Medicare eligibility to provide diagnostic imaging and radiation oncology services
Information about what practices need to do to be eligible for Medicare benefits for providing diagnostic imaging and radiation oncology services.
From 1 May 2020, capital sensitivity arrangements for Medicare benefits are changing. To prepare, make sure your diagnostic imaging equipment, including dates, are listed correctly in the Location Specific Provider Number (LSPN) Register.
Read about Capital Sensitivity on the Department of Health website.
Being eligible to claim Medicare benefits for diagnostic imaging and radiation oncology services
You and your patients can only claim Medicare benefits for diagnostic imaging or radiation oncology services if the practice:
- has registered for an LSPN
- is accredited to provide diagnostic imaging services.
Practices that only provide radiation oncology services don’t need to be accredited.
Registering for an LSPN
You must register for an LSPN before you can get accreditation.
You can complete the Register for or amend a Location Specific Practice Number form to register.
Make sure you’ve included all equipment details and completed all date fields on the form. This will help avoid delays with your registration.
Once we process your registration form, we’ll update the LSPN Register and:
- allocate an LSPN to your practice site
- register your equipment
- activate your LSPN from the date we get your form, or a future date you’ve nominated.
We’ll write to you to confirm your LSPN. We’ll also tell you if your application has been rejected and why.
You can send forms and supporting documents to us using the form upload function through HPOS Messages.
You can also view your LSPN details through HPOS.
You can use the LSPN Register to find registered practices and check if their registration is current.
If you provide diagnostic imaging services, you need to apply for accreditation once you have an LSPN. Your practice must be accredited before you or your patients can claim Medicare benefits.
You need to let your patients know if they can’t claim a Medicare benefit because your practice isn’t accredited. It’s an offence if you don’t tell your patients before providing the service. You can read about Health Professional Compliance on the Department of Health website.
Your practice must be accredited under the Diagnostic Imaging Accreditation Scheme (DIAS). This is a requirement for you to provide services in the Diagnostic Imaging Services Table (DIST). You can get accreditation from one of these bodies:
- HDAA Australia Pty Ltd (HDAA)
- National Association of Testing Authorities Australia (NATA)
- Quality Innovation Performance (QIP).
You don’t need accreditation to provide radiation oncology services. This is because radiation oncology services aren’t part of DIAS.
Registering as a practice site or a base for mobile diagnostic imaging equipment
To register, you need to identify as either a practice site or a base for mobile diagnostic imaging equipment. You will need to tell us either:
- the location of your site where the services are performed
- the location of the base for mobile diagnostic imaging services where equipment is normally located when it isn’t in use.
You should identify as a practice site when both of the following apply:
- you provide most of your services from the location your equipment is held
- the equipment you use is rarely taken offsite.
If most of your services are provided away from where you have your equipment, you should identify as a base for mobile diagnostic imaging equipment.
Maintaining your LSPN registration
It’s important to keep your information up to date for your LSPN registration. If you provide diagnostic imaging services, you must make sure you:
- list your equipment on the LSPN Register
- are accredited before you can perform Medicare claimable services.
Read about managing your LSPN in the LSPN HPOS User Guide.
How to renew your registration
We’ll ask you to update your LSPN details each year to maintain registration.
We’ll send a reminder letter to ask you to update your details on the register for your LSPN. If you don’t respond to update notices on time, we’ll suspend your LSPN registration and won’t pay Medicare benefits.
When your practice’s primary information changes
You need to let us know about changes to your practice’s primary information within 28 days. Primary information includes:
- the business name
- the Australian Company Number (ACN)
- the Australian Business Number (ABN)
- details of the equipment on the premises or base for mobile diagnostic imaging equipment
- the address of the premises
- for bases for mobile diagnostic imaging equipment, the address of the proprietor or base (if applicable)
Some details about a provider are also considered primary information. This includes when a provider:
- isn’t employed or contracted to provide services at the practice
- has a financial interest in any of the equipment listed on the LSPN Register.
You can tell us about these changes by completing a Register for or amend a Location Specific Practice Number form.
If the authorised representative can’t sign the amendment or declaration forms because they’re sick or on leave:
- have the forms signed by someone in a managerial position at the practice
- include a letter on practice stationery outlining the change, if someone other than the authorised representative signs the declaration form.
Your Medicare benefits may be affected if you don’t advise us within 28 days.
When your authorised representative changes
Use the Register for or amend a Location Specific Practice Number form to tell us about changes to your authorised representative.
If the authorised representative can’t sign the form, a responsible executive can sign it to approve the changes. For example, the Chief Executive Officer, a General Manager, or Director.
When there are changes to your equipment
You can use the Register for or amend a Location Specific Practice Number form to:
- add new or extra equipment
- tell us the date you upgraded your existing equipment
- replace existing equipment
- update details about equipment
- remove equipment.
You can read about equipment upgrades on the Department of Health website.
