Private health insurance clinical category definitions 1 November 2022

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 Benefit Schedule (MBS) items that should be covered. The list of items is derived from the 'XML-20221101.v2-MBS (XML 7,935 KB)' released through MBS Online on 17 October 2022, effective 1 November 2022 and includes changes to the General Medical Services Table (GMST), Pathology Services Table (PST) and Diagnostic Imaging Services Table (DIST) and indexation to the greatest permissible gap. In addition, this file also includes the October changes to the MBS, co-dependant pathology services, psychiatry telehealth and Better Access Initiative services.

Update as of 1 November 2022: An error was identified in the Private Health Insurance Legislation Amendment Rules (No. 12) 2022 for 21 MBS items which had amendments to the clinical category and procedure type when these should not have been amended. The Private Health Insurance Legislation Amendment Rules (No. 13) 2022 repeals Private Health Insurance Legislation Amendment Rules (No.12) 2022 and will restore existing MBS items 36531, 36532, 36533, 36537, 36543, 36546, 36549, 36552, 36558, 36561, 36564 to the ‘Kidney and bladder’ Clinical category and items 39300, 39303, 39306, 39307, 39309, 39312, 39315, 39318, 39319 and 39321 to ‘Brain and nervous system’.  This updated ‘Clinical categories definitions table‑1 November 2022 v3’ supersedes the table provided on 21 October 2022.

The MBS Online November 2022 News provides a summary of MBS changes for 1 November 2022. Key MBS item changes for private health include:

• new co-dependent item (73436) for METex14sk testing in patients with locally advanced or metastatic non-small cell lung cancer
• amendment to three existing pathology MBS items (73337, 73341 and 73344) to replace reference to the specific drug ‘pembrolizumab’ with a general reference to ‘immunotherapy’
• two new items (30661 and 30662) and four (43882, 44108, 44111 and 44114) amended items for paediatric surgery
• new item (36530) for cryoablation for biopsy-confirmed renal cell carcinoma
• new item (39141) for reprogramming of a neurostimulator for the management of chronic neuropathic pain
• seven new items (31377 to 31383) and six amended items (31371 to 31376) for melanoma excision
• amended item (45617) for Oculoplastic surgery to support patient access by removing reference to visual field testing
• new item (40863) for deep brain stimulation for the treatment of Parkinson’s disease, essential tremor, and dystonia
• two new items (11736 and 11737) for cardiac implanted loop recorders
• amendment to six varicose veins items (32520, 32522, 32523, 32526, 32528 and 32529) to allow co-claiming with appropriate venography items
• amendment to eight cardiothoracic surgery items (38510, 38513, 38516, 38517, 38555, 38556, 38557 and 38572)
• three new items (47790, 47791 and 47792) and five amended items (47967, 49212, 49236, 49215 and 49734) for orthopaedic surgery to address unintended consequences, such as service gaps, in response to MBS Taskforce Review recommendations
• removal of one item (173) and amendment to four acupuncture items (193, 195, 197 and 199) to allow appropriately credentialled medical practitioners to provide acupuncture services
• new item (63563) for pelvic MRI for the investigation of sub-fertility
• amendment to existing obstetric MRI item (63454) to expand clinical indication to include all suspected fetal abnormalities
• new obstetric MRI item (63549) for multiple pregnancies for fetal abnormalities
• six new (55740, 55741, 55742, 55743, 55757 and 55758) pregnancy ultrasound items
• new positron emission tomography (PET) item (61612) for initial staging for patients diagnosed with rare and uncommon cancers
• amendment to liver MRI item (63545) to include all cancer types that have potentially spread to the liver
• amendment to breast MRI item (63464) to increase eligible age
• permanent introduction of three nuclear medicine diagnostic imaging items (61333, 61336 and 61341) to support patient access to alternative PET imaging services during radiopharmaceutical technetium-99m (Tc-99m) supply disruptions
• seven new items (73422 to 73428) for genetic testing for the diagnosis of early-onset or familial neuromuscular disorders
• removal of one item (73073) and amendment to two National Cervical Screening Program items (73072 and 73074) to expand access to self-collected cervical screening and other administrative amendments
• other minor technical and administrative amendments.

The clinical category definitions reflect the amendments made to the following categories:

• ‘Bone, joint and muscle’
• ‘Brain and nervous system’
• ‘Joint reconstructions’
• ‘Kidney and bladder’
• ‘Male reproductive system’
• ‘Pain management with device’
• ‘Skin’

New MBS Pathology Services Table (PST) items and Diagnostic Imaging Services Table (DIST) are automatically categorised as Support treatments so do not need to be listed in the clinical categories table.

The assignment of MBS items by clinical category reflects the PHI rules, which will be accessible on the Federal Register of Legislation over the coming weeks. Formal notification will be provided by Private Health Insurance Circular, and on the Federal Register of Legislation following the finalisation of regulatory approval processes.

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.