Medicare Benefits Schedule - Item 15932

Megavoltage treatment—level 1.2

Radiation therapy and image verification for simple treatment, with imaging for field setting, if:

(a) the treatment is delivered using a device that is included in the Australian Register of Therapeutic Goods; and

(b) image‑guided radiation therapy (IGRT) imaging is used to implement a two‑dimensional plan, and

(c) two‑dimensional treatment is delivered; and

(d) image verification decisions and actions are documented in the patient’s record

Applicable once per plan per day

Fee: $113.65 Benefit: 75% = $85.25 85% = $96.65

(See para TN.2.1, TN.2.3 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

Multiple treatment sites at one attendance (15930 to 15948)

Where patients are being treated with radiation therapy to multiple separate sites of disease at one attendance, each treatment site must be documented in a separately prescribed plan. Sites must be clearly identified and differentiated by name in billing notes (e.g., Breast, Pelvis, Brain). For each site the complexity level of the treatment regimen must match the corresponding complexity level associated with planning for that site.

Definition of multiple treatment sites 

1.       locoregional and/or distant disease under one diagnosis treated under multiple separate prescription plans, or

2.       synchronous primaries with each treatment prescribed under separate diagnosis.

Treatments requiring general anaesthetic

Items 15918 and 15948 apply to all patients requiring general anaesthetic or sedation supervised by an anaesthetist for treatment delivery. For patients who do not require general anaesthetic or supervised sedation then other appropriate items should be used.

Radiation oncologist attendance

For all treatments, a radiation oncologist should be available to physically review patients when required.

For complex treatments, a radiation oncologist should be immediately available for critical decision making.

For highly complex treatments, such as stereotactic treatments, a radiation oncologist or trained delegate with documented competencies in stereotactic treatments should 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, a radiation oncologist must be immediately available for critical decision making.

Motion management

Motion management is the use of additional technology to ensure the dose to the target is not compromised by physiological motion or the dose to a critical organ-at-risk adjacent to the target is minimised. This includes:

(a)     Reducing physiological motion (for example breath hold); or

(b)     Quantifying physiological motion (for example 4D-CT or 4D-CBCT); or

Using technology to detect motion and actively control treatment or simulation.

Related Items: 15930 15932 15934 15936 15938 15940 15942 15944 15946 15948