Medicare Benefits Schedule - Item 15922

Megavoltage re‑planning—level 4

Additional dosimetry plan for re‑planning of intracranial stereotactic radiation therapy (SRT) or stereotactic body radiation therapy (SBRT) treatment, if:

(a) an initial treatment plan described in item 15918 or 15920 has been prepared; and

(b) treatment adjustments to the initial plan are inadequate to satisfy treatment protocol requirements

Applicable once per course of treatment

Fee: $3,338.05 Benefit: 75% = $2,503.55 85% = $3,239.35

(See para TN.2.1, TN.2.2 of explanatory notes to this Category)

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Level 1.1 Items (Simple or Single Field)

In items 15902 and 15930: Simple or single-field complexity external beam radiation therapy is localised, planned and delivered through a clinical mark-up process without the requirements of simulation, computer or volumetric dosimetry and beam modulation. Patient stabilisation is simple using standard devices. Determination of the treatment volume is by clinical assessment and mark-up with the prescribed dose identified on the surface or at depth. Single-field delivery via wide margins determined through the clinical assessment process will not require image verification. The final dosimetry plan is validated by a radiation therapist or medical physicist, using quality assurance processes, with the plan approved by the radiation oncologist prior to delivery.

Level 1.2 Items (Two-Dimensional Simple or Multiple Field)

In items 15904 and 15932: Simple or multiple-field complexity external beam radiation therapy is localised through a process of either two-dimensional simulation (single plain film views or CT or digitally reconstructed radiograph delineation) or three-dimensional simulation (plain film views or CT volumetric delineation) to identify the treatment region. Patient stabilisation is simple using standard devices.

Planning is based on two‑dimensional planning processes with simple beam shaping but no modulation or inverse planning requirements, optimisation is not required on organs at risk. Multiple-field delivery via multileaf collimator (MLC) shaped beams requires verification. The final dosimetry plan is validated by a radiation therapist or medical physicist, using quality assurance processes, with the plan approved by the radiation oncologist prior to delivery.

Level 2.1 Items (Three-Dimensional without motion management)

In items 15906 and 15934: Three-dimensional standard or multiple-field complexity external beam radiation therapy is localised through a process of three-dimensional simulation (plain film views or volumetric delineation) to identify the treatment region and organs at risk.

Planning is based on three‑dimensional planning processes with simple beam shaping (multileaf collimators—MLCs) and simple modulation (large-segment field in field, wedges, MLCs or tissue compensation) to deliver a conformal dose distribution and assessment of dose to organs at risk. Multiple-field delivery via MLC shaped beams requires image verification. Examples include three-dimensional planned spine treatments (single or opposed fields) breast tangents without target volumes definition, and image-based planning for electrons. The final dosimetry plan is validated by a radiation therapist or medical physicist, using quality assurance processes, with the plan approved by the radiation oncologist prior to delivery.

Level 2.2 Items (Three-Dimensional with motion management)

In items 15908 and 15936: Three-dimensional complex or multiple-field complexity external beam radiation therapy is localised through a process of three or four-dimensional (three-dimensional volumetric delineation or four-dimensional volumetric delineation with consideration of tumour and organs at risk excursion) simulation to identify the treatment region and organs at risk (including excursion of targets and organs at risk). Patient stabilisation requires the use of devices to support positional reproducibility. Motion management includes four-dimensional CT, deep inspiration breath hold, deep expiration breath hold, use of manual compression and other methods that account for tumour movement.

Planning is based on three or four-dimensional planning processes with complex beam shaping (multileaf collimators—MLCs) and modulation (MLC or small-segment field in field) to deliver a conformal dose distribution and assessment and management of dose to organs at risk. Multiple-field delivery via MLC shaped beams requires daily image verification prior to treatment delivery. Consideration for re-planning is not required. The final dosimetry plan is validated by a radiation therapist or medical physicist, using quality assurance processes, with the plan approved by the radiation oncologist prior to delivery.

Level 3.1 Items (Standard IMRT Multiple Field)

In items 15910 and 15938: Standard inverse planned intensity modulated radiation therapy (IMRT) to a single dose level prescription and without motion management is localised through a three-dimensional (CT volumetric delineation) simulation to identify clinical and planning targets, organs at risk and normal tissue.

Planning is based on delivery to a single-dose level target and includes optimisation of the dose based on assessment of organs at risk doses. This technique involves very sharp dose gradients adjacent to both targets and organs at risk of increasing the consequences of any geometric uncertainty, making daily treatment image verification (Image-guided radiation therapy—IGRT) an essential component of quality IMRT. It is the tumour location, adjacent organs and dosimetry that define the appropriate role for IMRT, and support an approach where the clinical circumstances rather than specific diagnoses are the most important determinants for using IMRT. Final dosimetry plan is validated by both the radiation therapist and medical physicist, using quality assurance processes, with the plan approved by the radiation oncologist prior to treatment delivery.

