Medicare Benefits Schedule - Item 61333

 

Lung ventilation study using Galligas and lung perfusion study using gallium-68 macro aggregated albumin (⁶⁸Ga-MAA), with PET, if the service is performed because the service to which item 61348 applies cannot be performed due to unavailability of technetium-99m (R)

Bulk bill incentive

Fee: $443.35 Benefit: 75% = $332.55 85% = $376.85

(See para IN.0.17 of explanatory notes to this Category)

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Nuclear medicine imaging services other than PET

Benefits for a nuclear scanning service (other than PET) are only payable when the service is performed:

• by a credentialed specialist or consultant physician, or by a person acting on behalf of the specialist; and
• the final report of the service is compiled by the specialist or consultant physician who performed the preliminary examination of the patient and the estimation and administration of the dosage.

Additional benefits will only be attracted for specialist physician or consultant physician attendance under Category 1 of the Schedule where there is also a referral letter from the patient’s treating medical practitioner for a full medical examination of the patient. The referral letter needs to be distinct from the request for the nuclear medicine scan.

Credentialling for nuclear medicine imaging services

Payment of Medicare rebates for nuclear medicine imaging services is limited to specialists or consultant physicians who are credentialled by the Joint Nuclear Medicine Credentialling and Accreditation Committee (JNMCAC) of the Royal Australian College of Physicians (RACP) and the Royal Australian and New Zealand College of Radiologists (RANZCR).

The scheme was developed by the profession in consultation with Government to ensure that specialists in nuclear medicine are appropriately trained and licensed, provide appropriate personal supervision of procedures and are involved in ongoing continuing medical education.

For information regarding the Scheme and for application forms, please go to RANZCR’s website at www.ranzcr.com or RACP’s website at www.racp.edu.au.

Radiopharmaceuticals

The schedule fees for nuclear medicine imaging services incorporate the costs of radiopharmaceuticals.

Myocardial perfusion studies - various items

See notes IN.1.10 to IN.4.3 and IR.0.1 to IR.4.2.

Pulmonary Embolism (PE) – items 61328, 61340 and 61348

Medical practitioners requesting imaging for suspected PE should read and consider the RANZCR 2015 Choosing Wisely recommendations, or such clinical RANZCR Choosing Wisely recommendations that succeed it.

Hepatobiliary study (pre-treatment) - item 61360

Item 61360 - the standard hepatobiliary item - also includes allowance of the pre-procedural cholagogue administration for preparatory emptying of the gall bladder and also morphine augmentation.

Hepatobiliary study (infusion) - item 61361

Item 61361 applies specifically to a standard hepatobiliary study to which has been added an infusion of cholagogue following which acquisition is continued and quantification of gallbladder ejection fraction and/or common bile duct activity time curves are performed.

Whole body studies - items 61426-61438

"Whole body" studies must include the trunk, head and upper and lower limbs down to the elbow and knee joints respectively, whether acquired as multiple overlapping camera views or whole body sweeps (runs) with additional camera views as required. Any study that does not fulfil these criteria is a localised study.

Repeat studies - item 61462

Item 61462 covers repeat planar (whole body or localised) and/or SPECT imaging performed on a separate occasion using the same administration of radiopharmaceutical. The repeat planar and SPECT imaging when performed on a separate occasion using the same administration of radiopharmaceutical should be itemised as item 61462 and the original item and date of service should be indicated for reference purposes.

This item does not apply to bone scans, adrenal studies or gastro-oesophageal reflux studies, myocardial perfusion studies, colonic transit or CFS transport studies, where allowance for performance of the delayed study is incorporated into the baseline benefit fee.

Thyroid study - item 61473

Item 61473 incorporates the measurement of thyroid uptake on a gamma camera using a proven technique, where clinically indicated.

Positron Emission Tomography (PET) - items 61523 to 61647

General

PET services must be:

• performed by or under the personal supervision of:
  • specialist or consultant physician credentialled under the Joint Nuclear Medicine Specialist Credentialling Program for the Recognition of the Credentials of Nuclear Medicine Specialists for Positron Emission Tomography overseen by the Joint Nuclear Medicine Credentialling and Accreditation Committee of the RACP and RANZCR; or
  • practitioner who is a Fellow of either the RACP or RANZCR, and who, prior to 1 November 2011, reported 400 or more studies forming part of PET services for which a Medicare benefit was payable, and who holds a current license from the relevant State radiation licensing body to prescribe and administer the intended PET radiopharmaceuticals to humans;
    
    
• provided in a comprehensive facility that can provide a full range of diagnostic imaging services (including PET, CT, X-Ray and diagnostic ultrasound) and cancer treatment services (including chemotherapy, radiation oncology and surgical oncology) at the one site;
  
  
• provided using equipment that meets the Requirements for PET Accreditation (Instrumentation & Radiation Safety) 3rd Edition (2017) issued by the Australian and New Zealand Society of Nuclear Medicine Inc;
  
  
• only provided following a request from a specialist or consultant physician; and
  
  
• all PET providers must complete a specific PET provider Statutory Declaration prior to being eligible to claim Medicare rebates. Statutory declarations can be obtained directly from Services Australia.
   

