MBS Telehealth Documentation Requirements: A Compliance Guide
MBS telehealth items have specific documentation requirements beyond ordinary face-to-face notes — patient consent, modality used, location of patient, and (for many GP items) the eligible-telehealth-practitioner test (formerly called the "established clinical relationship" requirement). This guide details what each note must contain.
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Summary
MBS telehealth items have documentation requirements that face-to-face items don't. Notes must capture: patient consent to telehealth, the modality (video or phone), the location of the patient, and (for many GP items) the eligible-telehealth-practitioner test — the requirement formerly known as the "established clinical relationship" requirement. (The Department of Health and Aged Care's AskMBS advisory of November 2025 renamed the test from "established clinical relationship requirement" to "eligible telehealth practitioner requirement"; the underlying rule is unchanged.) This guide covers the standard tests.
Consent documentation
Patient consent to telehealth is a Medicare requirement and a privacy consideration. Document:
- That telehealth was offered, with the alternative of in-person service.
- That the patient consented to telehealth for this consultation.
- Any specific consent points (recording, third parties present, etc.).
A standing consent in the file is acceptable for ongoing care, refreshed at appropriate intervals.
Modality
MBS items for video and phone telehealth are different. Document:
- The modality used.
- For video: the platform (e.g. Zoom for Healthcare, Coviu, GP-integrated platform).
- For phone: that no video option was available or appropriate, where the item type makes that distinction.
Location of patient
MBS items often require the patient to be in Australia. Some items have geographic carve-outs (e.g. specific MMM regions). Document the patient's location at the start of the consultation.
The eligible-telehealth-practitioner requirement (formerly "established clinical relationship")
For most non-specialist GP telehealth items, the patient must have had at least one face-to-face consultation with the same GP, or another practitioner at the same practice, within the previous 12 months. The requirement is rolling — each telehealth consultation must be assessed against the previous-12-months window. Document the prior visit date and provider, even if briefly.
MyMedicare alternative for Level C/D phone items. From 1 November 2023, the new Level C (longer than 20 minutes) and Level D (longer than 40 minutes) phone items are available exclusively to patients who are registered in MyMedicare at the practice claiming the service. For these specific items, MyMedicare registration replaces the eligible-telehealth-practitioner requirement.
Exceptions exist (after-hours telehealth, certain mental health items, patients in Modified Monash Model 6–7 areas, certain vulnerable cohorts). Where claiming an exception, document the basis.
Standard clinical content
The clinical content of the note still needs to satisfy the underlying item descriptor. Telehealth doesn't relax the requirement to document a relevant history, examination findings (where possible), assessment, and plan. Where physical examination components could not be conducted via the telehealth modality, note that explicitly.
Common audit failures
- No telehealth consent documented.
- Modality not stated.
- Eligible-telehealth-practitioner / 12-month relationship test not addressed (the most common gap).
- MyMedicare registration claimed but not documented in the patient record.
- Telehealth item billed where the descriptor required face-to-face delivery.
- Notes that read identically to the practitioner's face-to-face notes — no acknowledgment of telehealth modality.
Related reading
How we review this guide
Library guides reference original Australian source authorities — not secondary commentary — and are updated when source material changes. Each guide cites the regulator, item descriptor, or governing standard it draws from so you can verify it directly.
- Sources checked
- Medicare Benefits Schedule (MBS)
- Review cadence
- Reviewed annually and whenever a cited source authority publishes a material change. Last reviewed .
- Not advice
- Reference content for Australian practitioners and education staff. Not legal, clinical, or billing advice — verify against your governing body and current source documents.
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