Level 3.2 Items (Complex IMRT Multiple Field)

In items 15914 and 15940: Complex inverse planned intensity modulated radiation therapy (IMRT) to multiple-dose level prescription or IMRT with motion management is localised through three or four dimensional (volumetric imaging) to identify clinical and planning targets, organs at risk and normal tissue (and tumour and organs at risk excursion in the case of four-dimensional applications).

Planning is based on delivery to multiple-dose level targets or IMRT with motion management and includes optimisation of the dose based on assessment of organs at risk doses. This technique involves very sharp dose gradients adjacent to both targets and organs at risk increasing the consequences of any geometric uncertainty, making daily treatment verification (Image-guided radiation therapy—IGRT) an essential component of quality IMRT. In the case of four-dimensional applications, treatment delivery utilises some form of motion management and further complicates the planning, delivery and quality assurance processes. Motion management includes four-dimensional volumetric imaging, deep inspiration breath hold, deep expiration breath hold, use of manual compression and other methods that account for tumour movement. It is the tumour location, adjacent organs and dosimetry that define the appropriate role for IMRT and support an approach where the clinical circumstances, rather than specific diagnoses, are the most important determinants for using IMRT. Pre-treatment quality assurance validation will be required and consideration for re-planning is included. Final dosimetry plan is validated by both the radiation therapist and medical physicist, using quality assurance processes, with the plan approved by the radiation oncologist prior to treatment delivery. Small-field fractionated treatment strategies (using either an IMRT or multiple, non-coplanar, rotational or fixed beam delivery) are included in this complexity level.

Level 4 Items (Intracranial Stereotactic Radiation Therapy)

In items 15918 and 15942: Stereotactic radiation therapy delivered using a Therapeutic Goods Administration approved device using specifically calibrated small fields. Dedicated and customised patient positioning and immobilisation and multi-modality image based targeted identification of the treatment volume, surrounding organs at risk and normal tissue. Where relevant formal structured assessment of motion and patient suitability for complex and lengthy delivery may include fixed head frame. Lengthy treatment sessions may require patient education to support positional and physiological control requirements. Dosimetry delivers small-field collimation and shaping of the dose to complex targets. Pre-treatment quality assurance validation will be required and consideration for re-planning is included. Very tight margins and steep dose gradients mandates the use of daily treatment verification. Final dosimetry plan is validated by both the appropriately qualified radiation therapist and medical physicist, using quality assurance processes, with the plan approved by the radiation oncologist prior to treatment delivery.

Level 4 Items (Stereotactic Body Radiation Therapy)

In items 15920 and 15944: Stereotactic body external beam radiation therapy with or without motion management is localised through a three or four-dimensional (three-dimensional volumetric delineation or four-dimensional volumetric delineation with consideration of tumour and organs at risk excursion) simulation to identify clinical and planning targets, organs at risk and normal tissue (and tumour and organs at risk excursion in the case of four-dimensional applications). Requires dedicated and personalised patient positioning and immobilisation and multi-modality image based targeted identification of the treatment volume, surrounding organs at risk and normal tissue. Lengthy treatment sessions may require patient education to support positional and physiological control requirements. Motion management includes four-dimensional CT, deep inspiration breath hold, deep expiration breath hold, use of manual compression and other methods that account for tumour movement.

Stereotactic body radiation therapy (SBRT) and stereotactic ablative radiation therapy (SABR) are used interchangeably and are defined as high precision, image-guided radiation therapy (IGRT) dose delivery with highly conformal dose and steep dose gradients, with larger doses per fraction, fewer treatments as determined by standard clinical protocols, eg. 5 for prostate treatments or 8 for central lung treatments and where there is intrafraction motion management where applicable.

For stereotactic treatments this requires on the first day of treatment, a radiation oncologist or trained delegate with documented competencies in stereotactic treatments must be present at the start of the treatment fraction (prior to irradiation) to verify the integrity of the patient set-up at the treatment machine, patient repositioning using image guidance, and directly manage any clinical issues. For subsequent fractions in the same course, the radiation oncologist must be immediately available for critical decision making. Patient specific pre-treatment quality assurance validation may be required and consideration for re-planning and is included. Very tight margins and steep dose gradients mandates the use of daily image verification of treatment. Final dosimetry plan is validated by both the appropriately qualified radiation therapist and medical physicist, using quality assurance processes, with the plan approved by the radiation oncologist prior to delivery.

