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NEW AGE MODIFIER - 25012

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In November, the age modifier 25015 was adjusted to allow its use for patients less than 4 years or 75 years or over. However, owing to problems in the interpretation of the description, claims for patients aged between 3 and 4 years have been rejected. To manage this, Medicare has introduced a new item, 25012, specifically to cover patients between 3 and 4 years. Eligibility for the new item has been backdated to 1 November 2019.

 

We have released an updated AA items file to include this new item, and a new program update to manage the automatic insertion of the correct age modifier.

 

•         AA will automatically insert either item 25015 or 25012 depending on the patient’s age at the time of the operation.

•         Patients aged less than 3 should use the 25015 modifier, and those aged 3 years and less than 4 years should use 25012.

•         AA will not change existing accounts, unless items are added or removed.

•         To update the modifier for an existing account, re-enter the DOB or operation date, or select the age modifier from the Mods list on the Items page.

•         The Medicare fee for item 25012 is the same as for 25015 - $20.10, or 1 RVG unit.

•         At present, health fund fees for the new item are unknown, so AA will use the same fee as the fund’s 25015 item fee.

•         The ASA has not yet released details of their new RVG schedule, so at present, AA will use the standard criteria of less than 4 years for the age modifier.

•         WAG fees, effective from 1 December, will use the <4 yrs criteria for 25015, until otherwise notified.

•         We understand that Medicare will pay claims rejected from November. However, we don’t know how this will be managed, especially given that claims for the single item 25012 are likely to be rejected if transmitted electronically.

•         For older patients, item 25015 is applicable to patients aged 75 and over for MBS and WAG, and 70 and over for ASA RVG.

 

Medicare has provided a fact sheet on the changes on the MBS Online website.

 

It is possible that the new item will be revised in May 2020 once Medicare has reviewed the issues.

 

There have been a small number of other changes made to AA version 9.4, as described in the What’s New webpage.

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HEALTH FUND FEE UPDATES

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HCF

HCF has provided a new fee schedule effective on 1 January 2020 which has now been incorporated into AA. This includes decreases in fees for quite a few items, including anaesthetic items, as described below on the HCF website.

 

"Please note – A review of the HCF Medicover rates has been conducted. To ensure we continue to provide value for our members and support affordability and sustainability into the forward years, some procedures across the specialty categories of anaesthetics, orthopaedic, diagnostic procedures and ophthalmology have been reduced.

These changes will be effective from 1 January 2020."

 

ADF

There still is no update from BUPA regarding ADF fees from November 2019. See https://www.bupa.com.au/campaigns/adf-hsc-provider-signup#s-fees.