Guideline for substantiating that a patient had a pre-existing condition at the time of the service

Page last updated: 15 January 2016

What you need to know

This guideline outlines what you can do to substantiate that an individual had a specified condition before the service is eligible. This relates to Medicare Benefits Schedule (MBS) items 11823, 18350 and 30511.

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, we may determine more information is needed and request additional documentation to substantiate services you have claimed.

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 practicable after the treatment occurred. It should include the patient's name and the date the treatment was provided.

To substantiate that a patient had a specified condition at the time of the service you may provide:
  • an excerpt from the patient's clinical file - clearly showing the patient's name, the date of the service and evidence of the existence of the condition. This may include:
      • a test result (for example: fasting glucose, HbA1c, spirometry report)
      • a diagnostic imaging report
      • a letter from a specialist or consultant physician verifying presence of the condition
      • sufficient clinical information, such as findings on history and examination, verifying presence of the condition
The Department has no role in determining if the clinical opinion is correct as to the existence of the specified condition.
  • any document created during or as soon as practicable after the service - that contains a reference to the condition existing, including a test result or note from another practitioner
  • an excerpt from a GP management plan - clearly showing the patient's name, date of the GP management plan and a comment that the condition exists
In most cases, a patient's clinical information will be the only way to confirm that the patient had a specified condition at the time of the service, and to substantiate you received the correct Medicare benefit.

If you need to use a patient's clinical information you can de identify or 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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