The MBS, the ECG, and the GP

AS part of its review of cardiac imaging services, the Australian Government Department of Health has introduced changes to item numbers in the Medicare Benefits Schedule (MBS) for electrocardiography (ECG), echocardiography, and myocardial perfusion studies, effective from 1 August 2020. I believe they have made a mistake.

There are 29 new items; 18 items have been deleted. The changes will affect patients in regard to access and referral for these services. The changes will affect providers, including consultant physicians, specialists and GPs. The focus for this article is the effects of the changes for GPs.

For clarification, although the Medical Board of Australia describes vocationally registered GPs as specialists, the MBS uses the term “specialist” exclusively to describe non-GP specialists.

The changes, according to the MBS, are intended “to support high-value care and ensure patients have access to the most appropriate tests for their individual symptoms and conditions”, and “to encourage best practice and improve patient outcomes”.

Previous item numbers

Before 1 August, when a GP recorded and reported an ECG trace in their clinic, the patient was eligible for a Medicare benefit for item 11700 ($27.45). If a GP only recorded an ECG trace in their clinic, with no report, the patient was eligible for a Medicare benefit for item 11702 ($13.65). In practice, it would be unusual for a GP not to provide a report on an ECG trace that has been recorded in their clinic. However, a GP could refer the patient’s ECG trace to another medical practitioner for a report, and the patient was eligible for a Medicare benefit for this service under item 11701 ($13.65).

These items – 11700, 11701 and 11702 – were deleted on 1 August 2020.

New item numbers

The new item number for GPs’ ECGs is 11707 (12-lead electrocardiography, tracing only). The Medicare benefit for item 11707 is $16.15. The descriptor indicates that item 11707 is for an ECG to produce a trace only, with the following requirements:

• the ECG is necessary for clinical decision making;
• the ECG does not need to be fully interpreted or reported on;
• the ECG must be reviewed in a clinically appropriate time frame to identify potentially serious or life-threatening abnormalities;
• the maximum number of times that this item can be used in one day is two.

The first requirement seems superfluous, as in general practice, an ECG will influence clinical decision making in any context. Presumably, this requirement has been stipulated to counter the use of the so-called routine ECG. It is not clear if pre-anaesthetic ECGs will be eligible under this item number. This is particularly relevant for rural GPs.

The second requirement implies that full interpretation and a full report are optional but not necessary. The Medicare benefit is the same, whether the GP provides a full interpretation and full report or not.

The third requirement does not state if the ECG must be reviewed by the GP who arranged the trace, or if the ECG trace must be sent to a consultant physician or specialist for review.

The fourth requirement is not practical in the context of serial ECGs (more than two), which are required in the assessment and management of suspected or confirmed acute coronary syndrome and in the assessment and management of acute arrhythmia. The item 11707 does not apply if the patient is admitted to hospital. This is relevant for rural GPs.

In practice, when a patient has an ECG trace recorded in a GP’s clinic, the GP will review the ECG trace as soon as it has been recorded. This review will identify “potentially serious or life-threatening abnormalities”, such as myocardial infarction, ischaemia and arrhythmia. This review could also be considered to constitute a full interpretation and report.

What is the definition of a full report for an ECG? The explanatory notes in the MBS describe a formal report as follows:

The formal report is separate to any letter and entails interpretation of the trace commenting on the significance of the trace findings and their relationship to clinical decision making for the patient in their clinical context, in addition to any measurements taken or automatically generated.

Most ECG machines and ECG recording devices connected to computers produce a computer algorithm-generated report, with rate, rhythm, axis, PR interval, QRS duration, QTc duration, chest lead voltages, identification of acute ischaemic changes (ST elevation/depression, T inversion, Q waves), and an interpretative summary. In conjunction with the GP’s analysis and interpretation of the trace, and the patient’s clinical context, the computer-generated report provides decision support for a full report.

I contend that, in practice, a GP provides a formal report when the GP reviews the ECG trace with the patient. In a sense, Medicare is getting an ECG report for free.

To meet the criteria for 11707, a GP is expected to review the ECG, so the descriptor is a misnomer, as the service is “trace and review”, not “trace only”. However, if a GP reviews the ECG, the patient is not eligible for a Medicare benefit for the report.

