6.           PE Imaging Items

6.1        MBS items for PE Imaging

Table 6 Items for PE imaging introduction table

Item

Descriptor [date last amended]

Schedule fee

57351

COMPUTED TOMOGRAPHY - spiral angiography with intravenous contrast medium, including any scans performed before intravenous contrast injection - 1 or more spiral data acquisitions, including image editing, and maximum intensity projections or 3 dimensional surface shaded display, with hardcopy recording of multiple projections, where:

a) the service is not a service to which another item in this group applies; and
(b) the service is performed for the exclusion of acute or recurrent pulmonary embolism; acute symptomatic arterial occlusion; post operative complication of arterial surgery; acute ruptured aneurysm; or acute dissection of the aorta, carotid or vertebral artery; and
(c)  the services to which 57350 or 57355 apply have been performed on the same patient within the previous 12 months; and
(d) the service is not a study performed to image the coronary arteries (R) (K) (Anaes.)

$510.00

57356

COMPUTED TOMOGRAPHY - spiral angiography with intravenous contrast medium, including any scans performed before intravenous contrast injection - 1 or more spiral data acquisitions, including image editing, and maximum intensity projections or 3 dimensional surface shaded display, with hardcopy recording of multiple projections, where:
a) the service is not a service to which another item in this group applies; an
b) the service is performed for the exclusion of acute or recurrent pulmonary embolism; acute symptomatic arterial occlusion; post operative complication of arterial surgery; or acute ruptured aneurysm; acute dissection of the aorta, carotid or vertebral artery; and
(c) the services to which 57350 or 57355 apply have been performed on the same patient within the previous 12 months; and
(d) the service is not a study performed to image the coronary arteries (R) (NK) (Anaes.)

$264.15

 

61328

Lung perfusion study, with planar imaging and single photon emission tomography or planar imaging, or single photon emission tomography (R)

$227.65

61340

Lung ventilation study using aerosol, technegas or xenon gas, with planar imaging and single photon emission tomography or planar imaging or single photon emission tomography (R)

$253.00

61348

Lung perfusion study and lung ventilation study using aerosol, technegas or xenon gas, with planar imaging and single photon emission tomography, or planar imaging, or single photon emission tomography (R)

$443.35

6.2        MBS data for PE Imaging

Table 7: MBS 2014-15 Statistics – Computed Tomography Pulmonary Angiography

Item numbers

57351

57356

Services 2014/15

9,949

57

Benefits 2014/15

$4.5 million

$12,224

2011-12 to 2014-15 growth in benefits

40.1%

550.1%

Number of patients

8,870

48

Number of providers

1,737

25

Source: Department of Health, published and unpublished data, based on date of processing data for financial year 2014-15

 

Table 8: MBS 2014-15 Statistics – Ventilation Perfusion (V/Q) Scans

Item numbers

61328

61340

61348

Services 2014/15

465

135

20,841

Benefits 2014/15

$94,688

$31,142

$8.3 million

2011-12 to 2014-15 growth in benefits

20.9%

-32.3%

15.5%

Number of patients

452

134

19,275

Number of providers

139

63

428

Source: Department of Health, published and unpublished data, based on date of processing data for financial year 2014-15

There were no concerns with the data provided for MBS items for PE imaging, including data on the number of services performed in 2014–2015 by requester's clinical specialty. The MBS data for the items was considered to be reasonable and compatible with clinically appropriate imaging use. Additionally, it was noted that the number of PE items was relatively small, on a per capita basis, likely because the majority are performed outside of Medicare, while most DVT items were requested in primary care.

Additional data on the number of services for PE items requested by different provider specialities showed a relatively small number of services for PE diagnosis in comparison to DVT. This small number of Medicare services can be attributed to the large number of PE diagnoses conducted in the public hospital emergency department setting, where services are not billed to Medicare.

