What each MBS item requires in the record

Item numbers, minimum durations, eligibility rules and required components are amended between MBS releases.

• Read the descriptor and the explanatory notes for its category on MBS Online before you claim it.
• Match the descriptor to the date of service.
• Confirm the item number still exists. Items are added, amended, renumbered and withdrawn between releases.
• Check the conditions attached to the item: frequency limits, a referral requirement, a co-claiming restriction, an eligible provider type.

Medicare compliance activity and the Professional Services Review both work from an adequate and contemporaneous records standard, whatever item is claimed.

• Legible and retrievable by another practitioner, in the patient's file.
• A separate dated entry for each attendance, carrying the patient's identifying details.
• Written at the time of the attendance or as soon as practicable.
• Clinical information adequate to explain the type of service: what was asked, what was found, what was concluded and what was planned.
• Comprehensible to a colleague continuing the patient's care from the entry alone.
• Amendments visible: a correction carries its own date and author, and the original text stays readable underneath.

Each tier carries a minimum duration set in the descriptor, and the record carries the duration and the clinical work that filled it.

• Time spent: start and finish times, or the duration, recorded against the entry.
• History: the presenting problem and the history obtained at that attendance.
• Examination: the findings elicited, including the relevant negatives.
• Assessment: the diagnosis or differential those findings led to.
• Management: investigations ordered, medicines started or changed, referrals made, and the follow-up agreed with the patient.

Planning and assessment items require a documented plan or assessment carrying the components the descriptor lists. The chronic condition family has been restructured, so confirm the current item numbers.

• Chronic condition management: the conditions covered and the current treatment, goals and actions agreed with the patient, the services and providers involved, the patient's agreement and the offer of a copy, contributions from other providers where the descriptor requires collaboration, and what changed at review.
• Mental health treatment planning: presenting problem, relevant history, mental state examination and risk assessment, the outcome tool used and the score returned, goals, treatment, referrals and crisis arrangements, the patient's agreement, and progress against the goals at review.
• Health assessments: the age, cohort or circumstance that brings the patient within the item, the components the descriptor lists, the findings including areas assessed as unremarkable, recommendations and follow-up, and the time taken matched to the tier claimed.

• Modality: video or telephone, stated in the entry.
• Telehealth eligibility: the basis on which the patient met the existing-relationship requirement, or the exemption relied on.
• Consent to the modality: the patient's agreement to be seen remotely.
• Time of the service, plus the urgency basis where an after-hours descriptor requires one.
• Where the parties were, for descriptors that turn on the patient's location.

The procedure note carries the evidence for the claim.

• Indication: the clinical reason the procedure was performed.
• Consent: what was explained, the risks discussed, and the patient's agreement.
• What was performed: the procedure, the site and side, the anaesthesia used, and any specimen taken.
• Findings and complications: what was seen, what was done about it, and the patient's condition at the end.
• Who performed it, and any assistant claimed separately.
• The report a diagnostic item requires, and the date it was issued.