Referral Guidelines

1 service only in a period of 24 consecutive months

• prolonged glucocorticoid therapy;
• conditions associated with excess glucocorticoid secretion;
• male hypogonadism; or
• female hypogonadism lasting more than 6 months before the age of 45.

1 service only in a period of 12 consecutive months

• primary hyperparathyroidism;
• chronic liver disease;
• chronic renal disease;
• proven malabsorptive disorders;
• rheumatoid arthritis; or
• conditions associated with thyroxine excess.

1 service only in a period of 24 consecutive months

• established low bone mineral density; or
• the confirmation of a presumptive diagnosis of low bone mineral density made on the basis of 1 or more fractures occurring after minimal trauma.

1 service only in a period of 12 consecutive months

• unexplained seizure
• unexplained chronic headache with suspected intracranial pathology

• cervical radiculopathy

• cervical spine trauma

• inability to extend the knee suggesting the possibility of acute meniscal tear or;
• clinical findings suggesting acute anterior cruciate ligament tear

Head

Head and neck vessels

Head and cervical spine

Spine – one region or two contiguous regions

Spine – three contiguous regions or two non-contiguous regions

Cervical spine and brachial plexus

Musculoskeletal (MSK) system

Cardiovascular system MRA

Paediatric (<16)

Body scan – both breasts

• a dedicated breast coil is used; and
• the woman has had an abnormality detected as a result of a service described in item 63464 performed in the previous 12 months

(1 per year)

Body scan – one or both breast

• a dedicated breast coil is used; and
• the request for the scan identifies that the patient:
  • has or is suspected of having a silicone breast implant manufactured by Poly Implant Prosthese (PIP); and
  • presents with symptoms where implant rupture is suspected; and
  • the result of the scan confirms a loss of integrity of the implant (R)

• a dedicated breast coil is used; and
• the request for the scan identifies that the patient:
  • has or is suspected of having a silicone breast implant manufactured by Poly Implant Prosthese (PIP); and
  • presents with symptoms where implant rupture is suspected; and
  • the result of the scan does not demonstrate a loss of integrity of the implant (R)

Pelvis and upper abdomen

• a histological diagnosis of carcinoma of the cervix has been made and
• the patient has been diagnosed with cervical cancer at FIGO stage 1B or greater

(1 in a lifetime)

(1 in a lifetime)

• a phased array body coil is used, and
• the request for scan identifies that the indication is for the initial staging of rectal cancer (including cancer of the rectosigmoid and anorectum).

(1 in a lifetime)

Body – pancreas and biliary tree MRCP

Pelvis and upper abdomen – for specified conditions (Crohn’s Disease)

• Evaluation of disease extent at time of initial diagnosis of Crohn’s disease
• Evaluation of exacerbation/suspected complications of known Crohn’s disease
• Evaluation of known or suspected Crohn’s disease in pregnancy
• Assessment of change to therapy in patients with small bowel Crohn’s disease

Assessment of change to therapy can only be claimed once in a 12 month period.

• Evaluation of pelvic sepsis and fistulas associated with established or suspected Crohn’s disease
• Assessment of change to therapy of pelvis sepsis and fistulas from Crohn’s disease

Assessment of change to therapy can only be claimed once in a 12 month period.

Where there is a reason to suspect the presence of malignancy because of:

• the past occurrence of breast malignancy in the patient or members of the patient’s family (blood relative); or
• symptoms or indications of malignancy found on an examination of the patient by a medical practitioner

Symptoms or indications of malignancy include: localised mass, localised lumps, localised pain, localised tenderness.

For previous history of malignancy in patient or family member please provide relevant history.

The following criteria will NOT attract a Medicare rebate: screening, cyst, generalised tenderness or pain, previous benign lump, lumpy breasts, non-specific follow up, or no clinical indication.

It is helpful to include any relevant clinical information such as past history of breast surgery, breast reduction or augmentation and specific information relating to the area of interest, including the side, size and location within the breast.

Where there is reason to suspect the presence of malignancy because of:

• the past occurrence of breast malignancy in the patient or members of the patient’s family; or
• symptoms or indications of malignancy found on an examination of the patient by a medical practitioner.

Symptoms or indications of malignancy include: localised mass, localised lumps, localised pain, localised tenderness.

For previous history of malignancy in patient or family member please provide relevant history.

The following criteria will NOT attract a Medicare rebate: screening, cyst, generalised tenderness or pain, previous benign lump, lumpy breasts, non-specific follow up, or no clinical indication.

It is helpful to include any relevant clinical information such as past history of breast surgery, breast reduction or augmentation and specific information relating to the area of interest, including the side, size and location within the breast.

