Chronic disease GP Management Plans and Team Care Arrangements

Information for medical practitioners about supporting patients needing chronic disease management (CDM).

If your patient has a chronic medical condition, they may be eligible for services under any or all:

  • General Practitioner Management Plan (GPMP)
  • Team Care Arrangements (TCAs)
  • Mental Health Case Conferences (MHCC).

Chronic medical conditions are those that have been, or are likely to be, present for at least 6 months. This includes:

  • asthma
  • cancer
  • cardiovascular disease
  • diabetes
  • kidney disease
  • musculoskeletal conditions
  • stroke.

These care plans help you to coordinate care and reduce the need for ad hoc consults. They’re useful for recording comprehensive, accurate and up-to-date information about a patient’s condition and treatment.

Developing a care plan can also help encourage your patient to take responsibility for their care. Patients may be able to identify things they could do to achieve the goals of the treatment.

Find out more about Changes to MBS items during the coronavirus (COVID-19) response.

How to prepare a GPMP, TCAs or MHCC

The patient’s usual medical practitioner or someone at the same practice should provide GPMP and TCAs items. You’re a patient’s ‘usual medical practitioner’ if you:

  • have provided the majority of services to the patient in the past 12 months
  • will provide the majority of services in the following 12 months.

GP Management plan (GPMP)

When preparing a GPMP you should:

  • explain the steps involved in preparing the plan to your patient
  • record their agreement to proceed.

Then you should write a plan that describes:

  • the patient’s healthcare needs, health problems and relevant conditions
  • management goals and actions for your patient
  • treatment and services that your patient will need
  • arrangements for providing the treatment and services
  • arrangements to review the plan.

Once your patient agrees on their GPMP, offer them a copy and add a copy to their medical record. You can bill items 229 or 721 to prepare a GPMP.

Team Care Arrangements (TCAs)

You must consult with a multidisciplinary team when developing TCAs. A multidisciplinary team includes:

  • the patient’s usual medical practitioner
  • at least 2 other collaborating health or care providers, one of whom may be another medical practitioner.

Each person in the team must be providing a different type of ongoing treatment or service. Not all members need to be Medicare eligible health professionals.

Your patient’s informal or family carer is not counted as part of this team.

When coordinating the TCAs:

  • discuss the steps involved in developing the TCAs with your patient
  • record whether your patient agrees to proceed
  • discuss the multidisciplinary team who’ll contribute to the TCAs and provide treatments and services.

When documenting the TCAs, include:

  • treatment and service goals for the patient
  • treatment and services that collaborating providers have agreed to give
  • actions the patient needs to take
  • review dates.

Once you have completed the TCAs document:

  • offer a copy of it to the patient
  • give copies of the relevant parts of the document to the collaborating providers
  • add a copy of the document to the patient’s medical record.

You can bill items 230 or 723 to prepare TCAs for patients needing treatment for any of the following conditions:

  • chronic disease
  • mental health (MH)
  • eating disorder (ED).

Mental Health Case Conferences (MHCC)

Your patient is eligible for MHCC if they’re being managed under either:

  • a mental health treatment plan
  • an eating disorder treatment and management plan.

Read more about Mental Health Case Conferencing items on the MBS Online website.

You must consult with a multidisciplinary team for MHCCs.

Allied health professionals are eligible if they meet qualification requirements and offer any of the following:

  • psychological therapy health service
  • focussed psychological health service
  • dietetics health service.

This table shows the MBS items for MHCC.

Health professionalAttend, organise and coordinate case conferenceAttend and participate in case conference
GP930, 933, 935937, 943, 945
Non GP medical practitioner969, 971, 972973, 975, 986
Psychiatrist or Paediatrician946, 948, 959961, 962, 964
Allied health professionalN/A80176, 80177, 80178

Each person in the team must be providing a different type of ongoing treatment or service.

Your patient’s informal or family carer is not counted as part of this team.

When coordinating the MHCC you should discuss all of the following with your patient:

  • the steps involved in developing the MHCC
  • the multidisciplinary team who’ll contribute to the MHCC and provide treatments and services
  • whether your patient agrees to proceed, noting their response in the patient’s medical records.

When documenting the MHCC, include:

  • treatment and service goals for the patient
  • treatment and services that collaborating health professionals have agreed to give
  • actions the patient needs to take
  • review dates.

