MBS reviews have identified rapid increases in vitamin B12, folate and vitamin D testing over the last decade.1-3 During the period 2003/04 – 2012/13:

  • Item 66602 (serum B12 and red cell folate and, if required, serum folate) increased by 307%.2
  • Item 66599 (serum B12 or red cell folate and, if required, serum folate) more than doubled (119% increase).2
  • Items 66608 and 66609 (vitamin D or D fractions) increased by 3587%.3

MBS item numbers for vitamin B12 testing

Before November 2014, vitamin B12 and folate tests were linked in the same MBS item numbers (66599 and 66602) and could be used singularly or together to find vitamin deficiency. Linking these tests resulted in difficulty identifying which test or tests were being ordered at an individual patient level and may have led to over-ordering. 2

To encourage the quality use of testing under Medicare, vitamin B12 and serum folate are now listed as separate items.2 The following item numbers need to be used when investigating B12 levels.4


Item description


Serum vitamin B12 test (item is subject to rule 25*)


Quantification of vitamin B12 markers such as holotranscobalamin or methylmalonic acid, where initial serum vitamin B12 result is low or equivocal

* Rule 25: For any particular patient, this item is applicable not more than once in a 12-month period

† Check with laboratory pathologist to determine if this test is clinically warranted. Laboratories will perform serum B12 when indicated and when the result is ‘low’ or ‘equivocal’ (ie, not clearly replete and not clearly deficient) the laboratory pathologist can determine if holotranscobalamin or methylmalonic acid is required as a reflex test

Who requires vitamin B12 testing?

The MBS review did not identify any prospective studies that evaluated the clinical indications for vitamin B12 testing.2 However, several guidelines recommend testing vitamin B12 levels to investigate the following clinical indications:

  • initial evaluation of anaemia in chronic kidney disease5
  • initial evaluation of mild cognitive impairment or dementia in elderly patients.6, 7 The incidence of low vitamin B12 levels in Australia appears to increase with age (>65 years)8, 9
  • patients with polyneuropathy10
  • patients with Crohn's disease with macrocytic anaemia or who do not respond to iron treatment11
  • patients with symptoms or signs of macrocytic anaemia11
  • patients with chronic fatigue syndrome or myalgic encephalopathy, if they have already undergone pre-test investigations (such as full blood examinations).12, 13

Guidance on whether other special populations should be tested for B12 deficiency (eg, patients with suspect neuropsychiatric abnormalities) remains unclear.2, 11, 14, 15

MBS item number for folate testing

The following item number needs to be used when investigating folate levels.4


Item description


Serum folate test and, if required, red cell folate test for a patient at risk of folate deficiency, including patients with malabsorption conditions, macrocytic anaemia or coeliac disease

Who requires folate testing?

The MBS review did not identify any prospective trials that evaluate the clinical indications for folate testing.1

With the introduction of mandatory folate fortification of wheat flour for bread-making in Australia, folate deficiency is now very rare.16, 17 However, folate deficiency may still occur in some people because of inadequate nutritional intake caused by poor diet, alcoholism, increased requirements such as in pregnancy and lactation, and impaired absorption and intake, for example, coeliac disease. 18, 19

Folate testing is not required to inform folate supplementation before and during pregnancy. All women should be given folic acid supplements prophylactically (0.5 mg/day, or 5 mg/day if at high risk of having babies with neural tube defects) for 1 month before conception and for the first trimester. 20


MBS item number for vitamin D testing

The MBS review of vitamin D testing noted a substantial increase in the number of claims for vitamin D testing over the past 10 years and concluded that most of these services are being requested for the purposes of screening or testing, rather than follow-up monitoring.3

To encourage the quality use of testing under Medicare, vitamin D testing has been split into two types:3

  • 25-hydroxyvitamin D testing for high-risk patient populations to assess overall vitamin D status and diagnose vitamin D deficiency
  • 1,25-dihydroxyvitamin D testing for patients with hypercalcaemia.

The following item numbers will need to be used when investigating vitamin D levels.4


Item description


25-hydroxyvitamin D, quantification in serum, for the investigation of a patient who:
(a) has signs or symptoms of osteoporosis or osteomalacia; or
(b) has increased alkaline phosphatase and otherwise normal liver function tests; or
(c) has hyperparathyroidism, hypo- or hypercalcaemia, or hypophosphataemia; or
(d) is suffering from malabsorption (for example, because the patient has cystic fibrosis, short bowel syndrome, inflammatory bowel disease or untreated coeliac disease, or has had bariatric surgery); or
(e) has deeply pigmented skin, or chronic and severe lack of sun exposure for cultural, medical, occupational or residential reasons; or
(f) is taking medication known to decrease 25OH-D levels (for example, anticonvulsants); or
(g) has chronic renal failure or is a renal transplant recipient; or
(h) is less than 16 years of age and has signs or symptoms of rickets; or
(i) is an infant whose mother has established vitamin D deficiency; or
(j) is a exclusively breastfed baby and has at least one other risk factor mentioned in a paragraph in this item; or
(k) has a sibling who is less than 16 years of age and has vitamin D deficiency


A test described in item 66833 if rendered by a receiving Approved Pathology Practitioner

(Item is subject to Rule 18*)


1, 25-dihydroxyvitamin D – quantification in serum, if the request for the test is made by, or on advice of, the specialist or consultant physician managing the treatment of the patient


1, 25-dihydroxyvitamin D – quantification in serum, if:
(a) the patient has hypercalcaemia; and
(b) the request for the test is made by a general practitioner managing the treatment of the patient


A test described in item 66835 or 66836 if rendered by a receiving Approved Pathology Practitioner (Item is subject to Rule 18*)

* Rule 18: an arrangement under which Medicare benefits payable in a patient episode for a set of pathology services containing more than three items, ordered by a general practitioner for a non-hospitalised patient, will be equivalent to the sum of the benefits for the three items with the highest Schedule fees.