Level 5 Items (Specialised)

In items 15924, 15926, 15946 and 15948: Patient acuity requires multidisciplinary medical and technical support during the simulation and treatment processes (for example, general anaesthetic for complex cases or monitoring for patients receiving Total Body Irradiation). Complex dosimetry requirements are driven by large field or large volume requirements in total skin electron therapy (TSE) or total body irradiation (TBI) cases and highly personalised dosimetry requirements with younger paediatric patients, and patients requiring general anaesthetic or supervised sedation. Clinical and Technical complexity requires prolonged, complex multidisciplinary team involvement and direct involvement in the treatment delivery process; including in vivo dosimetry. Patient specific complex quality assurance validation pre-treatment and during treatment is required and consideration for re-planning is included. Final dosimetry plan is validated by both the radiation therapist and medical physicist, using quality assurance processes, with the plan approved by the radiation oncologist prior to delivery.

Radiation therapy treatment to correspond with planning

The complexity level of the treatment regimen must be appropriate for the plan. Accordingly, treatment items must not be billed at higher levels than the complexity level associated with planning item for that site.

Treatment can be billed however at a higher sublevel within a band. For example, it may be appropriate to use Level 3.2 treatment for a site planned at Level 3.1, but billing for Level 3 treatment items following Level 2 planning would not be processed. 

If treatment is for multiple sites, each site must be clearly identified and differentiated by name in billing notes (e.g., Breast, Pelvis, Brain).

Related Items: 15902 15904 15906 15908 15910 15912 15914 15916 15918 15920 15922 15924 15926 15928 15930 15932 15934 15936 15938 15940 15942 15944 15946 15948

Radiation therapy planning (15902 – 15928, 15950, 15970 – 15980)

One plan only will attract Medicare benefits in a course of treatment. Benefits are payable however for further planning items where planning is undertaken for a synchronous primary or different tumour site to that (or those) specified in the original prescription by the radiation oncologist. Sites must be clearly identified and differentiated by name in billing notes (e.g., Breast, Pelvis, Brain).

Protocols for documenting quality assurance processes for treatment plans (15902 to 15928 and 15970 to 15980, 15964 and 15968)

Treatment plans should be produced using quality assurance processes to ensure, where appropriate:

(a)     Data within the oncology information system is accurate; and

(b)     Data transfer to the Oncology Information System has been completed without any loss of data integrity; and

(c)     The plan is deliverable without loss of dosimetric accuracy on the radiation therapy apparatus which will be used for clinical delivery (including particular consideration given to geometric accuracy where tight margins or steep dose gradient are employed); and

(d)     Motion management strategies and accuracy of delivery have been appropriately assessed; and

(e)     The dose calculation of the treatment plan (including on the patient planning images) is accurate; and

(f)      The accuracy of any image fusions performed; and

(g)     The final treatment plan is validated by a radiation therapist or medical physicist, using quality assurance processes, with the plan approved by the radiation oncologist prior to delivery .

The quality assurance processes should be established, maintained and performed by radiation therapists and medical physicists and should be formally documented.

Protocols for documenting quality assurance processes for treatment re-plans (15912, 15916, 15922 and 15928)

Treatment re-plans can only be performed if:

(a)     An initial treatment plan has been prepared in accordance with the item descriptor; and

(b)     Treatment adjustments to the original plan are inadequate to satisfy treatment protocol requirements.

Treatment re-plans should be produced using quality assurance processes to ensure, where appropriate:

(a)     Data within the oncology information system is accurate; and

(b)     Data transfer to the Oncology Information System has been completed without any loss of data integrity; and

(c)     The re-plan is deliverable without loss of dosimetric accuracy on the radiation therapy apparatus which will be used for clinical delivery (including particular consideration given to geometric accuracy where tight margins or steep dose gradient are employed); and

(d)     Motion management strategies and accuracy of delivery have been appropriately assessed; and

(e)     The dose calculation of the treatment re-plan (including on the patient planning images) is accurate; and

(f)      The accuracy of any image fusions performed.

(g)     The additional dosimetry re-plan should be established, maintained, validated and performed by both a radiation therapist and medical physicist, using quality assurance processes, with the re-plan approved by the radiation oncologist prior to delivery.

Only one additional dosimetry re-plan is payable during the treatment course (at 50% of the Schedule Fee for the associated item) and the clinical need for re-planning must be consistent with the guidance provided in the item descriptor and clearly documented in the patient’s record.

Re-planning items 15912, 15916, 15922 and 15928 cannot be claimed in association with any other service under this subgroup except for the item descriptor that relates.

Image Fusion

Where appropriate, when determining the target volumes and organs at risk for treatment, relevant multi-modality imaging should be used to delineate targets and organs at risk.

Related Items: 15902 15904 15906 15908 15910 15912 15914 15916 15918 15920 15922 15924 15926 15928