00
16504	Attendance for the treatment of habitual miscarriage by injection of hormones, each injection up to a maximum of 12 injections	22.00
16505	Attendance for threatened abortion, threatened miscarriage or hyperemesis gravidarum	22.00
16508	Attendance for pregnancy complicated by acute intercurrent infection, intrauterine growth retardation, threatened premature labour with ruptured membranes or threatened premature labour treated by intravenous therapy	22.00
16509	Attendance for the treatment of preeclampsia, eclampsia or antepartum haemorrhage	22.00
16511	Purse string ligation of cervix	109.75
16512	Removal of purse string ligature of cervix	32.95
16514	Antenatal cardiotocography in the management of high-risk pregnancy	16.55
16515	Management of vaginal delivery as an independent procedure where the patient's care has been transferred by another medical practitioner for management of the delivery	175.60
16518	Management of labour, incomplete, where the patient’s care has been transferred to another medical practitioner	175.60
16519	Management of labour and delivery by any means (including Caesarean Section), including postpartum care for 5 days	329.15
16520	Caesarean section and post-operative care for 7 days where the patient’s care has been transferred by another medical practitioner	329.15
16522	Management of complicated birth	438.90
16525	Management of second trimester labour, with or without induction, for intrauterine fetal death, gross fetal abnormality or life-threatening maternal disease	153.70
16527	Management of vaginal delivery, if the patient's care has been transferred by a participating midwife for management of the delivery, including all attendances related to the delivery. Payable once only for a pregnancy.	175.60
16528	Caesarean Section and post-operative care for 7 days, if the patient's care has been transferred by a participating midwife for management of the birth. Payable once only for a pregnancy.	329.15
16564	Evacuation of retained products of conception (placenta, membranes or mole) as a complication of confinement, with or without curettage of the uterus	219.45
16567	Management of postpartum haemorrhage by special measures such as packing of uterus	219.45
16570	Vaginal correction of acute inversion of the uterus	219.45
16571	Repair of extensive laceration or lacerations of the cervix	219.45
16573	Repair of third-degree tear, involving anal sphincter muscles and rectal mucosa	219.45
16590	Planning and management of a pregnancy that has progressed beyond 20 weeks.	219.45
16591	Planning and management of a pregnancy where the care of the patient will be transferred to another medical practitioner for the labour and delivery	109.75
16600	Amniocentesis	32.95
16603	Chorionic villus sampling	65.90
16606	Fetal blood sampling from umbilical cord or fetus	131.75
16609	Fetal intravascular blood transfusion, using blood already collected, including neuromuscular blockade, amniocentesis and fetal blood sampling.	252.40
16618	Amniocentesis, therapeutic	104.30
16624	Drainage of fetal fluid-filled cavity	142.65
16627	Feto-amniotic shunt, insertion of, into fetal fluid-filled cavity, including neuromuscular blockade and amniocentesis	307.25
16633	Procedure on multiple pregnancies relating to Items 16606, 16609, 16612, 16615 and 16627	230.50
16636	Procedure on multiple pregnancies relating to Items 16600, 16603, 16618, 16621 and 16624	87.85

#Note: Actual EMSN benefit received depends on the out-of-pocket cost incurred by a patient.

