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 Data file ‘MBS-XML-20230701.V2 (XML 7879 KB)’ released on 9 June 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.

Key MBS item changes of potential interest to stakeholders are summarised below, and outlined in the MBS Online July 2023 News:

• plastic and reconstructive surgery services item changes (for further information on changes to approximately 360 MBS items, see Plastic and reconstructive surgery MBS changes Fact Sheets)
• amendment to items for skin excision (including 31340, 31356, 31358, 31359, 31361, 31363, 31367, 31369) and skin flap (including 45000, 45003, 45200, 45201, 45203, 45206 and 45207) to include co-claiming restrictions with the seven new items for clinically suspected melanoma that were implemented from 1 November 2022
• new mental health case conferencing services items (including 930, 933, 935, 937, 943, 945, 946, 948, 959, 961, 962, 964, 969, 971, 972, 973, 975, 986)
• amendment to general medical services item 38680 for cardio-thoracic tumour excision so that tumour excision services under this item may only be performed in-hospital
• amendment to orthopaedic item descriptor 49706 for arthrotomy of the ankle joint to allow patients to access this service where no infection is indicated
• amendment to therapeutic nuclear medicine item 16015 for the treatment of painful bony metastases to amend patient eligibility to apply to patients with all cancer types
• amendment to items 13761 and 13762 for extracorporeal photopheresis (ECP) for chronic graft versus host disease (cGVHD) to apply once per each treatment in a 25-session treatment cycle, rather than once per cycle
• therapeutic nuclear medicine items changes including, increased scheduled fee for therapeutic nuclear medicine items 16003, 16006, 16009, 16012 and 16018 to reflect the cost of the radiopharmaceuticals used
• introduction of new nuclear medicine item 61466 for cerebro-spinal fluid transport studies using indium‑111
• amendment to the descriptor for nuclear medicine item 61409 to specify use of technetium‑99m and a fee increase to better reflect the cost of this radiopharmaceutical
• amendment of MRI item 63545 to clarify claiming requirements for liver MRIs to ensure appropriate use of this item, aligning with the original policy intent of changes implemented 1 November 2022
• new pathology services item 73429 for diagnostic somatic gene panel testing
• new items 73434 and 73435 for single gene testing for diagnosis of heritable neuromuscular disorders
• amendment of item 73427 to include item 73434 as a pathway for services provided under item 73427
• new pathology services item 69505 for whole genome sequencing for antimicrobial drug susceptibility testing in patients who have an infection caused by a pathogen in the Mycobacterium tuberculosis complex
• other administrative and machinery changes.

The MBS XML V2 released on 9 June 2023 also included:

• extension of MBS Item 32221 for removal or revision of an artificial bowel sphincter (note this item was initially due to cease so was not in the 4 April release of the 1 July 2023 MBS XML Data File, and related 4 May 2023 release of an interim PHI Spreadsheet. Item 32221 was extended)
• amendment to the fee for item 30630
• amendment to pathology item 73343
• new item 31227
• new item 61470
• various other changes made under subsection 3C(1) of the Health Insurance Act 1973.

Further information including fact sheets and quick reference guides is at MBS Online.

The clinical category definitions reflect amendments made to the MBS items assigned 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, and the
• lists of Support treatments and Common treatments

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 1 July 2023-v2.

The assignment of MBS items by clinical category reflects the Private Health Insurance Legislation Amendment Rules for 1 July 2023 which will be published on the Federal Register of Legislation  following the finalisation of regulatory approval processes. Details of the changes will be available in the Explanatory Statement that will accompany the Amendment Rules.

Formal notification of the Amendment Rules registration from the Department of Health and Aged Care will be via Private Health Insurance Circular.

Subscribe for notification of new Circulars using Health’s Latest News RSS (Really Simple Syndication) feed.

Receive notification of updates to PHI Spreadsheets, and other PHI information, by emailing PHI@health.gov.au requesting subscription to the email newsletter.

For previous versions of PHI Spreadsheet publications, review the Private health insurance clinical category and procedure type collection, or visit the National Library's web archive.