Guideline for substantiating claims for diagnostic imaging and pathology services rendered to emergency department patients of public hospitals

Page last updated: 14 January 2016

What you need to know

This guideline outlines what you can do to substantiate diagnostic imaging and pathology services rendered to emergency department patients of public hospitals and claimed under Medicare.

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

However, we may request additional documents from you if more information is needed to substantiate the services you have claimed.

We have concerns that diagnostic imaging and pathology services may have been incorrectly billed to Medicare for emergency department patients in public hospitals.

Public hospitals are funded under an arrangement with the Australian Government to provide free public hospital services to eligible patients. This includes diagnostic imaging and pathology services provided to public hospital emergency department patients. A patient who presents to a public hospital emergency department should be treated as a public patient. If that patient is subsequently admitted they may elect to be treated as a private patient for those admitted services.

For a Medicare claim to be paid for a patient in a public hospital, the patient must be admitted as a private patient at the time the service was rendered.

Where a service for a patient in a public hospital has been billed to Medicare, the hospital or rendering practitioner may be asked to substantiate these claims.

Read the health professional guidelines about substantiating claims for Medicare compliance purposes before proceeding.

Documents you may use to substantiate a claim

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

Substantiating a patient was admitted as a private patient when the service was rendered.

Documents you may use include:
    • the form which the patient (or next of kin, carer or guardian) - has signed indicating that the patient has elected to be admitted as a private patient, and
    • patient records - that show the patient was admitted as a private patient at the time the service was rendered
Note: for Medicare benefits to be paid, a request for the diagnostic imaging or pathology service is also required.

Substantiating the request for the diagnostic imaging service was effective for Medicare purposes.

The request must be in written form (including electronic) and include:
    • a description of the diagnostic imaging service
    • the date of the request
    • the requesting practitioner details including, signature, surname, initial or given names, practice address, provider number, and
    • the patient's name and address
Substantiating the request for the pathology service was effective for Medicare purposes.

The request must be in written form (including electronic) and include:
    • a description of the pathology service
    • the date of the request
    • the requesting practitioner details including, signature, surname, initial or given names, practice address, provider number
    • the patient's name, address, and
    • the details of the hospital status of the patient. This is, whether the patient was or will be, at the time of the service and when the specimen is obtained:
        • a private patient in a private hospital, or approved day hospital facility
        • a private patient in a recognised hospital
        • a public patient in a recognised hospital, or
        • an outpatient of a recognised hospital
You are not expected to produce clinical information relating to a patient unless those details are necessary to substantiate an effective pathology or diagnostic imaging request for a private patient existed.

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.

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