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Category 5 - DIAGNOSTIC IMAGING SERVICES
61563 - Additional Information
Whole body prostate-specific membrane antigen PET study performed for
the initial staging of intermediate to high-risk prostate adenocarcinoma, for a
previously untreated patient who is considered suitable for locoregional
therapy with curative intent
Applicable once per lifetime (R)
Fee: $1,300.00 Benefit: 75% = $975.00 85% = $1,212.10
(See para IN.0.17 of explanatory notes to this Category)
Category 5 - DIAGNOSTIC IMAGING SERVICES
Group I4 - Nuclear Medicine Imaging
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 a request for a full medical examination accompanied by a referral letter or note of referral.
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 of the Royal Australian College of Physicians (RACP) and 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 phone the RACP or RANZCR.
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 as 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
Payment of Medicare rebates for PET services is limited to credentialled specialists or consultant physicians who meet eligibility requirements in the Diagnostic Imaging Services Table Regulations. PET services must be:
- performed under the 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) 3nd Edition (2017) issued by the Australian and New Zealand Society of Nuclear Medicine Inc; and
- only provided following referral from a recognised specialist or consultant physician.
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 to be used for surveillance nor for assessment of patients with suspected (as opposed to confirmed) disease recurrence.
Whole body FDG PET studies should be used as an alternative rather than additional to conventional CT scanning.
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 specialist or consultant physician is to record in the clinical notes and the 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 specialist or consultant physician is to record in the clinical notes and the 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 PSA serum 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 an appropriate request has been received. 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.
Please refer to clause 2.2.2 of the Health Insurance (Diagnostic Imaging Services Table) Regulations (as amended).
Temporary PET items to replace non-PET Nuclear Medicine Items
Nuclear medicine items 61311, 61332, 61365, 61377, 61380, 61418, 61422, 61333, 61336, 61337, 61341 and 61344 may only be used during specified time periods, following a valid referral for the equivalent nuclear medicine imaging item on which it is based. Items 61311, 61332, 61333, 61336, 61337, 61341 and 61344 were available for a period from 14 September 2019 until 20 December 2019. All items were available for a further period from 1 December 2020 until 28 February 2021.
In the event that there is a future national shortage in the supply of technetium, these items may again become available. Announcements about the commencement of temporary nuclear medicine items will be published on the Department of Health's Nuclear Medicine and Positron Emission Tomography (PET) webpage.
The schedule fees for PET services incorporate the costs of radiopharmaceuticals.
- Assist - Addition/Deletion of (Assist.)
- Amend - Amended Description
- Anaes - Anaesthetic Values Amended
- Emsn - EMSN Change
- Fee - Fee Amended
- Renum - Item Number Change (renumbered)
- New - New Item
- NewMin - New Item (previous Ministerial Determination)
- Qfe - QFE Change