Feedback on 85% Rebate for MBS Item 18379

In 2025, the Department of Health and Aged Care removed the 85% rebate level for several procedural items. This followed a review which deemed certain procedures should be performed only in hospital or a hospital equivalent setting.

USANZ and ANZAUS advocated that the 85% rebate for certain items be reinstated. As part of this process, ANZAUS is seeking Member feedback on Item 18379, as performed outside of a hospital or hospital-equivalent setting. Item 18379 refers to Botulinum Toxin Type A Purified Neurotoxin Complex (Botox), intravesical injection of, with cystoscopy, for the treatment of urinary incontinence.

It is important to clarify that procedures performed in hospital or hospital-equivalent settings, are considered as "Hospital treatment" as defined in Section 121.5 of the Private Health Insurance Act 2007. The specific points to note are:

• Procedures performed at a declared hospital site are generally classed as "Hospital treatment" and therefore can only attract the 75% benefit and not the 85% benefit. This includes services provided to admitted and non-admitted patients in a declared hospital, or in a ‘day-hospital’ section of a declared hospital.
• Procedures performed outside of hospital or hospital-equivalent settings (e.g. in private rooms) are generally not considered as "Hospital treatment" and only the 85% rebate applies (unless formal accreditation as a hospital-equivalent day facility has been granted to the location, in which case the 75% rebate would apply).
• Private rooms located in proximity to a hospital is a grey area, in which the rooms may be considered as either in hospital or not in hospital depending on the specific location of the rooms in relation to the hospital site. Members should check with The Department which rebate to claim depending on their specific circumstance if there is any uncertainty. 
• A facility cannot claim both the 75% and 85% rebate for the same procedure.

For additional information on the 85% rebate, access the Department's Guidance on Claiming 75 / 85 / 100% Benefits Under Medicare.

To provide your feedback, please complete this brief survey, to help inform ANZAUS's response to the Department.