Chronic Disease Management services - supporting Indigenous health

An overview of services in the MBS for managing Indigenous patients with a chronic or terminal condition. Includes a case study.

Make sure you read the relevant Medicare Benefits Schedule (MBS) item descriptions and explanatory notes on MBS Online.

Chronic Disease Management services

Chronic Disease Management (CDM) services help eligible practitioners coordinate health care for patients with chronic or terminal medical conditions. These medical conditions are present or are likely to be present for 6 months or longer, or are terminal. Examples include:

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

Practitioners who can claim for CDM items include:

  • general practitioners (GPs)
  • prescribed medical practitioners.

The patient’s usual medical practitioner or someone in the same practice should provide CDM items. ‘Usual medical practitioner’ means:

  • the medical practitioner or a medical practitioner in the same practice who has provided the majority of services to the patient in the past 12 months
  • the medical practitioner who is likely to provide the majority of services in the following 12 months.

CDM services also include Mental Health Case Conferences (MHCC).

Read more information for medical practitioners about Chronic disease GP Management Plans and Team Care Arrangements.

Read more about CDM services on the MBS Online website.

Assisting with CDM items

Other health professionals can help eligible practitioners deliver some services, including:

  • CDM plan development
  • monitoring and support services - items 10997, 93201 and 93203.

The tables below give further details.

CDM plan development

Health professionals who can helpType of support they can giveRequirements
  • Practice nurses
  • Aboriginal and Torres Strait Islander health practitioners
  • Aboriginal health workers
  • Other health professionals

Can help to prepare, contribute and review CDM items, including:

  • performing patient assessment
  • identifying patient needs
  • arranging for services.

Eligible practitioners must meet all Medicare item requirements, including:

  • reviewing and confirming assessments
  • seeing the patient.

Monitoring and support services items 10997, 93201 and 93203

Health professionals who can helpType of support they can giveRequirements
  • Practice nurses
  • Aboriginal and Torres Strait Islander health practitioners on behalf of a medical practitioner
May provide up to 5 services per calendar year for a patient who has a current CDM plan.

The service must be:

  • provided on behalf of and under the supervision of the eligible practitioner
  • consistent with the patient’s CDM plan.

Closing the gap on Indigenous health

These initiatives provide support for Aboriginal and Torres Strait Islanders to better manage chronic disease:

Case study

This case study focuses on an Indigenous patient. It provides examples of suitable CDM items for different health professionals providing coordinated health care.

A 52-year-old Indigenous patient presents with an infected foot that requires wound management and antibiotics.

Their medical history includes:

  • hypertension and high cholesterol
  • mild renal condition
  • myocardial infarction
  • type 2 diabetes
  • increasing circulation concerns with associated foot issues.

As well as this, they:

  • have a family history of heart disease
  • smoke
  • have a poor diet
  • seldom seek medical attention
  • usually attend the clinic every 6 months for script renewals
  • aren’t effectively managing their chronic conditions.

Actions to develop the care plan

First visit

This visit you:

  • discuss the patient’s health issues
  • outline the potential benefits of a care plan
  • outline the process of putting a structured plan in place to better manage their chronic conditions
  • decide to develop a GPMP, items 229 or 721, and TCAs, items 230 or 723, to manage the patient’s care needs
  • collaborate with and coordinate treatment by a multidisciplinary team of health and care providers
  • tell the patient you’ll start developing the plan
  • discuss it further with them when they come back in a few days for wound review
  • ask if the patient minds if an Aboriginal and Torres Strait Islander health practitioner assists you
  • explain what is involved to the patient.

The patient agrees to the plan.

Follow-up visit

The next visit you:

  • go through the draft plan and discuss your goals and actions for the patient and the health care team
  • discuss arrangements for services with allied health professionals
  • make arrangements for specialist services at the local public hospital with a cardiologist, endocrinologist, renal physician and ophthalmologist
  • offer a copy of the plan to the patient
  • ask if you can distribute relevant information from the plan to other health and care professionals
  • explain that you can refer them for some Medicare-subsidised allied health services.

The patient agrees with your decisions.

Referrals

You decide to refer your patient for allied health services, including:

  • 3 individual services with a podiatrist - item 10962
  • 2 individual services with an Aboriginal Health Worker - item 10950
  • one assessment for suitability for group education services with a diabetes educator - item 81100.

Monitoring and support services

As well as these services, you ask the patient to attend services with the Aboriginal and Torres Strait Islander health practitioner. This will be under MBS item 10997, 93201 or 93203.

This is to:

  • check on the patient’s clinical progress
  • monitor medication compliance
  • provide self-management advice
  • collect information to support future reviews of care plans.

More information

Read more about:

Contact us for MBS item interpretation.

Provide your feedback on our education resources.

Page last updated: 20 February 2024.
QC 31796