Processing radiation oncology 011-43010150

Processing radiation oncology can be complex and Service Officers must take extra care when processing these claims. It is important to check the patient account/invoice and/or transmitted claims have all the relevant information provided to assess the claim according to legislation. See Radiation oncology (radiotherapy) for details about assessing these claims.

If any errors are keyed, or fields/sites are overlooked during processing, an incorrect benefit could be paid and a latter-day adjustment may be required.

Radiation oncology claims must only be processed by experienced Service Officers. If a Service Officer is not skilled in processing radiation oncology claims, the claim must be proficiency raised in PaNDA and/or escalated to the Claims Interpretation (CI) queue.

Mainframe return message

Some return messages in mainframe include the term 'fields'. Relevant full return messages have been amended for fields/sites:

• Fields were relevant to derived fee services before 1 July 2024
• Sites are relevant to services from 1 July 2024

Other existing return messages also have new content. Service Officers must read and action all return messages to ensure claims are correctly assessed and paid.

Note: these are vulnerable customers and processing their accounts/invoices incorrectly may cause unnecessary pressure on them and their families.

From 1 July 2024, radiation oncology items reduced from 90 to 43.

Under the new legislation, all premises:

• need accreditation with a Location Specific Practice Number (LSPN) number, and
• must register all radiation oncology equipment

From 1 July 2024, items are no longer structured around the number of fields. Service Officers no longer need to use fields for claims.

From 1 November 2024, the derived fee for item 15954 was replaced with a flat schedule fee of $22.00, indexable each year in line with other items.

Items 15952 and 15954 should be claimed as follows:

• 15952 billed when one anatomical site only is being treated at the attendance
• Treatment to 2 or more anatomical sites during the same attendance:
• 15952 billed for the first site, and
• 15954 billed for each additional site (maximum of 10 sites)

One site treated

15952 - Delivery of kilovoltage radiation therapy (50 kV to 500 kV range) to one anatomical site (excluding orbital structures where there is placement of an internal eye shield).

Additional sites treated

15954 - Delivery of kilovoltage radiation therapy (50 kV to 500 kV range) to each additional anatomical site following delivery to one anatomical site treated under item 15952 (excluding orbital structures where there is placement of an internal eye shield).

If multiple sites are treated, the account/invoice/transmitted claim must include the initial site item 15952 and the additional sites item 15954. For example, 15952 + 15954 +15954 where 3 sites are treated at the same attendance. Appropriate text must be included on each item as to what site was treated.

If a claim indicates additional sites that have not been itemised on the account/invoice, do not process the claim without first contacting the health professional to clarify. The Process page contains details about processing these claims.

The Resources page contains details about initial and additional items and return messages.

Appropriate text

Multiple planning and treatment items can be paid for planning and treatment of multiple sites on the same date of service.

The full name of the anatomical sites treated must be clearly identified and differentiated in the claim text. In general, this applies to each item for planning, re-planning, or treatment. The Resources page contains a link to revised explanatory notes in the updated schedule.

Example of appropriate text

Full anatomical name of specific body areas (no abbreviations). For example, 'right breast', 'left breast', 'arm', 'rib'.

Note: text/notes containing 'separate episodes of care', 'separate times', 'separate sites', 'AM' or 'PM' will not be accepted. The full name of the specific body area is required, except for item 15954.

The Resources page contains information about processing claims with text or notes and a link to MBS Online.

Claim details - check fields

The level of benefit depends on the:

• number of fields treated
• equipment used

If multiple fields are treated, the account/invoice must include the single field base item and the additional field derived fee item.

When the charge quoted includes additional fields that have not been itemised on the account/invoice, do not process the service without first contacting the health professional to clarify. The Process page contains information about how to process these claims.

When processing a radiation oncology claim the base item (one field) and correlating derived fee item (2-5 fields) must be associated. The system returns an error message if the incorrect items have been used.

See the Resources page for more details on:

• base and derived fee items
• return messages

Appropriate text

Where multiple items are claimed and restrictions apply, the health professional must provide text or a note to support their claim.

The text required may differ depending on the item and whether the claim is submitted manually or electronically.

Examples of appropriate text include:

• times of each service as noted in the Text field (Service Time field often defaults to the transmission time for online claims)
• separate attendance
• specific body areas, for example right breast, left breast
• HGL and HGR (for online claims)
• sacrum 10am and femur 2pm
• separate episode of care

The Resources page contains information about processing claims with text or notes.

Item structure

The items in group T2, subgroup 3 of the Medicare Benefits Schedule (MBS) are structured according to:

• the equipment used
• the body region being treated:
• lung
• prostate
• breast
• other region
• whether the region is the:
• primary site
• secondary site
• single field base item - additional field derived fee item, to a maximum of 5 additional fields

The Resources page contains a link to MBS Online.

Restrictions on radiation oncology items may need manual intervention. Follow the assessing rules in QITI and refer to the general explanatory notes on MBS Online when processing and before providing any advice.

See the Resources page for a table that outlines the restrictions and the appropriate text required to override the restrictions.