Items 11704, 11705 and 11714

GPs have three options for referral for ECG:

• a GP can refer the patient to a consultant physician or specialist for an ECG trace and formal report — the patient is eligible for a Medicare benefit for this service under item 11704 ($27.45);
• a GP can record the patient’s ECG trace at the GP’s clinic (item 11707), and refer the patient’s ECG trace to a consultant physician or specialist for a report — the patient is eligible for a Medicare benefit for this service under item 11705 ($16.15); and
• a GP can refer the patient to a consultant physician or specialist for the ECG trace and an interpretation or clinical note (not a report) — the patient is eligible for a Medicare benefit for this service under item 11714 ($21.25; by the way, the benefit is listed incorrectly in the Quick Reference Guide as $19.55).

A GP could refer a patient to a dermatologist, an ophthalmologist or any surgical specialist for an ECG trace and interpretation or clinical note. This is an unlikely scenario, but it would be supported by item 11714.

Item 11729 (exercise ECG)

The descriptor for the new item for exercise ECG, 11729, stipulates that in addition to the medical practitioner who is conducting the exercise ECG, there must be “a second person trained in cardiopulmonary resuscitation … at the premise where the testing is performed and is immediately available to respond at the time the exercise test is performed on the patient, if required”. However, the answer to a question about this issue indicates that a “person” is required, not a “medical practitioner”.

Indications for ECG in general practice (“necessary for clinical decision making”)

• Acute
  • chest pain;
  • dyspnoea;
  • palpitations;
  • irregular pulse;
  • pre-syncope and syncope;
  • stroke/transient ischaemic attack (atrial fibrillation?);
  • delirium;
  • unwell patient with diabetes;
  • coronary heart disease;
  • heart failure
• Chronic disease management – monitoring
  • coronary heart disease;
  • diabetes;
  • heart failure;
  • hypertension
• Preventive activities (not recommended in the Red Book (Guidelines for preventive activities in general practice, 9th edition)
  • hypertension;
  • diabetes;
  • smoking;
  • absolute cardiovascular disease risk.

What will these changes to the ECG item numbers mean for general practice?

One can only speculate about the impact of these changes on general practice as a specialty and on GPs.

Many GPs will be offended and annoyed by the implication that they are not competent to read and report an ECG trace, and that they require a specialist or consultant physician for this. GPs are trained to interpret ECGs through medical school and through vocational training in general practice.

The lower Medicare benefit for recording an ECG in general practice may be a disincentive to performing ECGs, potentially resulting in one or more of the following:

• fewer ECGs being recorded in general practice;
• access to ECGs being reduced for patients due to
• practices reducing or ceasing the use of ECG;
• increased fees and out-of-pocket costs for patients;
• patients who rely on bulk-billing being unable to afford fees for ECGs that exceed the Medicare benefit (item 11707, $16.15)
• more patients being referred to pathology services or to cardiologists for ECGs;
• more patients being transferred to emergency departments by ambulance;
• more cardiac diagnoses being missed in general practice.

As alternatives to ECGs in general practice, these are suboptimal outcomes for patients, the health budget, safety, and risk management.

What if fewer patients had ECGs recorded and reported in general practice?

If a patient were referred elsewhere for an ECG or an ECG report, there would be a delay in getting the ECG trace and/or the ECG report, so that the consultation with the GP and the ECG report would not be contiguous. This could lead to delays in diagnosis and management.

It would be unsafe to transfer a patient with a possible acute coronary syndrome to a pathology service or to a cardiologist for the purposes of obtaining an ECG. The patient is potentially unstable, and at risk of arrhythmia or cardiac arrest. The waiting room of a pathology service is no substitute for a treatment room in a general practice with a practice nurse and monitoring equipment.

What if GPs continue – and possibly increase – the recording and reporting of ECG traces?

A GP provides a contemporaneous report on the ECG trace in the context of the patient’s clinical presentation. This enables early diagnosis and prompt management, with the potential for better outcomes for the patient and, considering general practice as a whole, the potential for better outcomes for population health.

Examples include:

• reduced myocardial damage in patients presenting with the ECG features of acute coronary syndrome;
• reduced risk of stroke, syncope, and cardiomyopathy in patients presenting with ECG-diagnosed atrial fibrillation;
• recognition of “silent” coronary heart disease or ventricular hypertrophy (eg, in patients with risk factors for cardiovascular disease, in particular, diabetes and hypertension).

A GP can assess the patient, record an ECG trace, report on the ECG trace, and if appropriate, call a cardiologist to discuss the clinical problem. The ECG findings will help to inform the cardiologist’s opinion and advice.