6.3        Issues

Through the Choosing Wisely initiative, the Royal Australian and New Zealand College of Radiologists (RANZCR) recommends that PE diagnosis should be commenced by using PE-rule out tools, including negative D dimer results, before applying imaging tests, such as computed tomography pulmonary angiography (CTPA).

For patients who do require imaging there is a need to consider the relative clinical utility of CTPA and ventilation perfusion (V/Q) scans in the broad population and in specific groups such as pregnant women.

The principal purpose of this review of imaging (including CTPA and V/Q) to exclude PE was to consider:

 whether PE should be diagnosed using PE-rule out tools, including negative D dimer results, rather than imaging tests such as CTPA

 the relative utility of V/Q lung scans versus CTPA in various patient populations including pregnant women

 if explicit guidance on prerequisites for testing are required for the MBS items.

Using the MBS data, it is not possible to know the indication for the use of the imaging tests. Similarly, a data request which looks at the claiming of a D dimer test for patients that had either of the below imaging tests is not possible, as the D dimer test is bundled in an item with other coagulation studies.

6.4        Recommendation 4 - MBS explanatory notes for the MBS items dealing with diagnostic imaging for PE

6.4.1        Recommendation

 Introduce an MBS explanatory stating that medical practitioners referring patients for suspected PE (items 57351, 57356, 61328, 61340, 61348) should read and consider the following Royal Australian and New Zealand College of Radiologists RANZCR 2015 Choosing Wisely recommendations:

- Don’t request any diagnostic testing for suspected pulmonary embolism (PE) unless indicated by Wells Score (or Charlotte Rule) followed by PE Rule-out Criteria (in patients not pregnant). Low risk patients in whom diagnostic testing is indicated should have PE excluded by a negative D dimer, not imaging.

 Education of target referrers on the Choosing Wisely Recommendations should be implemented. The provision of educational strategies is not within the remit of the MBS but rather the MBS could leverage off educational strategies developed by the Colleges or a third-party organisation such as NPS MedicineWise whose primary role is to provide general education to health professionals.

6.4.2        Rationale

 The Committee advised against replacing imaging tests with PE-rule out tools for the diagnosis of PE.

 PE-rule out tools can guide the appropriate use of diagnostic imaging in patients whose clinical indication and circumstance fit the diagnostic rules. However, PE-rule out tools are not designed to replace imaging tests, as they are not applicable to all clinical circumstances.

 Incorporating the Choosing Wisely recommendations on the use of PE-rule out tools into MBS item descriptors would be difficult as:

- PE-rule out tools, written in clinical guidance language, are not readily adaptable to linear-list MBS DIST descriptors which are written in legislative regulatory language and can result in inappropriate patient inclusion or exclusion.

- MBS item descriptors are static while PE-rule out tools should be regularly revised in response to change in patient demographics, evolution of disease pathology and new research.

 The Committee advised against incorporating the RANZCR Choosing Wisely recommendations into the MBS item descriptors used for PE diagnostic imaging because in the future these recommendations may no longer be consistent with good clinical practice.

 The Committee noted that V/Q studies should not be restricted to pregnant patients as there are a number of valid indications for these studies in non-pregnant patients.

 In regard to the relative clinical utility of V/Q and CTPA in their use to diagnose PE, it was observed that:

- patient populations and valid clinical scenarios exist where one test is clinically advantageous over the other;

- patients and valid clinical scenarios exist where one of the two tests cannot be used at all on safety or practical grounds, and the other test must be used instead; for example, patients who are unable to lie down, patients who require a lower radiation dose or patients who may have contraindications to CTPA;

- a small non-zero technical failure and indeterminacy rate for each test exists, which may necessitate using the other test as backup;

- patient populations and valid clinical scenarios (typically complex and chronic) exist, where combined utilisation of both the tests is clinically appropriate and correct;

- the two tests provide equivalent diagnostic information in the majority of patients and clinical circumstances, and the relative utilisation reflects local expertise and availability.