EXPLANATORY STATEMENT
Health Insurance Act 1973
Health Insurance (Radiation Oncology) Determination 2008
Issued by the authority of the Minister for Health and Ageing
This determination is made under Subsection 3C(1) of the Health Insurance Act 1973 (the Act).
The Act provides for payment of Medicare benefits in respect of professional services rendered to eligible persons. The professional services for which Medicare benefits are payable are set out in three tables: the general medical services table; the diagnostic imaging services table; and the pathology services table (“the Tables”). These Tables are made by regulation.
Radiation oncology treatment items are included in the general medical services table. However, radiation oncologists also use imaging procedures such as x-rays, ultrasound and computed tomography as a quality assurance tool to verify that the radiation oncology treatment they are providing is being applied to the correct area throughout the course of treatment.
There are no specific radiation oncology items for treatment verification. Instead, radiation oncologists have been using the most relevant diagnostic imaging item in the diagnostic imaging services table to enable patients to claim Medicare benefits for treatment verification services.
From 1 July 2008, diagnostic imaging practices providing diagnostic imaging services other than nuclear medicine imaging, cardiac imaging and obstetric and gynaecological ultrasound, must be accredited under the Diagnostic Imaging Accreditation Scheme in order for Medicare benefits to be payable for those services. Radiation oncology treatment verification procedures are not used for diagnostic purposes and as such, this activity is not relevant to the Diagnostic Imaging Accreditation Scheme.
It has therefore become necessary to develop items that more appropriately describe radiation oncology treatment verification outside of the diagnostic imaging services table.
Subsection 3C(1) of the Act allows the Minister, by writing, to determine that a health service not listed in an item in the Tables shall be treated, for the purposes of specified provisions in the Act, the regulations made under the Act, the National Health Act 1953 or the regulations under that Act as if it were so listed.
The Health Insurance (Radiation Oncology) Determination 2008 (the Determination) provides that two new items for radiation oncology treatment verification services, one new item for brachytherapy treatment verification and one new item covering radiation source localisation for high dosed brachytherapy treatment planning are to be treated as if they were both professional and medical services and as if they were items listed in the general medical services table relating to the services and specifying a fee relating to the services. This allows the payment of Medicare benefits for these radiation oncology treatment verification services.
The new items were developed in consultation with the radiation oncology profession, primarily through a committee representing various sectors of the profession.
A detailed explanation of the items and other provisions in the Determination is contained in the Attachment.
The Determination commences on 1 July 2008.
ATTACHMENT
Health Insurance (RADIATION oNCOLOGY) Determination 2008
Explanation of Sections
Section 1
This section provides that the formal name of the Determination is the Health Insurance (Radiation Oncology) Determination 2008.
Section 2
Section 2 provides that the Determination commences on 1 July 2008.
Section 3
Subsection 3(1)
This subsection defines terms used in the Determination.
The definitions of ‘brachytherapy treatment verification’ and ‘radiation oncology treatment verification’ encompass what is involved in the treatment verification process and the types of imaging procedures used in the process. Under the definitions, x-ray images may be taken using any method, including portal imaging on a linear accelerator (which is the most common method of treatment verification), x-ray equipment attached to a linear accelerator (often referred to as ‘on board imaging’), or stand alone diagnostic x-ray equipment. In relation to ultrasound, the equipment needs to be capable of reconstructing the images captured into three dimensions in order to produce a clinically acceptable image of the treatment site.
The definitions are used in the item descriptors for items 15700, 15705 and 15800 as shown in the Schedule to the Determination.
The term 'relevant service' for the purpose of this Determination means a service defined in subsection 3C(8) of the Act that is specified in the Schedule. That subsection defines the types of services that are health services for the purposes of determinations under subsection 3(C)(1) of the Act.
It also notes that terms used in the Determination, in accordance with statutory conventions, take their meaning from the principal Act, in this case the Health Insurance Act 1973.
Subsection 3(2)
This subsection provides that a reference to a provision of an Act or regulations in this Determination is a reference to that provision as it is in force from time to time.
Section 4
Subsection 4(a) provides that a relevant service specified in the Schedule to the Determination shall be treated as if it were both a professional service and a medical service for the purposes of the provisions of the Act, the National Health Act 1953 and the regulations made under those Acts that make provision for medical or professional services.
Subsection 4(b) provides that a relevant service specified in the Schedule to the Determination (ie Items 15700, 15705, 15800 and 15850) is to be treated as if there were an item in the general medical services table that related to the service and which specified a fee in respect of that service, being the fee specified in the Determination in relation to the service.
Section 5
Items 15700 and 15705 apply to verification undertaken in respect of ‘non-contiguous’ sites. This section defines the meaning of ‘non-contiguous’. The terms ‘distinct planning tumour volume’ and ‘treatment plan’ are clinical terms accepted and understood by the radiation oncology profession.
Schedule
The Schedule sets out the relevant services and assigns to each service the applicable item number, item descriptor and fee.
Item 15700
This item covers treatment verification provided by external beam radiation (produced by a linear accelerator) where the images are taken in the one plane. There is no limit to the number of non-contiguous treatment sites for which the item can be claimed. Non-contiguous is defined in section 5 of the Determination.
Item 15705
This item covers treatment verification where images are taken in more than one plane, for example axial and lateral views. It applies once only per non-contiguous treatment site. Medicare benefits are payable for a maximum of three services per attendance. Up to three services per attendance is generally accepted by the profession as being reasonable clinical practice.
Item 15800
This item covers brachytherapy treatment verification. The item applies to one service only per treatment session.
Note: For the verification items above, it is not necessary that the patient have treatment at the same attendance at which verification is undertaken.
Item 15850
This item covers radiation source localisation for high dosed brachytherapy treatment planning. It is based on an existing item (Item 15513) for prostate seed implant brachytherapy, commonly known as low dose brachytherapy treatment.
The item applies to brachytherapy provided to any part of the body.