Billing of diagnostic and pathology services in emergency departments and for public patients

There are many situations that can arise in the administration of Medicare billing in public hospitals. These case studies have been constructed to help you know how you can improve your Medicare billing practices.

Case study

Mr A presents to a public hospital emergency department with a suspected fracture.

The emergency physician requests an X-ray, and an INR (a test to see how thin the blood is), from contracted private diagnostic imaging and pathology services (as Mr A is on warfarin).

Following confirmation of the fracture, Mr A signs an election form to be treated as a private patient. He is admitted as a private patient at the public hospital with a fractured forearm and is treated by Dr B, an orthopaedic surgeon.

The contracted private diagnostic imaging and pathology services bill Medicare for the requests from the emergency department

Is this appropriate?

No.

Clause G20 of the National Health Reform Agreement stipulates that where a patient chooses to be treated as a public patient components of the public hospital service (such as pathology and diagnostic imaging) will be regarded as a part of the patient's treatment. They will be provided free of charge.

Medicare benefits are not payable for services provided to a patient in a public hospital emergency department.

Diagnostic imaging and pathology service providers should check the patient's status before billing Medicare. This is generally done through a request form.

The companies concerned should have billed the hospital for the services.

Mr A signed an election form, with informed financial consent, to be treated as a private patient once a fracture was confirmed by X-ray. All future clinically relevant MBS services could be billed to Medicare.

It is noted that sometimes request forms do not indicate whether a patient is public or private. In these circumstances, it remains the responsibility of the biller to ensure the patient is eligible for a Medicare-billed service. Including through contacting the requesting physician.

Key Points

  • Medicare benefits are not payable for services provided to a patient in a public hospital emergency department.
  • Diagnostic imaging and pathology services providers should check the patient's status before billing Medicare.
Last updated: 
11 August 2021

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