Medicare Online Overrides

Not Normal Aftercare:

Services provided in the time period following a procedure are classified as aftercare and, in the case of lots of surgical procedures, the benefit for expected aftercare is included in the procedural item fee. If an item is unrelated to the previous attendance (i.e. patient has complications or secondary unrelated issues) it should be marked as 'Not Normal Aftercare' so Medicare knows it is payable. For a detailed explanation of when it is appropriate to use this override see the Medicare Aftercare and Post Op Treatment Education Guide 

Not Duplicate Service:

When billing an item more than once you need to indicate to Medicare this was purposeful using the 'Not Duplicate Service' override so they know that two separate instances of the same item were indeed done (e.g. attendances at different times, biopsies taken at different physical locations, x-rays of separate limbs and not for comparison purposes). Some more information can be found in Medicare Multi-Item Billing Education Guide 

Service Text is usually required to provide further information. For a list of acceptable abbreviations (particularly helpful for radiology) see Medicare Online / ECLIPSE Data Elements Education Guide 

Not Multiple Procedure

The multiple procedure rule is used when billing multiple items within the same attendance to recognise the efficiency to the provider. The 'Not Multiple Procedure' override should be used if the services were legitimately independent, even though they were done during the same attendance, to indicate to Medicare full benefit should be paid on each service (rather than being reduced using 100/50/25). Some more information can be found in Medicare Multi-Item Billing Education Guide. 

Self Deemed

Relevant for both pathology and diagnostic claims. Means that the service was deemed necessary by the provider during the course of the patient care and was not directly requested by another provider. Service provided by a consultant physician or specialist (other than a specialist in diagnostic radiology) or a self-deemed service by a radiologist as an additional service to a valid requested service. 

All self-deemed diagnostic imaging services should be submitted without additional service text. If additional service text must be included then the text field should begin with 'Self Determined'. 

Substituted Service

Relevant for requested diagnostic claims only. Means that a particular service was requested by Provider A but Provider B is claiming a different service instead. According to Medicare, a provider may substitute a service when: 

• the provider determines, from the clinical information provided on the request, that the substituted service would be more appropriate for the diagnosis of the patient's condition, and
• the provider has consulted with the requesting practitioner or taken all reasonable steps to do so before providing the substituted service, and
• the substituted service was one that would be accepted as a more appropriate service in the circumstances by the practitioner's speciality group. 

 

Note: the override check box does not appear in the Sales window, will need to be marked at the time of adding the item to the voucher in ECLIPSE if applicable as per the above screenshot. 

More information about diagnostic ultrasound services, including information about requests, can be found in the Medicare Ultrasound Services (items 55005 - 55855) Education Guide.

Separate Sites:

The 'Separate 'Sites' override should be used to indicate that, while the item descriptions would usually cover the same service, multiple independent services were done on different locations on the body. For an example of this override being used see the 'Independent Procedures' section of the Medicare Multi-Item Billing Education Guide. 

Not Related

Specific to care plan items (mainly used by GP's & Allied Health). Used to indicate that an item is not related to the current care plan / cycle of care. This could be something like a separate service (e.g. mole check) provided at the same attendance as a care plan service (e.g. consultation). 

Not for Comparison

Services done for comparison purposes are usually not payable so you need to indicate to Medicare that there was a separate clinical need for each item. Often used in conjunction with the 'Not Duplicate Service' override and only relevant for radiology / diagnostic services.

Example: Not Payable: Doctor takes an x-ray of the injured left elbow under item 57506, they see something unusual so x-ray the uninjured right elbow to compare - they cannot charge another 57506. 

Example: Payable:  Patient has injured both elbows so doctor x-rays both to assess the damage of each - they could mark the items as 'Not for Comparison' and charge 2x 57506. 

Lost

Appears in logs as 'L'. Indicates a lost, stolen or destroyed referral. This applies to initial attendance items only and a referral should be obtained for subsequent attendances 

In Hospital

Appears in logs as 'H'. Indicates an in-hospital referral where a referral for a privately admitted patient is generated in a hospital for a service in that hospital. 

For ECLIPSE In-patient Medical Claims (IMC) claim types – Agreements (AG), Schemes (SC), billing agent Medicare and private health insurer (MB) or billing agent Medicare only (MO) are set, the referred within: <Facility Id> data will be automatically populated in the claim. You don’t have to enter these details in the service text. For other online claim types this requires either the ‘hospital provider number (facility ID)’ or ‘the hospital name’ details in the service text. 

Emergency

Appears in logs as 'E'. Indicates service provided without referral in an emergency situation. This applies to initial attendance items only and a referral should be obtained for subsequent attendances 

Not Required

Appears in logs as 'N'. Indicates that a referral was not needed for this service. Only applicable to certain services.