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. For details about assessing these claims, see Radiation oncology (radiotherapy).

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, with only one derived fee item.

Under the new legislation, all premises:

• need accreditation with an 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. Under the new radiation oncology items, only one derived fee item exists. This requires the number of sites to be entered to calculate the benefit.

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), other than a service to which item 15954 applies.

Additional sites treated

15954 - Delivery of kilovoltage radiation therapy (50 kV to 500 kV range) to 2 or more anatomical sites (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 single site base item 15952 and the additional sites derived fee item 15954.

When processing a radiation oncology claim it is important that the base item 15952 (one site) is in the same claim as the associated derived fee item 15954 (2 or more sites). This is so the system can calculate the correct benefit. The system returns an error message if the base item is missing, or incorrect items have been used.

If multiple base items (each with a derived fee item) are claimed for the same date of service, the 2 claims must be submitted separately. For example: 15952 + 15954 in one claim and 15952 + 15954 in a separate claim. The system cannot calculate the correct benefit if more than one derived fee item for the same date of service exists in the claim.

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. See the Process page for details.

See the Resources page for more details on base and derived fee 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. See the Resources page for a link to revised explanatory notes in the updated schedule.

Examples of appropriate text include:

• full anatomical name of specific body areas (no abbreviations). For example, 'right breast', 'left breast', 'arm', 'rib' etc.
• for item 15954, the number of subsequent sites treated. For example, '7' or '3'

Note: text/notation 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.

See the Resources page for a table to help with processing claims with text or notation 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. See the Process page for details.

When processing a radiation oncology claim it is important that the base item (one field) and correlating derived fee item (2-5 fields) are 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 notation 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

See the Resources page for a table to help with processing claims with text or notations.

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.

See the Resources page for 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.