Processing radiation oncology 011-43010150

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.

These customers are in vulnerable situations. Processing claims incorrectly may cause added pressure for them and their families.

Radiation oncology claims are often highly valued. Service Officers must make sure claims include all the required and relevant information to enable the claim to be assessed according to legislation. See Radiation oncology (radiotherapy) for details about assessing these claims.

If any errors are keyed, or the claim not assessed correctly, an incorrect benefit could be paid and a latter-day adjustment may be required.

Mainframe return message

Some return messages in mainframe include the term 'fields' or ‘sites’:

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

Service Officers must read and action all return messages to make sure claims are correctly assessed and paid.

From 1 July 2024, radiation oncology items reduced from 90 to 43. All items before 1 July 2024 (except for item 15900) have ended. 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.

All radiation oncology treatment premises:

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

See Eligibility and Location Specific Practice Number (LSPN) registration for Diagnostic Imaging (DI) and Radiation Oncology (RO) for more information.

Claims for each planning item must clearly identify a unique site in claim text.

The Resources page contains details about acceptable text.

Multiple sites treated on same day

A course of treatment is specific to each anatomical site that is being treated.

When multiple sites are treated on the same day, the claim for each treatment item must clearly identify a separate anatomical site in the claim text.

If one or more of the sites are being treated twice on the same day, health professionals must also identify the first and second treatments on the same day in claim text.

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.

Twice daily treatments (Megavoltage items 15930 - 15940 and 15948)

From 1 July 2025, health professionals are required to provide supporting text when submitting a claim for 2 treatment items to the same site, on the same day. Claims will include the word 'first' for the initial treatment of the day and 'second' for the second treatment of the day.

If a claim is submitted for multiple treatment items on the same date of service, check the claim or the patient’s history that:

• one claim indicates the text as 'first', and
• one claim indicates the text as 'second'

Where the supporting information has been provided, override the restriction as per the return message.

If a claim is submitted for multiple treatment items on the same date of service, and multiple plans are evident check treatment items in the claim or the patient’s history indicate that:

• the treatments are for separate anatomical sites i.e. liver, lung, and
• one claim indicates the text as 'first', and
• one claim indicates the text as 'second'

Where the supporting information has been provided, override the restriction as per the return message.

Note: the twice daily treatments do not have to be processed in order - first before second. This may occur in claims where treatment is split between a bulk bill and a patient claim.

The Resources page contains details about acceptable claim text.

Kilovoltage treatment items 15952 and 15954

Items must be claimed as:

• 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 (each anatomical site must be identified in claim text)

Acceptable claim text

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

Where patients need plans for radiotherapy treatment to multiple separate sites of disease at one attendance, each treatment site must be documented in a separately prescribed plan. Claim text must clearly state the separate anatomical sites by name (for example left breast, right breast, pelvis, brain).

For items 15930 - 15940 and 15948, health professionals must differentiate the first and second treatments, if treated on the same date of service, by notating 'first' and 'second'.

Restrictions must be overridden if claims include acceptable text, follow the relevant assessing rulings on QITI.

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 acceptable claim text and explanatory notes in the MBS.

Example of appropriate text

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

Note: claim 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.

The Resources page contains information about processing claims with text or notes and 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 the appropriate text required to override restrictions.

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 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.