It is that time of year again. The time when the Federal Department of Health shakes up the rule-book and surgeons need to adjust the way that we all navigate the health system, and how the reimbursements work.
In 2018, there has been another major shake up of the descriptions of item numbers (Medicare codes) in many categories. Many item numbers that plastic surgeons use are being limited or removed in Medicare’s efforts to limit the amount of the health budget that is spent on elective or discretionary surgery. Whilst most plastic surgeons would argue that there are functional benefits from many procedures (such as breast reduction or abdominoplasty), the grey area between a functional operation and a purely cosmetic procedure can be difficult to define. This has lead to the “Safeguarding Medicare Against Cosmetic Misuse Project 2018”.
Cosmetic surgery has been under the spotlight in NSW over the last few years, and has gained attention on a Federal level recently. Given that there is a shrinking health care budget, it is not surprising that procedures that affect quality of life are being restricted so that treatment of life threatening conditions can be prioritised.
Key changes that will affect our patients are:-
- Direct browlift (scar above the eyebrow) – new item number/indication for reduced visual fields
- Upper blepharoplasty – additional requirement for documentation of reduced visual fields
- Labioplasty – will only attract an item number for women over 18 years old and with photographic evidence of labial hang of more than 8cm when standing.
- Breast ptosis – specification of photographic evidence to show more than 2/3 of breast volume beneath the infra-mammary fold. Still only available to women within 1-7 years from the birth of their last child.
- Breast implant removal and replacement – needs on table photographic evidence to show that there would be unacceptable deformity if the implant was not replaced
- Rhinoplasty – patients need to complete a pre-op nasal airway function score. If the functional impairment (NOSE score) is not severe enough, there is no item number/Medicare rebate as the procedure would be deemed to be primarily cosmetic
- Otoplasty – now has a maximum age of 18 years old to attract a Medicare rebate
There are many other changes, but they will have administrative requirements for Dr Sandercoe and his staff, but should not impact on patients substantially.
These changes need to be considered in conjunction with the NSW Cosmetic Surgery Legislation.
https://www.health.nsw.gov.au/legislation/Pages/cosmetic-surgical-procedures.aspx
Of note, as it stands, labioplasty is specified as a procedure that is required to be performed in a facility that has the capacity to perform a full general anaesthetic. With the restriction of item numbers to only women with labial protrusion of greater than 8cm, getting Medicare assistance (an item number) will become almost impossible. At this stage, we cannot offer to perform this procedure under sedation and local anaesthetic in the rooms, although this would be perfectly feasible and safe.
The other change in our processes is that we are likely to be performing more upper blepharoplasties under sedation and local anaesthetic in the rooms, without seeking an item number or Medicare rebate. It is likely to cost patients more in the long run to document their visual field defects and improvements than they will receive back from Medicare for their procedure.
These item numbers will have an impact on anyone who has a procedure after the 1st November 2018. If you have a procedure booked for after 1st November 2018, please contact Elise (patients@drgavinsandercoe.com.au) to discuss if these changes will impact on your costs.