Once you’ve completed the MHCC document:

  • offer a copy of it to the patient
  • give copies of the relevant parts of the document to the collaborating health professionals
  • add a copy of the document to the patient’s medical record.

Patient eligibility

To be eligible for a GPMP, your patient must have a chronic or terminal medical condition.

If they need ongoing treatment from a multidisciplinary team, they’re also eligible for TCAs.

While many patients will be eligible for both a GPMP and TCAs, you can provide the services independently.

CohortPrepare a GPMPCoordinate TCAs

Contribute to a:

  • multidisciplinary plan
  • review of a plan.
Review of a GPMP or TCAs
Patients in the community229, 721230, 723231, 729233, 732
Private in-patients being discharged from hospital229, 721230, 723231, 729233, 732
Public in-patients being discharged from hospital  231, 729 
Private in-patients being discharged from hospital who are residents of aged care facilities229, 721230, 723 233, 732
Care recipients in a residential aged care facilities  232, 731 

You can check a patient’s eligibility by using the MBS Online Items Checker in HPOS to:

  • view and check patient eligibility based on their MBS history
  • check your own eligibility for claiming MBS items
  • check claiming conditions for MBS items.

You can also call the Medicare provider enquiry line to check your patient’s eligibility.

Read the explanatory notes on MBS Online for more information on CDM items.

Claiming CDM items

Read more about MBS Telehealth Services on the MBS Online website.

Service descriptionItem numberClaiming frequency
Preparation of a GPMP229, 721Once every 12 months
Coordination of the development of TCAs for CDM230, 723Once every 12 months
Coordination of the development of TCAs for MH or ED230, 723Once every 12 months
Contribution to a Multidisciplinary Care Plan or to a review for a patient who isn’t in a residential aged care facility231, 729Once every 3 months
Contribution to an Multidisciplinary Care Plan or to a review for a resident in an aged care facility232, 731Once every 3 months
Review of either a GPMP, TCAs for CDM or TCAs for MH/ED233, 732Once every 3 months

You can provide these services more frequently in exceptional circumstances. For example, when there is a significant change in a patient’s condition.

You can claim the review items 3 times on the same day, once for a review of each:

  • GPMP,
  • TCAs for CDM
  • TCAs for MH/ED.

We suggest that practices call and encourage patients to attend an appointment to review their care plan.

Make a note on the patient’s account or include service text for electronic claims. This includes:

  • exceptional circumstances
  • significant change in clinical condition
  • GPMP review, TCAs CDM review or TCAs MH/ED review.

This helps us to assess the claim.

Read the explanatory notes on MBS Online for more information on Chronic Disease Management items.

Co-claiming restrictions

You can’t claim these CDM and general attendance items for the same patient on the same day.

General attendance itemsCDM items
3, 4, 23, 24, 36, 37, 44, 47, 52, 53, 54, 57, 58, 59, 60, 65, 123, 124, 151, 165, 179, 181, 185, 187, 189, 191, 203, 206, 301, 303, 585, 588, 591, 594, 599, 600, 733, 737, 741, 745, 761, 763, 766, 769,772, 776, 788, 789 2197, 2198,2200, 5000, 5003, 5020, 5023, 5040, 5043, 5060, 5063, 5071, 5076, 5200, 5203, 5207, 5208, 5209 5220, 5223, 5227, 5228, 5261, 91790, 91792, 91794, 91800, 91801, 91802, 91803, 91804, 91805, 91806, 91807, 91808, 91890, 91891, 91892, 91893, 91900, 91903, 91906, 91910, 91913, 91916, 91920, 91923, 91926, 92210 and 92211.229, 230, 233, 721, 723, 732, 92024, 92025, 92028, 92055, 92056 and 92059

If your patient needs to visit a different practitioner on the same day, we’ll pay benefits for both consults.

Allied health services

You may decide that your patient would benefit from referral to allied health. They can receive 5 individual services using items 10950-10970, each calendar year.

Patients with type 2 diabetes can also access additional group services for:

  • diabetes education
  • exercise physiology
  • dietetics.

Use the referral forms available on the Department of Health and Aged Care website.

Allied health professionals must write a report back to you after the first and last individual service. They can write more reports if necessary.

Find out more about allied health on the Health Professional Education Resources website.

Page last updated: 3 January 2024.
QC 33191