The pregnancy is dated at less than 12 weeks gestation and one or more of the following conditions are present:

• hyperemesis gravidarum;
• diabetes mellitus;
• hypertension;
• toxaemia of pregnancy;
• liver or renal disease;
• autoimmune disease;
• cardiac disease;
• alloimmunisation;
• maternal infection;
• inflammatory bowel disease;
• bowel stoma;
• abdominal wall scarring;
• previous spinal or pelvic trauma or disease;
• drug dependency;
• thrombophilia;
• significant maternal obesity;
• advanced maternal age;
• abdominal pain or mass;
• uncertain dates;
• high risk pregnancy;
• previous post dates delivery;
• previous caesarean section;
• poor obstetric history;
• suspicion of ectopic pregnancy;
• risk of miscarriage;
• diminished symptoms of pregnancy;
• suspected or known cervical incompetence;
• suspected or known uterine abnormality;
• pregnancy after assisted reproduction;
• risk of fetal abnormality.

The pregnancy (as confirmed by ultrasound) is dated by a crown rump length of 45 to 84mm; and nuchal translucency measurement is performed to assess the risk of fetal abnormality; and one or more of the following conditions are present:

• hyperemesis gravidarum;
• diabetes mellitus;
• hypertension;
• toxaemia of pregnancy;
• liver or renal disease;
• autoimmune disease;
• cardiac disease;
• alloimmunisation;
• maternal infection;
• inflammatory bowel disease;
• bowel stoma;
• abdominal wall scarring;
• previous spinal or pelvic trauma or disease;
• drug dependency;
• thrombophilia;
• significant maternal obesity;
• advanced maternal age;
• abdominal pain or mass;
• uncertain dates;
• high risk pregnancy;
• previous post dates delivery;
• previous caesarean section;
• poor obstetric history;
• suspicion of ectopic pregnancy;
• risk of miscarriage;
• diminished symptoms of pregnancy;
• suspected or known cervical incompetence;
• suspected or known uterine abnormality;
• pregnancy after assisted reproduction;
• risk of fetal abnormality.

PELVIS or ABDOMEN dating of the pregnancy (by ultrasound) is 12 – 16 weeks and one or more of the following conditions are present:

• hyperemesis gravidarum;
• diabetes mellitus;
• hypertension;
• toxaemia of pregnancy;
• liver or renal disease;
• autoimmune disease;
• cardiac disease;
• alloimmunisation;
• maternal infection;
• inflammatory bowel disease;
• bowel stoma;
• abdominal wall scarring;
• previous spinal or pelvic trauma or disease;
• drug dependency;
• thrombophilia;
• significant maternal obesity;
• advanced maternal age;
• abdominal pain or mass;
• uncertain dates;
• high risk pregnancy;
• previous post dates delivery;
• previous caesarean section;
• poor obstetric history;
• suspicion of ectopic pregnancy;
• risk of miscarriage;
• diminished symptoms of pregnancy;
• suspected or known cervical incompetence;
• suspected or known uterine abnormality;
• pregnancy after assisted reproduction;
• risk of fetal abnormality.

• the patient is referred by a medical practitioner; and
• the dating for the pregnancy (as confirmed by ultrasound) is 17 to 22 weeks of gestation; and
• the service is not associated with a service to which an item in Subgroup 2 or 3 of this group applies; and
• the referring practitioner is not a member of a group of practitioners of which the providing practitioner is a member; and
• the service is not performed in the same pregnancy as item 55709.

PELVIS or ABDOMEN, pregnancy related or pregnancy complication, fetal development and anatomy, ultrasound scan of, by any or all approaches, with measurement of all parameters for dating purposes, where:

• the patient is referred by a medical practitioner who is a Member or a Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists or who has a Diploma of Obstetrics or has a qualification recognised by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists as being equivalent to a Diploma of Obstetrics or has obstetric privileges at a non-metropolitan hospital; and
• the dating of the pregnancy (as confirmed by ultrasound) is 17 to 22 weeks of gestation; and
• the service is not associated with a service to which an item in Subgroup 2 or 3 of this group applies; and
• the referring practitioner is not a member of a group of practitioners of which the providing practitioner is a member; and
• further examination is clinically indicated in the same pregnancy to which item 55706 applies.

• the patient is referred by a medical practitioner; and
• the dating of the pregnancy (as confirmed by ultrasound) is after 22 weeks of gestation; and
• the service is not associated with a service to which an item in Subgroup 2 or 3 of this group applies; and
• the referring practitioner is not a member of a group of practitioners of which the providing practitioner is a member; and
• the service is not performed in the same pregnancy as item 55723; and
• one or more of the following conditions are present:
  • known or suspected fetal abnormality or fetal cardiac arrhythmia;
  • fetal anatomy (late booking or incomplete mid-trimester scan);
  • malpresentation;
  • cervical assessment;
  • clinical suspicion of amniotic fluid abnormality;
  • clinical suspicion of placental or umbilical cord abnormality;
  • previous complicated delivery;
  • uterine scar assessment;
  • uterine fibroid;
  • previous fetal death in utero or neonatal death;
  • antepartum haemorrhage;
  • clinical suspicion of intrauterine growth retardation;
  • clinical suspicion of macrosomia;
  • reduced fetal movements;
  • suspected fetal death;
  • abnormal cardiotocography;
  • prolonged pregnancy;
  • premature labour;
  • fetal infection;
  • pregnancy after assisted reproduction;
  • trauma;
  • diabetes mellitus;
  • hypertension;
  • toxaemia of pregnancy;
  • liver or renal disease;
  • autoimmune disease;
  • cardiac disease;
  • alloimmunisation;
  • maternal infection;
  • inflammatory bowel disease;
  • bowel stoma;
  • abdominal wall scarring;
  • previous spinal or pelvic trauma or disease;
  • drug dependency;
  • thrombophilia;
  • significant maternal obesity;
  • advanced maternal age;
  • abdominal pain or mass.

