Private health insurance clinical category definitions 1 July 2023

Definitions of the clinical categories for hospital treatment policies as found in the Private Health Insurance (Complying Product) Rules 2015.

The clinical categories include an indicative list of Medicare Benefits Schedule (MBS) items that should be covered. This list of items is derived from the MBS-XML-20230701 (XML 7832 KB) released on 4 April 2023 through MBS Online and effective 1 July 2023. The current documents reflect changes made to items of the MBS General Medical Services Table, Pathology Services Table (PST), Diagnostic Imaging Services Tables (DIST) and the Health Insurance Regulations 2018. These files also include changes to various instruments made under subsection 3C(1) of the Health Insurance Act 1973.

The MBS Online July 2023 News provides a summary of MBS changes for 1 July 2023. Key MBS item changes for private health include:

• plastic and reconstructive surgery services item charges   
• new mental health case conferencing items (930, 933, 935, 937, 943, 945, 946, 948, 959, 961, 962, 964, 969, 971, 972, 973, 975, 986, 80176, 80177 and 80178)
• cardio-thoracic item 38680 will be amended so that tumour excision services under this item may only be performed in-hospital
• amendment to orthopaedic item descriptor 49706 to allow patients to access this service where no infection is indicated
• repeal of item 32221 for the removal or revision of an artificial bowel sphincter
• amendment to items 13761 and 13762 for extracorporeal photopheresis treatments of graft versus host disease to apply once per each treatment in a 25-session treatment cycle, rather than once per cycle
• amendment to therapeutic nuclear medicine item 16015 to apply to patients with all cancer types
• increased scheduled fee for therapeutic nuclear medicine items 16003, 16006, 16009, 16012 and 16018 to reflect the cost of the radiopharmaceuticals
• introduction of new nuclear medicine item 61466 for cerebro-spinal fluid transport studies using indium-111, mirroring existing MBS item 61409 but using a different radioisotope
• amendment to the descriptor for nuclear medicine item 61409 to specify use of technetium‑99m and a fee increase to better reflect isotope costs
• amendment of MRI item 63545 to clarify the item descriptor, aligning with the original policy intent of changes implemented on 1 November 2022
• new MBS pathology item (69505) for antimicrobial drug susceptibility testing for patients who have an infection caused by a pathogen in the mycobacterium tuberculosis complex
• one new MBS item (73429) for initial diagnosis somatic gene panel testing classification of gliomas, including glioneuronal tumours or glioblastoma
• two new MBS items (73434 and 73435) and one amended MBS item (73427) for single gene testing for the diagnosis of early-onset heritable neuromuscular disorders
• other administrative and machinery changes.
• The clinical category definitions reflect amendments made to the following categories:
• Bone, joint and muscle
• Brain and nervous system
• Breast surgery (medically necessary)
• Digestive system
• Male reproductive system
• Plastic and reconstructive surgery (medically necessary)
• Skin
• Weight loss surgery

New PST items and DIST items are automatically categorised as Support treatments so do not need to be listed in the clinical categories tables in the PHI Rules. All Support items are identified in the Private Health Insurance classification of MBS items.

The assignment of MBS items by clinical category reflects the PHI rules. The PHI Rules will be published on the Federal Register of Legislation and formal notification from the Department of Health and Aged Care will be via Private Health Insurance Circular following the finalisation of regulatory approval processes. Subscribe for notification of new Circulars using Health’s Latest News RSS (Really Simple Syndication) feed.

For older versions of this publication, review the Private health insurance clinical category and procedure type collection, or visit the National Library's web archive.