GP chronic condition management plans

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

• general practitioner chronic condition management plan (GPCCMP)
• multidisciplinary care plan.

A patient with an eligible care plan may be eligible for a range of MBS-supported individual and group services, including:

• allied health services
• Aboriginal and Torres Strait Islander health and wellbeing services
• other support services.

Read more information on CCM items in the explanatory notes on MBS Online.

General practitioner chronic condition management plan (GPCCMP) services

The GPCCMP items are intended for patients that would benefit from a structured approach to managing their chronic condition.

The patient’s usual medical practitioner or someone at the same practice should bill GPCCMP items. You’re a patient’s usual medical practitioner if you, or are located at a medical practice that either:

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

Patients registered in MyMedicare must access GPCCMP items from the practice where they are registered. Read more about MyMedicare.

Once your patient agrees with their GPCCMP, offer them a copy and add a copy to their medical record.

Multidisciplinary care plans

Multidisciplinary care plans:

• are part of the MBS framework for managing patients with chronic conditions
• allow you to contribute to or review a plan developed by other health professionals.

A multidisciplinary care plan requires a minimum of 3 collaborating providers supplying different types of services to the patient.

Billing chronic condition management (CCM) items

To be eligible for a GPCCMP or a multidisciplinary care plan, your patient must have at least one medical condition that has been, or is likely to be, present for at least 6 months or is terminal.

The review items allow you to periodically review and adjust your patient’s plan as required.

A patient must have had a GPCCMP prepared or reviewed in the previous 18 months to access allied health and Aboriginal and Torres Strait Islander health and wellbeing services.

There are requirements you must meet to bill these items.

Read the relevant item descriptions, fact sheets and explanatory notes on the MBS Online website.

General practitioner chronic condition management plan (GPCCMP) items

You can bill these items for preparing or reviewing a GPCCMP if you’re working in general practice and are either the patient’s:

• usual medical practitioner
• a general practitioner (GP) or prescribed medical practitioner (PMP) at the practice the patient is enrolled in for MyMedicare.

Chronic condition management (CCM) multidisciplinary care plan items

You can bill the following items for contributing to or reviewing a CCM multidisciplinary care plan prepared by another health professional.

The same items apply for both:

• contribution
• review.

Patients living in the community

Patients with a multidisciplinary care plan and living in the community are not eligible for MBS-supported allied health and Aboriginal and Torres Strait Islander health and wellbeing, and other services.

Patients who are residents of an aged care facility

Care recipients of a residential aged care facility who have a multidisciplinary care plan may be eligible for MBS-supported allied health and Aboriginal and Torres Strait Islander health and wellbeing, and other services.

Co-claiming restrictions

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

Read more about GPCCMP co-claiming restrictions on the MBS Online website.

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