Whole body FDG PET

In patients with Hodgkin and non- Hodgkin lymphoma (excluding indolent non- Hodgkin lymphoma), whole body FDG PET studies should not be used for surveillance nor for assessment of patients with suspected (as opposed to confirmed) disease recurrence.

PET for Alzheimer's disease

For item 61560:

• the study must include a quantitative comparison of the results with the results obtained from a PET study in a reference library of a normal brain.
• benefits are not payable for the item if the patient has a previous PET scan for Alzheimer’s disease claimed in the previous 12 months.
  
  
• benefits are not payable for the item if a cerebral perfusion study (item 61402) for the diagnosis or management of Alzheimer’s disease has been claimed in the previous 12 months.
  
  
• benefits are only payable for a maximum of three services in the patient’s lifetime.
   

Prostate-specific membrane antigen (PSMA) PET study for Prostate Cancer

Item 61563 - Whole body PSMA PET study for the initial staging of the patient

• The requesting specialist or consultant physician is to record in the clinical notes and the imaging request that the patient:
  • has intermediate to high-risk prostate adenocarcinoma, as defined below;
  • has previously been untreated; and
  • is considered suitable for locoregional therapy with curative intent.
• Patients with intermediate risk prostate adenocarcinoma can be defined as having at least one of the following risk factors in the absence of any high-risk features: PSA of 10-20 ng/ml, or Gleason score of 7 or International Society of Urological Pathology (ISUP) grade group 2 or 3, or Stage T2b.
  
  
• Patients with high-risk prostate adenocarcinoma can be defined as having at least one of the following risk factors: PSA >20 ng/ml, or Gleason score >7 or ISUP grade group 4 or 5, or Stage T2c or ≥T3.
  
  
• Benefits are only payable for a maximum of one service in the patient’s lifetime. 

Item 61564 - Whole body PSMA PET study for the restaging of the patient

• The requesting specialist or consultant physician is to record in the clinical notes and the imaging request that the patient has undergone prior locoregional therapy for prostatic adenocarcinoma and is considered potentially suitable for further locoregional therapy for recurrent disease.
  
  
• This item can be claimed by patients with:
  • a prostate specific antigen (PSA) increase of 2ng/ml above the nadir after radiation therapy; or
  • failure of PSA levels to fall to undetectable levels; or
  • rising serum PSA after a radical prostatectomy.
    
    
• Benefits are only payable for a maximum of two services in the patient’s lifetime.
   

Whole body PSMA PET study items 61563 and 61564 are not to be used for surveillance nor for assessment of patients with suspected (as opposed to confirmed) prostate adenocarcinoma or disease recurrence.

Claiming of diagnostic Computed Tomography (CT) with PET scans

Diagnostic CT items should not be co-claimed with a whole body PET scan unless the service is clinically relevant and appropriately requested. Under the Health Insurance (Diagnostic Imaging Services Table) Regulations, diagnostic CT items cannot be claimed with a PET item where the purpose of the CT is for attenuation correction or anatomical correlation. CT attenuation item 61505 is the correct item to be claimed in these circumstances.

Substitute PET items for use in radiopharmaceutical supply disruptions

Items 61333, 61336 and 61341 can be used if items 61348, 61402, 61421 or 61425 have been requested and:

1.     the requested service is not available due to a supply disruption of technetium-99m; and

2.     the patient's clinical condition requires the service to be performed before the resumption of normal isotope supply is anticipated; and

3.     the report of the service performed includes a justification for the substitute service and the unavailability of the original item.

Item 61612 – FDG PET study of the initial staging of eligible cancer types

For item 61612, the requesting specialist or consultant physician is to record in the clinical notes and the imaging request that the patient has a rare or uncommon cancer that meets the eligibility criteria as stated in the item descriptor. Benefits are only payable once per cancer diagnosis.
 

The following are considered rare or uncommon cancer types:

• anal cancer
• bladder cancer
• brain and other central nervous system (cancer of the)
• brain cancer
• gallbladder and extrahepatic bile ducts (cancer of the)
• gastrointestinal stromal tumours (GIST)
• Kaposi sarcoma
• liver cancer
• Merkel cell cancer
• mesothelioma
• multiple myeloma
• ovarian cancer (incidence only)
• ovarian cancer and serous carcinomas of the fallopian tube
• pancreatic cancer
• penile cancer
• peritoneal cancer
• placenta cancer
• small cell lung cancer
• small intestine (cancer of the)
• stomach cancer
• testicular cancer
• thyroid cancer
• unknown primary site (cancer of)
• uterine cancer
• vaginal cancer
• vulvar cancer.

 

Related Items: 61333 61336 61341 61563 61564 61612