Pregnancy ultrasounds

Item number	Description	2013 EMSN benefit cap ($)
55700	Pregnancy related scan – less than 12 weeks referred patient	32.95
55701^	Pregnancy related scan – less than 12 weeks referred patient	16.50
55703	Pregnancy related scan – less than 12 weeks non- referred patient	16.55
55702^	Pregnancy related scan – less than 12 weeks non- referred patient	8.30
55704	Pregnancy related scan –12 to 16 weeks referred patient	38.50
55710^	Pregnancy related scan –12 to 16 weeks referred patient	19.30
55705	Pregnancy related scan –12 to 16 weeks non-referred patient	16.55
55711^	Pregnancy related scan –12 to 16 weeks non-referred patient	8.30
55706	Pregnancy related scan – 17 to 22 weeks referred patient	54.90
55713^	Pregnancy related scan – 17 to 22 weeks referred patient	27.50
55707	Pregnancy related scan – rump length of 45 to 84mm referred patient	38.50
55714^	Pregnancy related scan – rump length of 45 to 84mm referred patient	19.30
55708	Pregnancy related scan – rump length of 45 to 84mm non-referred patient	16.55
55716^	Pregnancy related scan – rump length of 45 to 84mm non-referred patient	8.30
55709	Pregnancy related scan – 17 to 22 weeks non-referred patient	22.00
55717^	Pregnancy related scan – 17 to 22 weeks non-referred patient	11.05
55712	Pregnancy related scan –17 to 22 weeks referred patient by obstetrician	65.90
55719^	Pregnancy related scan –17 to 22 weeks referred patient by obstetrician	32.95
55715	Pregnancy related scan – 17 to 22 weeks non-referred patient, performed by obstetrician	22.00
55720^	Pregnancy related scan – 17 to 22 weeks non-referred patient, performed by obstetrician	11.05
55718	Pregnancy related scan – after 22 weeks referred patient	54.90
55722^	Pregnancy related scan – after 22 weeks referred patient	27.50
55721	Pregnancy related scan – after 22 weeks referred patient by obstetrician	65.90
55724^	Pregnancy related scan – after 22 weeks referred patient by obstetrician	32.95
55723	Pregnancy related scan – after 22 weeks non-referred patient	22.00
55726^	Pregnancy related scan – after 22 weeks non-referred patient	11.05
55725	Pregnancy related scan – after 22 weeks non-referred patient, performed by obstetrician	22.00
55727^	Pregnancy related scan – after 22 weeks non-referred patient, performed by obstetrician	11.05
55729	Duplex scanning after 24th week	16.55
55730^	Duplex scanning after 24th week	8.30
55762	Pregnancy related scan – 17 to 22 weeks non-referred patient which identifies multiple pregnancy	32.95
55763^	Pregnancy related scan – 17 to 22 weeks non-referred patient which identifies multiple pregnancy	16.50
55764	Pregnancy related scan – 17 to 22 weeks referred patient which identifies multiple pregnancy, performed by obstetrician	87.85
55765^	Pregnancy related scan – 17 to 22 weeks referred patient which identifies multiple pregnancy, performed by obstetrician	44.00
55766	Pregnancy related scan – 17 to 22 weeks non referred patient which identifies multiple pregnancy, performed by obstetrician	32.95
55767^	Pregnancy related scan – 17 to 22 weeks non referred patient which identifies multiple pregnancy, performed by obstetrician	16.50
55768	Pregnancy related scan – after 22 weeks referred patient which confirms multiple pregnancy	82.40
55769^	Pregnancy related scan – after 22 weeks referred patient which confirms multiple pregnancy	41.25
55770	Pregnancy related scan – after 22 weeks non referred patient which confirms multiple pregnancy	32.95
55771^	Pregnancy related scan – after 22 weeks non referred patient which confirms multiple pregnancy	16.50
55772	Pregnancy related scan – after 22 weeks referred patient by obstetrician which confirms multiple pregnancy	87.85
55773^	Pregnancy related scan – after 22 weeks referred patient by obstetrician which confirms multiple pregnancy	44.00
55774	Pregnancy related scan – after 22 weeks referred patient which confirms multiple pregnancy performed by obstetrician	38.50
55775^	Pregnancy related scan – after 22 weeks referred patient which confirms multiple pregnancy performed by obstetrician	19.30

#Note: Actual EMSN benefit received depends on the out-of-pocket cost incurred by a patient.
^ Items introduced under the Capital Sensitivity measure announced in the 2009-10 Federal Budget and claimable from 1 July 2011 for services provided using aged equipment.

Midwifery

Item number	Description	2013 EMSN benefit cap ($)
82100	Initial midwife attendance with a participating midwife – lasting at least 40 minutes	21.70
82105	Short antenatal attendance with a participating midwife – up to 40 minutes	16.30
82110	Long antenatal attendance with a participating midwife – lasting at least 40 minutes.	21.70
82115	Planning and management of pregnancy with a participating midwife that has progressed beyond 20 weeks lasting at least 90 minutes	54.10
82130	Short postnatal attendance with a participating midwife	16.30
82135	Long postnatal attendance with a participating midwife	21.70
82140	Six week postnatal attendance	16.30

#Note: Actual EMSN benefit received depends on the out-of-pocket cost incurred by a patient.