A GP who is not confident with ECG interpretation may record a patient’s ECG trace and then send the ECG trace to a cardiologist for a report. Alternatively, there may be another GP in the practice who can be approached to interpret and report the ECG.

A definitive diagnosis may not be made in general practice, but the ECG can inform a GP’s clinical decision making regarding management, for example, of the following actions:

• monitor in general practice (or in a rural emergency department); this may include repeat ECGs;
• send home and review;
• refer to hospital;
• call triple-0.

Diagnoses may require serial ECGs and urgent investigations (pathology tests, and imaging); these require the patient to be transferred to hospital.

Charging for recording and reporting an ECG trace in general practice

GPs can offset the low Medicare benefit for item 11707 for recording an ECG by charging appropriately for their service, clinical expertise, and time. For example:

• charge a higher ECG item fee to the patient — the patient gets the lower rebate compared with the prior rebate for item 11700, so the patient’s out-of-pocket expenses will be higher than in the pre-11707 era;
• bulk bill the patient for the ECG and for a longer attendance (the attendance includes the time for reporting the ECG and for discussing the report and its significance with the patient);
• do not charge for the ECG and instead charge for a longer attendance that includes the time to record and report the ECG trace and to review the ECG trace with the patient (private fee, or bulk bill for the longer attendance).

Clearly, the total duration of the consultation needs to meet the time indicator for the descriptor for the appropriate Medicare item for that consultation.

Co-claiming MBS item numbers

One or more of the following items may be co-claimed with item 11707:

• 10997
  • practice nurse or First Nations’ health practitioner service;
  • benefit $12.40;
  • for a patient who has a General Practice Management Plan and Team Care Arrangements;
  • up to five services per annum.
• 10987
  • practice nurse or First Nations’ health practitioner service;
  • benefit $24.75;
  • for a First Nations’ patient who has had a health assessment (Medicare item 715);
  • up to 10 services per annum.
• Bulk billing incentive for patients with a concession card (and children under 16)
  • 10990 (metropolitan), benefit $12.95;
  • 10991 (remote, rural, regional [Modified Monash Model 2–7]), benefit $19.60.

The COVID-19 bulk billing incentive payments can only be co-claimed with in-person and telehealth attendances; they cannot be claimed with ECG service item numbers.

In summary

The potential deleterious effects of the Medicare ECG item number changes include:

• fewer ECGs recorded and reported in general practice;
• reduced access to ECGs for patients;
• delayed and missed diagnoses, leading to:
• greater numbers of adverse patient outcomes;
• higher incidence of cardiovascular disease;
• poorer population health
• increased costs for patients due to lower rebates and/or higher fees;
• reduced income for GPs and their practices.

A potential benefit of the Medicare ECG item number changes for Medicare will be a decrease in the benefits paid by Medicare for ECGs in general practice. However, this is myopic. The decrease in costs to Medicare is likely to be more than offset by the increased costs to the health system incurred by delayed and missed diagnoses.

In general practice, GPs should consider:

• continuing to record ECG traces and to report these traces;
• increasing the number of ECGs that they record for acute presentations, chronic disease management, and preventive activities with the aim of better outcomes for patients through early diagnosis and intervention;
• working around the financial constraints imposed by the changes to the MBS ECG item numbers;
• getting the following for their practice, if they don’t have one:
• an ECG machine or computer-connected ECG recording device
• an AED
• upskilling in ECG diagnosis, and not becoming deskilled in the use and interpretation of ECGs

The changes to the Medicare items for ECGs in general practice not only devalue the Medicare rebate for ECG in general practice; the changes also devalue ECGs and GPs.

Missed and delayed diagnoses are inevitable, leading to adverse patient outcomes, and to downstream medical, social, and economic costs.

ECG is an essential diagnostic tool in general practice; its use in general practice should be enhanced and facilitated.

Medicare has made a mistake in implementing these changes to the MBS cardiac service item numbers.  The Royal Australian College of General Practitioners (RACGP), the Australian College of Rural and Remote Medicine (ACRRM), and the Australian Medical Association (AMA) must advocate on behalf of GPs for these changes to be reversed, and for the item numbers to be enhanced in favour of recording and reporting ECGs in general practice.

Dr Andrew Baird is a GP at the Elwood Family Clinic in Victoria. He is a tutor in professional practice for medical students at the University of Melbourne. 

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.