If you need a list of equipment for your practice, the proprietor or authorised representative can do 1 of the following:
Please allow 30 days for processing email requests.
When you can start and stop your equipment registration
The table below explains what dates you can use to start and stop equipment registration.
Whichever is later:
The date you specify on the form
When you request changes to MRI equipment
If you request a change to MRI equipment that’s eligible for Medicare benefits, you need approval from the Department of Health. You must get this approval before you submit any LSPN amendment forms.
If you’re registering MRI equipment that isn’t eligible for Medicare benefits, tick the box on the form to indicate it’s ineligible.
Read about MRI eligibility on the Department of Health website.
How to confirm MRI provider eligibility
If you’ve got an eligible MRI unit and there are doctors at your practice who want to provide eligible MRI services, you need to provide their details. Use an LSPN form and confirm both of the following:
- they’re specialists in diagnostic radiology
- they participate in the Royal Australasian College of Radiologists Quality and Accreditation Program.
We can’t pay Medicare benefits for MRI services provided with ineligible MRI equipment. However, practitioners may be able to claim for MRI services for a Department of Veterans’ Affairs (DVA) patients. You can provide MRI services to a DVA patient on ineligible MRI equipment. You’ll need to contact DVA to let them know you want to claim.
Changing your LSPN registration
You’ll need a new LSPN if you either:
- sell or takeover a registered practice site (change of proprietorship)
- move to another location.
This is because LSPNs are location specific. To make sure there are no gaps between billing dates, you’ll need to do all of the following:
- close your existing LSPN registration
- register your new premises.
To close your existing LSPN registration:
- complete the Register for or amend a Location Specific Practice Number form
- tell us date we should close the LSPN registration - this can be a date in the future
- ask the authorised representative or proprietor of the existing LSPN to sign the Declaration for LSPN registration closures.
To register new owners or a new premises:
- complete the remainder of the Register for or amend a Location Specific Practice Number form with the new practice site or ownership details
- tell us when you need the new LSPN registration to start—this can be the day after your existing LSPN closes
- ask the authorised representative or proprietor of the new LSPN to sign the Declaration for LSPN registrations and amendments.
When we give you the new LSPN, you can then organise accreditation to perform diagnostic imaging services. We can’t pay you Medicare benefits without your LSPN and accreditation.
Claiming Medicare benefits
When you claim a Medicare benefit make sure you include your LSPN on both of the following:
- patient accounts and receipts
- each claim for diagnostic imaging or radiation oncology services.
Your LSPN and accreditation to provide diagnostic imaging services must be current on the date you performed the service and be specific to the location.
Go to MBS Online to find appropriate MBS item numbers and payment rates for DIST Category 5 services.
What the Medicare items and exemptions are
There are different Medicare items for diagnostic imaging services listed in the DIST depending on:
- the age of the equipment used for the service
- if you upgraded the equipment
- if your practice has a location based exemption from equipment age requirements.
Use schedule K items for services you perform on newer or upgraded equipment.
Use schedule NK items for services you perform on older equipment.
The Medicare Benefits Schedule (MBS) fee for NK items is approximately 50% of the corresponding K item MBS fee.
Your equipment may be eligible for an age exemption depending on the practice location if either:
- the equipment hasn’t been upgraded and is older than the applicable effective life age
- the upgraded equipment is older than the maximum extended life age.
There are 2 types of exemptions:
- automatic exemptions that apply to practices located in Remoteness Area categories of outer regional, remote and very remote
- exemptions granted by the Department of Health that are for inner regional locations.
Go to the Department of Health’s website to find out about:
- applying for an exemption
- the rules for claiming schedule K and NK items as part of the Capital Sensitivity Measure for Diagnostic Imaging Equipment.
How to confirm your eligibility to provide Positron Emission Tomography (PET) items
Individual providers must be credentialed by the Joint Nuclear Medicine Credentialing and Accreditation Committee to claim Medicare benefits for PET items. When you get your credentials, you can complete and submit the Positron emission tomography - statutory declaration form.
When you can get a remote area exemption for providing diagnostic imaging services without a request
Individual providers can apply for a remote area exemption for a written referral to claim R‑type diagnostic imaging services. You can do this if there are no equivalent NR-type diagnostic imaging items.
You may get an exemption if either of the following apply:
- applying the requirements would cause a patient physical or financial hardship
- the location is in a remote area.
You need to be aware of your obligations when making a request for diagnostic imaging services.
Go to MBS Online to find the rules and requirements when applying for a remote area exemption.
You can read the supporting legislation for diagnostic imaging and radiation oncology services in the Federal Register of Legislation.
Page last updated: 10 September 2020
This information was printed 23 October 2020 from https://www.servicesaustralia.gov.au/organisations/health-professionals/services/medicare/medicare-eligibility-provide-diagnostic-imaging-and-radiation-oncology-services. It may not include all of the relevant information on this topic. Please consider any relevant site notices at https://www.servicesaustralia.gov.au/individuals/site-notices when using this material.