Guideline for substantiating Ears, Nose and Throat Surgical Services

Page last updated: 15 March 2017

What you need to know

This guideline outlines what you can do to substantiate valid general ears, nose and throat surgical services were provided such as Medicare Benefits Schedule (MBS) items 41846, 41764 and 30473.

The guideline is not exhaustive and you can respond to a Medicare compliance audit or review using any documents you think substantiate the concern raised.

However, the Department of Health may determine more information is needed and request additional documentation to substantiate services you have claimed.

Documents you may use to substantiate a claim

Any document you give us should have been created during or as soon as practicable after the treatment occurred. It should include the patient's name and the date the treatment was provided.

To substantiate that a valid general and ears, nose and throat surgical service was provided you may submit the following:

  1. An administrative record – Any document created as part of the service that includes the patient's name, date of service and a description of the service. This may include a signed patient consent, day book, appointment entry, payment receipt or account invoice.
  2. A report or plan from the service - This could include a health professional’s report of the service rendered or any plans prepared as part of the service. Examples include GP Mental Health Treatment Plans, Team Care Arrangements, operation reports and specialist reports. Where a service involves the review of a plan or report, records should reflect any changes or progress.
  3. Excerpts from the patient’s file or your notes – Any information in your records that demonstrates compliance when claiming Medicare benefits.
  4. A valid referral from a treating health professional – A referral must contain relevant information about the patient’s condition for investigation, opinion, treatment and/or management, the date of the referral and the signature of the referring practitioner.
In most cases, a patient's clinical information will be the only way to confirm that a specific service was provided, and substantiate you received the correct Medicare benefit.

If you need to use a patient's clinical information you can censor any details that aren't relevant. You can also choose to provide the information to one of our medical advisers.

Resources