Correct Medicare billing for a complete medical service PDF printable version of Correct Medicare billing for a complete medical service (PDF 17 KB)
Last updated 10 February 2011.
What is a complete medical service?
A long standing general principle in the Medicare Benefits Schedule (MBS) is that each professional service listed is a complete medical service in itself. To bill an item you must be confident you have fulfilled the service requirements as specified in the item descriptor. The full description of the service is important as it ensures correct identification of the service and thereby avoids the possibility of error in the processing and claiming of Medicare benefits.
Where a service is covered by more than one item it is important to understand the requirements of each item. Some comprehensive items will specify that other services should be provided in conjunction with that item and other items will describe only the specific service provided. In such cases the item representing the comprehensive or ‘complete’ service is the item that should be claimed, not the items representing the individual services.
Where a comprehensive item is used, separate items should not be claimed for any of the individual services included in the comprehensive service. For example, benefit is not payable for item 49809 (a foot tenotomy – cutting of the tendon) or item 50112 (correction of contracted joint) when claimed in association with item 49848 (correction of claw or hammer toe) since the cutting of the tendon and correction of contracted joint is an integral part of the operation for correcting claw or hammer toe.
Does this mean practitioners can only bill one item?
Where only one service is rendered, only one item should be billed. Where more than one service is rendered on one occasion of service, the appropriate item for each discrete service may be billed, provided that each service fully meets the item descriptor. Where an operation comprises a combination of procedures which are commonly performed together and for which there is an MBS item that specifically describes the combination of procedures then only that item should be billed.
The incorrect use of MBS items can result in penalties, including the health care provider being asked to repay monies that have been incorrectly received. Therefore, it is extremely important to understand the full requirements of each medical service, and the complete medical service principle, prior to billing a MBS item.
Will compliance of this be a key focus of the increased Medicare audits to be conducted by Medicare Australia?
Medicare Australia’s current risk assessment processes will continue to apply to all items claimed under Medicare. Practitioners are identified using a combination of the following techniques:
- artificial intelligence (predictive computer programs)
- claiming data analyses
- intelligence analysis (analysis of information specific to a case or person)
- top providers data analysis
- tip-offs from the public and referrals
Medicare Australia’s National Compliance Program is developed in consultation with stakeholders including the medical profession. The document is published every year and outlines where Medicare Australia will focus its efforts, identifying the key compliance risks and specifying the actions which will be taken to address these risks. The 2008-09 program was launched by the Minister for Human Services on 4 September 2008.
Practitioners should claim the most appropriate Medicare item for the service they provide to the patient. When billing for a service the practitioner should ask two questions:
(1) Does the service rendered comply with the time and content requirements of the MBS item descriptor? and
(2) Would the majority of my peers accept that the treatment provided during the service is clinically appropriate for this patient?
A practitioner who can confidently answer yes to both questions and who has adequately documented the service should be able to address any concerns raised in the event of an audit by Medicare Australia or an investigation by the Professional Services Review.
Is the Department of Health and Ageing planning other changes to assist practitioners to be confident they are claiming only items they are entitled to?
Medical practitioners who are unsure of the interpretation of the Schedule can contact Medicare Australia on 132 150.
There are more factsheets available from the Factsheets page
Created on 28 August 2008.