Chronic disease GP Management Plans and Team Care Arrangements

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

• General Practitioner Management Plan (GPMP)
• Team Care Arrangement (TCA).

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 consultations. 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 or TCAs

The patient's usual medical practitioner should provide GPMP and TCAs items. You’re a patients ‘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.

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.

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 Chronic Disease Management items.

Claiming Chronic Disease Management items

This table lists the Chronic Disease Management (CDM) items and how frequently you can claim.

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 twice on the same day. One for a review of a GPMP and one for a review of TCAs.

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 or TCA 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.

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

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.

The 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 education services for health professionals.