Understanding Medicare item numbers
It can be confusing to see a bill full of Medicare item numbers. Here are some of the common ones you’ll come across, if you are receiving regular eye injections or laser treatment for macular disease.
Medicare item 104 – Initial consultation
This item applies when you first visit an ophthalmologist for a specific condition.
Medicare item 105 – Subsequent consultation
This item applies for ongoing consultations. Please note, there is no longer a Medicare rebate for item 105 if you are receiving a procedure, such as an eye injection or laser, on the same day.
Medicare item 11215 (one eye): Fundus fluorescein angiography
Fundus fluorescein angiography is also known as an angiogram or FFA. It is retinal imaging to check for bleeding or leakage under the retina. It may be required before you first start injections in order to qualify for Pharmaceutical Benefits Scheme (PBS) reimbursement of the drug that is used to treat the bleeding or leakage. It may also be done to check for new leakage.
Medicare item 11218 (two eyes): Fundus fluorescein angiography
As above, but for two eyes.
Medicare item 11219: Optical coherence tomography (OCT)
An OCT scan shows the cross-sectional layers of the retina and is initially performed to confirm a diagnosis. OCT scans will also typically be undertaken on a regular basis while on a course of injections to monitor response to treatment.
One OCT scan per year may be reimbursed by Medicare, but only when the scan is performed by an ophthalmologist for an initial diagnosis to confirm eligibility for PBS-funded eye injections.
OCT scans for ongoing monitoring of disease are not currently reimbursed by Medicare. MDFA is continually advocating for reimbursement to be expanded to include ongoing monitoring.
Medicare item 42738: Intravitreal injection
Medicare item 42739: Intravitreal injection with sedation/anaesthetic
Either of these two Medicare items may be used for the injection procedure, depending on whether or not sedation or general anaesthetic is used, where an anaesthetist is present. These items may also appear on your bill as “Paracentesis” or “Injection”.
Medicare item 42809: Retina photocoagulation
This is commonly referred to as laser treatment.