Billing Information

Medicare funding criteria for radiology examinations

The majority of radiology examinations performed at Lake Imaging fall under the Medicare Benefits Schedule (MBS). For a patient to be eligible for a Medicare rebate the doctor’s referral must display:

  • Referrer name, provider number and contact details
  • Examination requested
  • All relevant clinical history

Lake Imaging provides referrers with customised referral pads, at no charge, to assist with the provision of correct documentation. You can order our referral pads online.

The Australian Government has strict criteria for Medicare rebates for a number of radiology procedures. Please use the information below to determine whether Medicare will cover your patient’s radiology test.

Bone Densitometry – DEXA

Bone densitometry items (MBS items 12306 to 12323) are outlined in a ministerial determination and published in the General Medical Services Table, one of several tables of medical services that collectively comprise the Medicare Benefits Schedule.

Currently, Medicare benefits are payable for:

  • Diagnosis and monitoring of bone loss if a patient has certain specific medical conditions, or is undergoing particular treatments likely to cause rapid bone loss
  • Confirmation of clinically suspected low bone mineral density, usually following a fracture
  • Subsequent monitoring of established low bone mineral density, and/or
  • Patients more than 70 years of age

Medicare restricts the time interval between tests to one test every 12 to 24 months depending on the condition, because bone density loss is a slow process. For conditions or particular treatments that might cause more rapid bone loss, a rebate is available for repeat testing at 12 monthly intervals.

Item 12321 allows for bone mineral density measurement following a significant change in therapy, for example a change in the class of drugs rather than for a change in the dosage regime.

Item 12323 enables the payment of a Medicare benefit for a bone densitometry service performed on a patient aged more than 70 years. The Government has decided to expand access to Medicare-subsidised bone mineral density testing to coincide with the expanded eligibility for the osteoporosis medication Alendronate under the Pharmaceutical Benefits Scheme.

An examination under any of these items covers the measurement of two or more sites, and interpretation and provision of a report. Two or more sites must include the lumbar spine and proximal femur. If technical difficulties preclude measurement at these sites, other sites may be measured. Measurement at either forearms or both heels or in combination is excluded from the Medicare benefit.

Referrals

Bone densitometry services are available on the basis of referral by a medical practitioner to a specialist or consultant physician. However, providers of bone densitometry to whom a patient is referred for management may determine that a bone densitometry service is required in line with the provisions of Items 12306, 12309, 12312, 12315, 12318, 12321 and 12323.

Item number

Eligibility rules
12306
  • > Confirmation of a presumptive diagnosis of low bone mineral density made on the basis of one or more fractures following minimal trauma
  • > Monitoring of low bone mineral density proven by bone densitometry at least 12 months previously

Note: one service only during a 24-month period
12312 For the diagnosis and monitoring of bone loss associated with one or more of the following:

  • > Prolonged glucocorticoid therapy
  • > Conditions associated with excess glucocorticoid secretion
  • > Male hypogonadism
  • > Female hypogonadism lasting more than six months less than 45 years’ old
  • > Hysterectomy less than 45 years’ old

Note: one service only during a 12-month period
12315 For the diagnosis and monitoring of bone loss associated with one or more of the following:

  • > Primary hyperparathyroidism
  • > Chronic liver or renal disease
  • > Proven malabsorptive disorders
  • > Rheumatoid arthritis
  • > Conditions associated with thyroxine excess

Note: one service only during a 24-month period
12318
  • > Prolonged glucocorticoid therapy
  • > Conditions associated with excess glucocorticoid secretion
  • > Male hypogonadism
  • > Female hypogonadism lasting more than six months before 45 years’ old
  • > Primary hyperparathyroidism
  • > Chronic liver or renal disease
  • > Proven malabsorptive disorders
  • > Rheumatoid arthritis, or
  • > Conditions associated with thyroxine excess.
12321 For the measurement of bone density 12 months following a significant change in therapy for:

  • > Established low bone mineral density
  • > Confirmation of a presumptive diagnosis of low bone mineral density made on the basis of one or more fractures occurring after minimal trauma

Note: one service only during a 12-month period
12323 For the measurement of bone density in patients more than 70 years old.
1111 Screening bone densitometry, which is not eligible for Medicare rebate

Definitions

Low bone mineral density is present when the bone mineral density falls more than 1.5 standard deviations below the age-matched mean, or more than 2.5 standard deviations below the young normal mean at the same site and in the same gender.

For Items 12312 and 12318

‘Prolonged glucocorticoid therapy’ is defined as the commencement of a dosage of inhaled glucocorticoid equivalent to, or greater than, 800 micrograms beclomethasone dipropionate or budesonide per day, or a supraphysiological glucocorticoid dosage equivalent to or greater than 7.5 mg prednisolone in an adult taken orally per day for a time period that is anticipated to last for 4 months or more. The bone density scan must be during the time of Glucocorticoid therapy. Patients no longer taking steroid medication do not qualify for a Medicare benefit.

For Items 12312 and 12318

  • Male hypogonadism is defined as serum testosterone levels below the age matched normal range, and
  • Female hypogonadism is defined as serum oestrogen levels below the age matched normal range.

For Items 12315 and 12318

A malabsorptive disorder is defined as one or more of the following:

  • Malabsorption of fat, defined as faecal fat estimated at greater than 18 gm per 72 hours on a normal fat diet
  • Bowel disease with presumptive vitamin D malabsorption as indicated by a sub-normal circulating 25-hydroxyvitamin D level, or
  • Histologically proven Coeliac disease.