Guideline for substantiating optometry services

Page last updated: 21 November 2016

What you need to know

This guideline outlines what you can do to substantiate optometry services for Medicare Benefits Schedule (MBS) items 10912, 10913, 10914, 10915, 10942 and 10943.

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 item 10912 - significant change in visual function that needs comprehensive reassessment within 24 months of the initial consultation where item numbers 10900, 10905, 10907, 10912, 10913, 10914 or 10915 apply at the same practice, you may provide:

  • a copy or excerpt of recorded evidence of the patient's clinical file or patient records - clearly explaining any significant changes in visual function.
To substantiate item 10913 – new signs or symptoms unrelated to the earlier consultation, that needs comprehensive reassessment within 24 months of an initial consultation where item numbers 10900, 10905, 10907, 10912, 10913, 10914 or 10915 apply at the same practice, you may provide:

  • a copy or excerpt of recorded evidence of the patient's clinical file or patient records - clearly explaining any new signs or symptoms suffered.
To substantiate item 10914 – progressive disorder (excluding presbyopia) that needs comprehensive reassessment within 24 months of an initial consultation where item numbers 10900, 10905, 10907, 10912, 10913, 10914 or 10915 apply at the same practice, you may provide:

  • a copy or excerpt of recorded evidence of the patient's clinical file or patient records - clearly explaining the nature of the progressive disorder.
To substantiate item 10915 – diabetes mellitus requiring comprehensive reassessment you may provide:

  • a copy or excerpt of recorded evidence of the patient's clinical file or patient records - clearly explaining the patient has been diagnosed with diabetes mellitus.
Note: these may not be due to an ocular condition. Examples include ocular symptoms from non- ocular causes such as migraine, cerebral lesions or hypertension which require comprehensive ocular examination.
To substantiate item 10942 and 10943 you may provide:

  • a copy or excerpt of recorded evidence of the patient's clinical file or patient records - clearly explaining the tests or assessments you carried out on the patient.
To claim item numbers 10942 and 10943, you must carry out additional tests or assessments on the patient. These can be claimed on the same day as a comprehensive or subsequent consultation.

Note: Item number 10942 can be paid twice in a 12 month period and 10943 can only be paid once in a 12 month period.

The tests or assessments you can claim for using MBS items 10942 and 10943 are outlined in the Schedule of Services Group A10—Optometric Services. You can download this from on the MBS Online website.

In most cases, a patient's clinical information will be the only way to confirm that a specific treatment was performed during the service, and to 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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