Medicare Benefits Schedule - Item 15908

Megavoltage planning—level 2.2

Three‑dimensional radiation therapy simulation and dosimetry for treatment planning with motion management, if:

(a) all of the following apply in relation to the simulation:

(i) treatment set‑up and technique specifications are in preparation for complex three‑dimensional planning with consideration of motion management;

(ii) patient set‑up and immobilisation techniques are reproducible for treatment;

(iii) a high‑quality three‑dimensional or four‑dimensional image volume dataset is acquired in treatment position for the relevant region of interest to be planned and treated with image verification; and

(b) all of the following apply in relation to the dosimetry:

(i) the three‑dimensional planning process is required to calculate dose to three‑dimensional volume structures (which must include structures moving with physiologic processes) and requires a dose‑volume histogram to complete the planning process;

(ii) based on review and assessment by a radiation oncologist, the three‑dimensional planning process is required to optimise the differential between target dose and normal tissue dose;

(iii) the planning target volume is rendered as a three‑dimensional structure on planning outputs (three‑dimensional plan review, three‑planar sections review or dose‑volume histogram);

(iv) organs at risk are delineated, and assessment of dose to these structures is derived from full calculation and inclusion in a dose‑volume histogram

Applicable once per course of treatment

Fee: $2,783.40 Benefit: 75% = $2,087.55 85% = $2,678.90

(See para TN.2.1, TN.2.2, TN.2.10 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 or three-dimensional simulation from an appropriate imaging dataset 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 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. 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 to account for tumour movement.

Planning is based on three or four-dimensional planning processes with complex beam shaping 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 imaging dataset 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, 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. 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 to 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, immobilisation and imaging for 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 IGRT. 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 simulation to identify clinical and planning targets, organs at risk and normal tissue (and excursion of tumour and organs at risk 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 to 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 including 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 IGRT. 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 and replanning to correspond with planning

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

Where planning/replanning/treatment is for multiple sites, each site must be clearly identified and differentiated by name in billing notes.

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

Megavoltage planning

Megavoltage radiation therapy planning – multiple sites (items 15902 – 15910, 15914, 15920, 15924, 15926)

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 uniquely identified in billing notes.

For intracranial stereotactic planning (item 15918), ‘intracranial’ is considered to be a single site.

Megavoltage radiation therapy re-planning (items 15912, 15916, 15922, 15928)

Only one 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.

Protocols for documenting quality assurance processes for treatment plans

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

1. Data within the oncology information system is accurate; and
2. Data transfer to the Oncology Information System has been completed without any loss of data integrity; and
3. 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
4. The dose calculation of the treatment plan (including on the patient planning images) is accurate; and
5. The accuracy of any image fusions performed; and
6. 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

In addition to protocols for documenting quality assurance processes for treatment plans, treatment re-plans can only be performed if:

1. An initial treatment plan has been prepared in accordance with an item descriptor of the same complexity or higher; and
2. Treatment adjustments to the original plan are inadequate to satisfy treatment protocol requirements.

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

This guidance provides details on billing information required by Services Australia to support the processing of Medicare claims for twice-daily treatments and claims for planning and treating multiple sites.

Claiming planning items for multiple sites (megavoltage items 15902-15910, 15914, 15920, 15924, 15926 and kilovoltage item 15950)

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 another tumour site to that (or those) specified in the original prescription by the radiation oncologist.

To attract Medicare benefits, the claim for each planning item must uniquely identify the tumour site in the corresponding claiming/billing note for that claim (see below).

For intracranial stereotactic planning (item 15918), ‘intracranial’ is considered to be a single site (the cranium being defined as everything inside the bones of the skull).

Structures outside the cranium – including the bones of the skull, the scalp, and skin overlying the scalp - may have multiple sites requiring separate plans.

Claiming treatment items for multiple sites at one attendance (megavoltage items 15930-15940, 15944, 15946, 15948, and kilovoltage item 15954)

Where patients are being treated with radiation therapy to multiple sites of disease at one attendance, the claim for each treatment item must uniquely identify the tumour site in the corresponding claiming/billing note for that claim (see below).

Stereotactic treatment items (15942 and 15944)

• Intracranial stereotactic radiation therapy (15942) is applicable once per day.
• Stereotactic body radiation therapy (item 15944) is applicable once per day per site, for a maximum of 2 sites. When multiple plans are to be delivered to more than 2 sites in the same time frame, treatments to additional sites can be billed if delivered on different days.

Unique identification of sites in claiming/billing notes

Where multiple sites are involved, claims for both planning and treatment items must clearly identify a unique site of less than 30 characters (including spaces) in corresponding claiming/billing notes.

Please do not number each site or include terms such as ‘multiple sites’.

The full name of a body part must be specified. Abbreviations will not be accepted.

To differentiate site location in the same body part, terms may include: anterior, posterior, medial, lateral, proximal, distal, upper, middle, lower etc.

Examples of claims/billing notes required when submitting claims for planning and treatment items:

Claiming twice-daily treatments (items 15930-15940 and 15948)

The Medicare claims system is hard-wired to identify duplicate claims on the same day. When two legitimate claims are submitted for treatment to the same site on the same day, it is important to distinguish one claim from the other so that one of the claims is not treated as a duplicate.

Please observe the following claiming practices:

i.    Include the word “first” in claiming/billing notes for the first treatment of the day.

ii.   Include the word “second” in claiming/billing notes for the second treatment of the day.

Examples of claims/billing notes required when submitting claims for twice-daily, single-site treatment items:

Twice daily treatments to multiple sites on the same day

iii.  When treating multiple sites on the same day, the claim for each treatment item must clearly identify a unique site in the claim/billing note (see above).

iv.  Additionally, if one or more of the sites are being treated twice on the same day, identify the first and second treatments on the same day in claims/billing notes, as detailed in (i) and (ii).

Examples of claims/billing notes required when submitting claims for twice-daily treatments of multiple sites:

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