Medicare changes coming on 1 March

12 February 2021

From 1 March this year, direct GP referrals for overnight diagnostic sleep study items 12203 and 12250 will require a ‘STOP-Bang’ screening score of 3 rather than 4. 

This change was prompted by research from a team from the University of Melbourne and Monash University that included ASA members Garun Hamilton and Chamara Senaratna. 

The paper, published in the Medical Journal of Australia in 2019, tested the effectiveness of OSA screening tools in primary care.

“We found that the sensitivity and specificity of these tests could be adjusted according to specific needs by varying the STOP‐Bang cut‐off score when combined with the Epworth Sleepiness Score of ≥ 8 criterion,” A/Prof. Garun Hamilton said. 

“As outlined in the paper, in patients with an ESS score of 8 or more, reducing the STOP-Bang cut-off score for referral for sleep studies from 4 to 3 would enhance detection of patients with significant OSA (from 30% to 50%) without markedly increasing the number of false positives (from 6% to 8%). These changes improve access to diagnostic sleep testing as they make it easier for patients to qualify for a sleep study, without first needing to see a sleep or respiratory medicine specialist.

“When the new sleep item numbers were introduced following the Medicare Benefits Schedule (MBS) Review, the ASA advocated for using a STOP-Bang cut-off score of 3, however at that stage there was no evidence to support how this performed when used in combination with the ESS. 

“With the publication of this study, we were able to include this new evidence when the item number changes were reviewed by the Department of Health and advocate for a change being made. It’s good to see MBS information now being updated according to the most recent and most relevant scientific research,” Garun Hamilton said.

At the same time, there will be some item number changes affecting thoracic medicine items. Details can be found in the Department of Health factsheet and the more detailed explanatory notes. These changes have been made after consultation with the ASA, TSANZ and ASOHNS.

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