Case descriptions
Agreement entered into between Director and person under review
Dr U
General practitioner
New South Wales
Medicare Australia had concerns about Dr U’s level C consultations and skin excision items. Dr U worked exclusively in skin cancer medicine. Medicare Australia statistics showed that Dr U was in the 99th percentile for item 30192, and his ratio of level B and C consultations was different from his peers. He was in the 98th percentile for item 30202 and in the 99th percentile for item 30203.38 Dr U frequently billed consultations with procedures during the review period.
Dr U’s records were examined. The Director had no major concerns over MBS items 23, 30192, 30196, 30202, 30203, 31230, 31260, 31270 and 31290;39 however, 40 per cent of Dr U’s item 36 services did not meet the standard for adequate record, as there was not sufficient detail or complexity to justify the item. As well, many of the lesions Dr U treated, and for which he claimed against MBS item 31275,40 were less than the 20 mm required by that item descriptor.
Dr U’s skin flap services raised major concerns. Some skin flaps were not performed in the area specified by the MBS item descriptor, and many were not generous enough when sutured in position. There was also no evidence of adhesive strips being used while sutures were in position, and no evidence of a pressure dressing to decrease swelling. Dr U had provided colour photographs of the lesions before excision, the skin markings for the use of a flap and the short- and longer-term results. A plastic surgeon reviewed these photographs and clinical notes and was very critical of the way Dr U had used skin flaps; many of Dr U’s flaps resulted in wound breakdown, as the flap was often not large enough to avoid undue tension in the suture line. The photographs revealed very poor long-term cosmetic results.
In his meeting with the Director, Dr U stated that he had changed his practice since the review to address Medicare Australia’s concerns. He had started to use light therapy for extensive lesions in place of skin flaps and no longer charged for double flaps. He stated he was now making more detailed notes. At a second meeting with Dr U, he explained that he was documenting management plans and had started using scales in all photos of lesions to ensure the lesions were the right size for the item number claimed. Dr U acknowledged the Director’s criticisms where skin flaps were concerned.
The Director decided that a negotiated agreement would be the most appropriate way to resolve the matter. Dr U agreed to be reprimanded by the Director, to repay $15,000 in Medicare benefits and to be disqualified from provision of items 45200 and 45206 for 18 months.
- 38 MBS items 30192, 30202 and 30203 relate to skin lesions treated by non-surgical means
- 39 MBS item 31290 is excision of basal cell or squamous cell carcinoma more than 20 mm
- 40 MBS item 31275 is excision of basal cell or squamous cell carcinoma from skin of face, neck or lower leg of more than 20 mm in diameter