MBS item number changes for colonoscopy – what it means for GPs and their patients

Nov 05, 2021

As GPs, you are frequently involved in referring patients for colonoscopy for cancer screening and surveillance, and to further investigate GI symptoms. In Australia, there have been significant changes in the provision of colonoscopy with major implications for your referral patterns and patient’s expectations. These changes have not been well communicated to referrers, resulting in significant confusion.

Historically, providers of colonoscopy (e.g. gastroenterologists, surgeons) could access an MBS item number for colonoscopy with unrestricted frequency and for any indication. An MBS item number is required for Medicare and health funds to reimburse providers for all medical services.

As of 1 November 2019, the two previous item numbers for colonoscopy were replaced by 20 new MBS items that delineate the indications for initial colonoscopy and ensure appropriate surveillance intervals for patients at increased risk of developing colorectal cancer. According to the Department of Health, these changes are intended to “address significant national variation in per capita use of colonoscopy that cannot be explained by clinical or patient demographic factors” (i.e. non-evidence based over-servicing by providers). These changes were made based on recommendations of the Medicare Benefits Schedule Review Taskforce.

Most new item numbers are restricted by indication, and are strictly limited in the frequency with which each can be claimed. The two major implications of these changes are:

1. Colon cancer screening via colonoscopy in those with a family history of colon cancer can only be used in those patients considered at moderately increased or high risk
2. Polyp surveillance colonoscopy frequency is restricted to intervals determined by evidence-based risk assessment derived from the patient’s previous two colonoscopies

Colon cancer screening implications

• Screening via colonoscopy can only be used in those with a significant family history of colon cancer, such as:
  • One first degree relative diagnosed aged < 55 years
  • Two first degree relatives on same side of family (any age of diagnosis)
  • One first degree relative and one second degree relative on same side of family (any age of diagnosis)
• Screening of patients with a family history outside of these criteria (e.g. parent with colon cancer diagnosed > 55 years, one grandparent with colon cancer) will need to be performed via FOBT, NOT COLONOSCOPY

More detailed assessment of familial risk and associated Australian evidence-based screening recommendations can be derived from the tables (Fig 1, Fig 2 Reference: Revised Australian national guidelines for colorectal cancer screening. Med J Aust. 2018; 209 (10) ).

Figure 1

Figure 2

Polyp surveillance implications

The new item numbers consider the number, type and size of polyps resected at the previous two colonoscopies only.

The decision regarding surveillance interval can be complex, particularly when both adenomatous and serrated-type lesions co-exist in the one patient. Detailed guidance directing intervals are derived from Cancer Council Australia Surveillance Colonoscopy Guidelines Working Party. Clinical Practice Guidelines for Surveillance Colonoscopy

As an example of surveillance interval decisions for patients with adenomas on index colonoscopy:

• 12 month interval – Can only be used if:
  • More than ten adenomas are removed
  • More than five adenoma with one >10mm or high-risk
  • 3 year interval – Can only be used if:
  • Between five and nine adenomas are removed
  • >10mm adenoma is removed
  • High-risk adenoma is removed (i.e. adenoma with high grade dysplasia, tubulovillous adenoma)
• 5 year interval – Can be used if less than five adenomas are removed and none are high-risk or >10mm

One important outcome of these changes is:

• Repeat surveillance colonoscopy cannot be performed if colonoscopy shows no neoplastic polyps (with a few caveats), and FOBT would be the means of monitoring in such cases

What has not changed?

In the following situations, patients are still able to access colonoscopy in an unrestricted fashion:

• Positive FOBT
• Any symptoms of concern

Provision of gastroscopy is not affected by these changes.

What you can do as a GP to optimise outcomes for your patients requiring colonoscopy

The new evidence-based restrictions on colonoscopy are valid and will reduce over-servicing and unnecessary colonoscopies. It is important to recognise that the changes are predicated on provision of high-quality colonoscopies, performed by well-credentialed proceduralists with high adenoma detection rates. In choosing which specialist you refer patients to for colonoscopy under this new paradigm, now more than ever, competency and quality are of utmost importance.

Dr David Swartz 

DSA Gastroenterology
27 Captain Cook Drive
Barrack Heights NSW 2528

P: 02 4296 9044
F: 02 4296 2235

W: www.dsagastro.com.au
E: admin@dsagastro.com.au