Guideline for substantiating urgent attendance after hours services

This guideline outlines how you can substantiate urgent attendance after hours sevices for Medicare Benefits Schedule (MBS) items 597, 598, 599 and 600.

Page last updated: 03 February 2017

What you need to know

This guideline outlines how you can substantiate urgent attendance after hours services for Medicare Benefits Schedule (MBS) Items 597, 598, 599, 600.

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

We may determine that 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 before proceeding.

Claiming an urgent attendance after hours service

Before including an MBS item number on an invoice, receipt or assignment of benefit (bulk bill claim) you should be satisfied that all elements of the item descriptor have been met. In any Medicare audit you will need to substantiate each element of the item descriptor. Depending on the item number you are using, you will need to substantiate the following.

To claim for an urgent attendance after hours MBS item 597 or 598 under Medicare the service is to meet each of the following four requirements and the fifth requirement when applicable. The urgent attendance must be:

  • a professional attendance by a general practitioner (item 597) or by a medical practitioner other than a general practitioner (item 598) on not more than one patient on the one occasion
  • an attendance provided during the following after-hours period:
    • a public holiday
    • a Sunday
    • before 8 am, or after 12 noon, on a Saturday
    • before 8 am, or after 6 pm, on any day other than a Saturday, Sunday or public holiday
    • not during unsociable hours (starting 11 pm and ending at 7 am on any day)
  • an attendance requested by the patient (or responsible person for the patient) not more than 2 hours before the start of, the same unbroken after hours period
  • an attendance provided because the patient’s medical condition requires urgent treatment;

and
  • if the attendance is performed at a consulting room, it must have been necessary for the practitioner to return to and specially open, the consulting rooms for the attendance

To claim for an urgent attendance after hours MBS item 599 or 600 under Medicare the service is to meet each of the following four requirements and the fifth requirement when applicable. The urgent attendance must be:
  • a professional attendance by a general practitioner (item 599) or by a medical practitioner other than a general practitioner (item 600) on not more than one patient on one occasion
  • an attendance provided during unsociable hours (starting 11 pm and ending at 7 am on any day)
  • an attendance requested by the patient (or responsible person for the patient) not more than 2 hours before the start of, the same unbroken after hours period.
  • an attendance provided because the patient’s medical condition requires urgent treatment;

and
  • if the attendance is performed at a consulting room, it must have been necessary for the practitioner to return to and specially open, the consulting rooms for the attendance.

The requirement for urgent treatment

Division 2.15 of the Health Insurance (General Medical Services Table) Regulation 2016 sets out certain criteria for MBS items 597 to 600. In particular, a practitioner needs to form a medical opinion that ‘the patient’s medical condition requires urgent treatment’. Therefore, it is important from a compliance perspective that the medical opinion can be substantiated. The division also outlines situations where item 597 to 600 do not apply to a service provided by a practitioner.

2.15.1 Meaning of patient’s medical condition requires urgent treatment

  • For items 597 to 600, a patient’s medical condition requires urgent treatment if:
      • medical opinion is to the effect that the patient’s medical condition requires treatment within the unbroken after‑hours period in, or before, which the attendance mentioned in the item was requested and
      • treatment could not be delayed until the start of the next in‑hours period
  • For subclause (1), medical opinion is to a particular effect if:
      • the attending practitioner is of that opinion and
      • in the circumstances that existed and on the information available when the opinion was formed, that opinion would be acceptable to the general body of medical practitioners.
2.15.3 Application of Group A11—Urgent attendances after hours

Items 597 to 600 do not apply to a service provided by a medical practitioner if:

  • the service is provided at consulting rooms and the practitioner:
      • routinely provides services to patients in after-hours periods at consulting rooms; or
      • provides the service (as a contractor, employee, member or otherwise) for a general practice or clinic that routinely provides services to patients in after-hours periods at consulting rooms.

Documents substantiating urgent attendance after hours services

To substantiate a claim for urgent attendance after hours services items 597, 598, 599 and 600 you may provide:
    • An excerpt from the patient's record or clinical file maintained by the practitioner showing the date of service, location of attendance, sufficient information to indicate the urgent nature of the attendance and either the eligible time of booking or time of attendance.
    • A copy of the booking maintained by the practitioner or practice showing the time of booking, date of service, location of attendance, sufficient information to indicate the urgent nature of the attendance and evidence which indicates the service occurred.
    • Any document created during the attendance that includes the date of service, location of attendance, sufficient information to indicate the urgent nature of the attendance and either the eligible time of booking or time of attendance.

Resources

For additional resources, follow the links provided below.