Account requirements for pathology services in Medicare 011-42090010

Part 3 – division 5 of the Health Insurance Regulations 2018 states that the following details must be recorded for a pathology service on the account, account receipt or assignment of benefit form:

• name and address of the provider who performed the service or provider number
• the name of the patient
• date of service
• name of the requesting provider or in the case of a referred test, the name of the original requesting provider
• date of the request or in the case of a referred test, the date on which the original request was made
• the requesting provider's provider number
• a description in words to clearly identify the service (a relevant item number can also be accepted)
• amount charged for service
• total amount paid for service
• any outstanding amount
• the specimen collection point (SCP) identification number

Note: where the Approved Pathology Practitioner (APP) determines or provides a pathology service on their own patient, the account must be endorsed with the letters SD.

Where services are referred from one APP to another APP, the request details to be shown on the second APP's account, account receipt or assignment form must be identical to those of the original requesting practitioner including the date of request.

Split billing of services for an Approved Pathology Provider

If the Approved Pathology Provider splits the billing of services within a patient episode, that is, some items are billed as patient claims and some are bulk billed, the Service Officer must process the claim appropriately.

There is no legislative requirement under the Health Insurance Act 1973 that all items of a patient episode must be billed through the same channel. For further information on the splitting of pathology bills, please contact the Medicare Claims Helpdesk.

Prescribed pathology tests

For prescribed pathology services (a pathology service in Group P9) the practitioner must ensure the account, account receipt or assignment form includes:

• the practitioner's name and address or provider number
• date of service
• a description in words to clearly identify the service (a relevant item number can also be accepted)

Accounts and receipts for pathology services from Group P1 to Group P8 of the Pathology Schedule must contain the following request details:

• the name of the requesting practitioner
• the requesting practitioner’s provider number
• the date on which the request was made by the treating practitioner

Accounts containing pathology services that have been self-determined must be endorsed:

• SD (self-determined)

A Specimen Collection Point (SCP) identifier is required to be present against pathology items if the specimen was collected in a licensed collection centre or approved pathology collection centre.

Medicare benefits are not payable in respect of a pathology service unless specified details are provided by the practitioner rendering the service, on their account, receipt or assignment form. These requirements are specified in the Regulations.

Account details

The following details must also be recorded on the account, receipt or assignment form of the approved pathology practitioner providing the service:

• The surname and initials of the treating practitioner who performed the service, or
• The surname and initials of the approved pathology practitioner who performed the service or on whose behalf the service was or can be performed in that laboratory, and either their practice address or provider number for the address.
• The name of the person to whom the service was rendered.
• The date on which the service was rendered.
• The name of the requesting practitioner who is the treating practitioner. Note: this applies regardless whether one Approved Pathology Practitioner (APP) refers tests to an unrelated APP.
• The date on which the request was made by the treating practitioner.
• The requesting practitioner's provider number if the request was generated at the practitioner's practice location or where the request was not generated from the practitioner's practice location, the provider number of any place at which the practitioner practices.
• The item number or a description of the pathology service in words which are derived from the item description in the Medicare Benefits Schedule and are of sufficient detail to identify the specific test in the Medicare Benefits Schedule that was rendered. A group abbreviation can also be used.
• The account must be endorsed self-determined (SD) when:
• The treating practitioner determines and provides a pathology service on their own patient.
• An APP who is not the patient's treating practitioner provides a pathologist determinable service based on the results of tests requested by the treating practitioner.
• The collection centre Identification number if the specimen was collected in a Licensed Collection Centre (HIR (13(9, 10 and 12)).