Medicare Benefits Schedule - Note IN.0.17

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 nuclear medicine credentialled specialist or consultant physician, or by a person acting on behalf of the specialist; and

• the final report of the service is compiled by a nuclear medicine credentialled specialist.

• Additional benefits will only be attracted for a nuclear medicine credentialled specialist 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 benefits 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 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, IN.4.1, IN.4.2, 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

"Whole body" studies should 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 in Subgroup 2 of Group I4

General

PET services must be:

• performed under the supervision of a PET credentialled specialist. The service does not need to be performed by a PET credentialled specialist. For example, the service may be performed by a medical imaging technician when supervised by a PET credentialled specialist. If personal attendance is required, the person attending must be either a PET credentialled specialist, a nuclear medicine credentialled specialist, or a specialist in diagnostic radiology.

• reported by a PET credentialled specialist.

• provided in a comprehensive practice. The Health Insurance (Diagnostic Imaging Services Table) Regulations (No.2) 2020 defines a comprehensive practice as a medical practice or hospital radiology department that provides x-ray, ultrasound and computed tomography (CT) services.

• 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.

• Additional benefits will only be attracted for a nuclear medicine credentialled specialist 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.

PET credentialled specialist means:

• a specialist or consultant physician who is 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 JNMCAC; or
• a specialist or consultant physician who:
  • is a Fellow of the RACP or RANZCR; and
  • has reported 400 or more studies forming part of PET services for which a Medicare benefit was payable; and
  • is authorised under State or Territory law to prescribe and administer to humans the PET radiopharmaceuticals that are to be administered to a person; and
  • met these requirements before 1 November 2011. 

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:

o    has intermediate to high-risk prostate adenocarcinoma, as defined below;

o    has previously been untreated; and

o    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:

o    a prostate specific antigen (PSA) increase of 2ng/ml above the nadir after radiation therapy; or

o    failure of PSA levels to fall to undetectable levels; or

o    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 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 (No. 2) 2020, 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.

Related Items: 61328 61340 61348 61360 61361 61426 61429 61430 61433 61434 61438 61462 61473 61563 61564 61612 61614

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Bulk bill incentive

Lung perfusion study (R)

Fee: $241.25 Benefit: 75% = $180.95 85% = $205.10

(See para IN.0.17, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Lung ventilation study using aerosol, technegas or xenon gas (R)

Fee: $268.15 Benefit: 75% = $201.15 85% = $227.95

(See para IN.0.17, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Lung perfusion study and lung ventilation study using aerosol, technegas or xenon gas (R)

Fee: $469.85 Benefit: 75% = $352.40 85% = $399.40

(See para IN.0.17, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Hepatobiliary study, including morphine administration or pre-treatment with a cholagogue when performed (R)

Fee: $427.45 Benefit: 75% = $320.60 85% = $363.35

(See para IN.0.17, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Hepatobiliary study with formal quantification following baseline imaging, using a cholagogue (R)

Fee: $489.00 Benefit: 75% = $366.75 85% = $415.65

(See para IN.0.17, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Whole body study using iodine (R)

Fee: $588.00 Benefit: 75% = $441.00 85% = $499.80

(See para IN.0.17, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Whole body study using gallium (R)

Fee: $575.50 Benefit: 75% = $431.65 85% = $489.20

(See para IN.0.17, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Whole body study using gallium, with single photon emission tomography (R)

Fee: $698.95 Benefit: 75% = $524.25 85% = $594.45

(See para IN.0.17, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Whole body study using cells labelled with technetium (R)

Fee: $526.70 Benefit: 75% = $395.05 85% = $447.70

(See para IN.0.17, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Whole body study using cells labelled with technetium, with single photon emission tomography (R)

Fee: $652.25 Benefit: 75% = $489.20 85% = $554.45

(See para IN.0.17, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Whole body study using thallium (R)

Fee: $713.20 Benefit: 75% = $534.90 85% = $608.70

(See para IN.0.17, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Repeat planar and single photon emission tomography imaging, or repeat planar imaging or single photon emission tomography imaging on an occasion subsequent to the performance of item 61364, 61426, 61429, 61430, 61442, 61450, 61453, 61469 or 61485, if there is no additional administration of radiopharmaceutical and if the previous radionuclide scan was abnormal or equivocal (R)

Fee: $136.70 Benefit: 75% = $102.55 85% = $116.20

(See para IN.0.17, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Thyroid study (R)

Fee: $185.90 Benefit: 75% = $139.45 85% = $158.05

(See para IN.0.17, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

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% = $1,195.50

(See para IN.0.17, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Whole body prostate-specific membrane antigen PET study performed for
the restaging of recurrent prostate adenocarcinoma, for a patient who:
(a) has undergone prior locoregional therapy; and
(b) is considered suitable for further locoregional therapy to determine
appropriate therapeutic pathways and timing of treatment initiation

Applicable twice per lifetime (R)

Fee: $1,300.00 Benefit: 75% = $975.00 85% = $1,195.50

(See para IN.0.17, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Whole body FDG PET study for the initial staging of cancer, for a patient who is considered suitable for active therapy, if:
(a) the cancer is a typically FDG-avid cancer; and
(b) there is at least 10% likelihood that a PET study result will inform a significant change in management for the patient
Applicable once per cancer diagnosis (R)

Fee: $953.00 Benefit: 75% = $714.75 85% = $848.50

(See para IN.0.17, IN.0.19 of explanatory notes to this Category)

Bulk bill incentive

Whole body FDG PET study, following initial therapy, performed for the evaluation of suspected residual, metastatic or recurrent cancer in a patient who is undergoing, or is suitable for, active therapy, if the cancer is a typically FGD-avid cancer (R)

Fee: $953.00 Benefit: 75% = $714.75 85% = $848.50

(See para IN.0.17, IN.0.19 of explanatory notes to this Category)