PELVIS or ABDOMEN, pregnancy related or pregnancy complication, fetal development and anatomy, ultrasound scan of by any or all approaches, where:

• the patient is referred by a medical practitioner who is a Member or a Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists or who has a Diploma of Obstetrics or has qualifications recognised by the Royal Australian and New Zealand College of Obstericians and Gynaecologists as being equivalent to a Diploma of obstetrics or has obstetric privileges at a non-metropolitan hospital; and
• the dating of the pregnancy (as confirmed by ultrasound) is after 22 weeks of gestation; and
• the service is not associated with a service to which an item in Subgroup 2 or 3 of this group applies; and
• the referring practitioner is not a member of a group of practitioners of which the providing practitioner is a member; and
• further examination is clinically indicated in the same pregnancy to which item 55718 applies.

• the patient is referred by a medical practitioner; and
• ultrasound of the same pregnancy confirms a multiple pregnancy; and
• the dating of the pregnancy (as confirmed by ultrasound) is 17 to 22 weeks gestation; and
• the service is not associated with a service to which an item in Subgroup 2 or 3 of this group applies; and
• the referring practitioner is not a member of a group of practitioners to which the providing practitioner is a member; and
• the service is not performed in conjunction with item 55706 or 55712 during the same pregnancy.

PELVIS or ABDOMEN, pregnancy related or pregnancy complication, fetal development and anatomy, ultrasound scan of, by any or all approaches, with measurement of all parameters for dating purposes, where:

the patient is referred by a medical practitioner who is a Member or Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists or who has a Diploma of Obstetrics or has a qualification recognised by the Royal Australian and New Zealand College of Obstericians and Gynaecologists as equivalent to a Diploma of obstetrics or has obstetric privileges at a non-metropolitan hospital; and

• ultrasound of the same pregnancy confirms a multiple pregnancy; and
• the dating of the pregnancy (as confirmed by ultrasound) is 17 to 22 weeks gestation; and
• the service is not associated with a service to which an item in Subgroup 2 or 3 of this group applies; and
• the referring practitioner is not a member of a group of practitioners to which the providing practitioner is a member; and
• further examination is clinically indicated in the same pregnancy to which item 55759 has been performed; and
• not performed in conjunction with item 55706 or 55712 during the same pregnancy.

• dating of the pregnancy (as confirmed by ultrasound) is after 22 weeks of gestation; and
• the ultrasound confirms a multiple pregnancy; and
• the patient is referred by a medical practitioner; and
• the service is not performed in the same pregnancy as item 55770; and
• the service is not associated with a service to which an item in Subgroups 2 or 3 of this group applies; and
• the referring practitioner is not a member of a group of practitioners of which the providing practitioner is a member; and
• the service is not performed in conjunction with item 55718 or 55721 during the same pregnancy.

PELVIS or ABDOMEN, pregnancy related or pregnancy complication, fetal development and anatomy, ultrasound scan of, by any or all approaches, where:

• dating of the pregnancy as confirmed by ultrasound is after 22 weeks of gestation; and
• the patient is referred by a medical practitioner who is a Member or Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists or who has a Diploma of Obstetrics or has a qualification recognised by the Royal Australian and New Zealand College of Obstericians and Gynaecologists as equivalent to a Diploma of obstetrics or has obstetric privileges at a non-metropolitan hospital; and
• further examination is clinically indicated in the same pregnancy to which item 55768 or 55770 has been performed; and
• the pregnancy as confirmed by ultrasound is a multiple pregnancy; and
• the service is not associated with a service to which an item in Subgroups 2 or 3 of this group applies; and
• the referring practitioner is not a member of a group of practitioners of which the providing practitioner is a member; and
• the service is not performed in conjunction with item 55718 or 55721 during the same pregnancy.

Where the service is provided, for the assessment of one or more of the following conditions or suspected conditions:

• evaluation of injury to tendon, muscle or muscle/tendon junction; or
• rotator cuff tear/calcification/tendinosis (biceps, subscapular, suspraspinatus, infraspinatus); or
• biceps subluxation; or
• capsulitis and bursitis; or
• evaluation of mass including ganglion; or
• occult fracture; or
• acromioclavicular joint pathology.

Benefits are not payable when referred for non-specific pain alone.

Where the service is provided for the assessment of one or more of the following conditions or suspected conditions:

• abnormality of tendons or bursae about the knee; or
• meniscal cyst, popliteal fossa cyst, mass or pseudomass; or
• nerve entrapment, nerve or nerve sheath tumour; or
• injury of collateral ligaments.

Benefits are not payable when referred for non-specific pain alone and including meniscal or cruciate ligament tears and assessment of chondral surfaces.