Information to help you review your claiming

Page last updated: 15 August 2018

Duplicate claims

The service rendered appeared to have been claimed and paid more than once.

Services claimed in excess of MBS restrictions

With the listing of new Hepatitis C medications on the Pharmaceutical Benefits Schedule in 01 March 2016, providers have requested information on MBS support for testing. The Hepatitis C MBS items Table provides a reminder of the allowable frequency of MBS testing relating to Hepatitis C. It is supported by the Australian recommendations for the management of Hepatitis C virus infection: a consensus statement (August 2017).

Mutually exclusive item pairs and similar item pairs

These concerns include services requested on the same day where one item descriptor includes or excludes another claimed service, and similar services requested on the same day.

Some item descriptors specify other item/s that cannot be requested on the same day, or some item descriptors differ because they include additional tests. Some item descriptors are for the same or similar conditions but are for use at different stages of a patient’s disease management.

When the items described in the Mutually Exclusive and Similar Item Pairs Table are requested on the same day in respect of the same patient, the Department is concerned that item descriptor requirements for both items may not have been met.

The requesting provider and the service provider (Pathologist) both have a responsibility to ensure that all tests requested/rendered to the same patient on the same day is in line with the correct use of the MBS items.

Co-claiming of MBS items not commonly claimed together

The Department has observed co-claiming of services on the same day involving items not commonly claimed together. While there may be circumstances where these items need to be claimed together, the Department is concerned when a health professional claims these combinations of items more frequently than their peers. Refer to the Co- claiming of MBS items not commonly claimed together Table

Unrestricted items claimed more frequently than restricted items

The Department has observed claiming of unrestricted items more frequently than restricted items; this may reflect services where item descriptor requirements have not been met.

Pathology Item Group Unrestricted item Restricted item(s)
Drug testing 66623 66626
Prostate specific antigen 66656 66659, 66660, 66655

Higher benefit items claimed within a group of similar pathology services

The Department has observed regular claiming of higher benefit items within a group of similar pathology services.

This pattern may indicate incorrect claiming. Refer to Table of higher benefit items claimed within a group of similar pathology services.

Additional information and resources

You can access MBS Online for the most current listing of Medicare Benefits Schedule

Health Insurance (Pathology Services Table) Regulations 2018

Legislations relating to Pathology