Guideline for substantiating proof of malignancy

Page last updated: 14 January 2016

What you need to know

This guideline outlines what you can do to substantiate histopathological proof of malignancy for Medicare Benefits Schedule (MBS) items 30196, 30197, 30202, 30203 and 30205.

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.

Documents you may provide to substantiate a claim, include one or more of the following:
    • a written specialist report - clearly showing the patient's name, date of service and enough information to indicate malignancy was confirmed
    • an excerpt from a specialist's patient clinical file - clearly showing the patient's name, the date of the service and enough information to indicate malignancy was confirmed
    • a histopathological report - showing malignancy within the lesion that was removed, or where multiple lesions are removed from a single anatomical region, a histopathological report showing malignancy within a lesion from that region.
Note: The proof of malignancy doesn't need to be available before the service being rendered but must be available before the service is billed.

In most cases, a patient's clinical information will be the only way to confirm malignancy, 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.

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