Who requires vitamin D testing?

Only patients listed in the MBS item descriptors should be tested. Guidelines recommend testing people with signs and symptoms of vitamin D deficiency and populations at high risk of moderate to severe vitamin D deficiency.21, 22

Data from two studies indicate that only 4% of Australians have moderate to severe vitamin D deficiency (serum 25-hydroxyvitamin D levels < 25 nmol/L).23, 24 Use of vitamin D testing for screening in healthy and low-risk populations is not necessary.21, 22



  1. Australian Government Department of Health. MBS reviews Folate Testing Report. February 2014. [DoH] accessed 31 August 2015).
  2. Australian Government Department of Health. MBS reviews, Vitamin\u00a0B12 testing report. February 2014. [DoH] (accessed 31 August 2015).
  3. Australian Government Department of Health. MBS reviews, Vitamin\u00a0D testing report. February 2014. [DoH] (accessed 31 August 2015).
  4. Australian Government Department of Health. Medicare Benefits Schedule: MBS Online 2015. [MBS Online] (accessed 31 August 2015).
  5. Anemia Work Group. Kidney Disease: Improving Global Outcomes KDIGO Clinical Practice Guideline for Anemia in Chronic Kidney Disease. Kidney inter Suppl 2012;2:279\u2013335. [KDIGO] .
  6. Galvin JE, Sadowsky CH, Nincds A. Practical guidelines for the recognition and diagnosis of dementia. J Am Board Fam Med 2012;25:367\u201382. [PubMed] .
  7. Flood VM, Smith WT, Webb KL. Prevalence of low serum folate and vitamin B12 in an older Australian population. Aust N Z J Public Health 2006;30:38\u201341. [PubMed] .
  8. Mirkazemi C, Tenni PC. Vitamin B12 deficiency in Australian residential aged care facilities. J Nutr Health Aging 2012;16:277\u201380. [PubMed] .
  9. England JD, Gronseth GS, Franklin G. Practice parameter: the evaluation of distal symmetric polyneuropathy: the role of laboratory and genetic testing (an evidence-based review). Report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine,\r\n and the American Academy of Physical Medicine and Rehabilitation. PM R 2009;1:5\u201313. [PubMed] .
  10. Health Quality Ontario. Appropriateness Phase 1 OHTAC Recommendations: Annual Health Exams, Aspartate Aminotransferase Testing, Chloride Testing, Creatine Kinase Testing, Ferritin Testing, Folate Testing, and Vitamin\u00a0B12 Testing. July 2013. [Health Quality Ontario] .
  11. Willis CD, Metz MP. Vitamin B12 and folate tests: the ongoing need to determine appropriate use and public funding. Med J Aust 2013;198:586\u20138. [PubMed] .
  12. Turnbull N, Shaw EJ, Baker R. Chronic fatigue syndrome/myalgic encephalomyelitis (or encephalopathy): diagnosis and management in adults and children. London: Royal College of General Practitioners, 2007. [NCBI] .
  13. Smellie WS, McNulty CA. Best practice in primary care pathology: review 1. J Clin Pathol 2005;58:1016\u201324. .
  14. British Columbia Medical Association. Cobalamin (vitamin\u00a0B12 ) Deficiency \u2013 Investigation &amp; Management. May 2013 [BC Guidelines] (accessed 22 September 2014).
  15. Brown RD, Langshaw MR, Uhr EJ. The impact of mandatory fortification of flour with folic acid on the blood folate levels of an Australian population. Med J Aust 2011;194:65\u20137. [PubMed] .
  16. Food Standards Australia New Zealand. Mandatory Folic Acid Fortification User Guide. 2009.\u00a0 Food Standards Australia New Zealand .
  17. Schrier SL. UpToDate: Diagnosis and treatment of vitamin\u00a0B12 and folate deficiency. 2014.\u00a0 UpToDate (accessed 20 September 2014).
  18. Farrell CJ, Kirsch SH. Red cell or serum folate: what to do in clinical practice? Clin Chem Lab Med 2013;51:555\u201369. [PubMed] .
  19. Tucker KL, Mahnken B. Folic acid fortification of the food supply. Potential benefits and risks for the elderly population. JAMA 1996;276:1879\u201385. [PubMed] .
  20. The Royal College of Pathologists of Australasia. Use and interpretation of vitamin\u00a0D testing. 2013 [Australian Institute of Medical Scientists] (accessed 31 August 2015).
  21. The Royal Australian College of General Practitioners. RACGP Red Book 8th Edition. 2012. [RACGP Red Book] (accessed 31 August 2015).
  22. Daly RM, Gagnon C, Lu ZX. Prevalence of vitamin D deficiency and its determinants in Australian adults aged 25 years and older: a national, population-based study. Clin Endocrinol (Oxf) 2012;77:26\u201335. [PubMed] .
  23. Boyages S, Bilinski K. Seasonal reduction in vitamin D level persists into spring in NSW Australia: implications for monitoring and replacement therapy. Clin Endocrinol (Oxf) 2012;77:515\u201323. [PubMed] .