Education guide - Chronic disease GP Management Plans and Team Care Arrangements

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

GP Management Plans and Team Care Arrangements

If a patient has a chronic medical condition, they may be eligible for services under a General Practitioner Management Plan (GPMP) or Team Care Arrangement (TCA). Chronic medical conditions are those that have been, or are likely to be, present for at least 6 months. Examples include:

asthma
cancer
cardiovascular disease
diabetes
kidney disease
musculoskeletal conditions
stroke.

GPMPs and TCAs help practitioners coordinate the care of people with chronic conditions. They also help to reduce the need for ad hoc consultations. Care plans are 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.

Who should prepare GPMPs and TCAs

Practitioners who can claim for GPMPs and TCAs include:

general practitioners (GPs)
non-vocationally recognised medical practitioners (non-VR MPs).

The patient's usual medical practitioner should provide GPMP and TCAs 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.

How to prepare GPMPs and TCAs

Preparing GPMP items 229 or 721

When preparing a GPMP you should:

explain the steps involved in preparing the plan to your patient, and
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.

Preparing TCAs items 230 or 723

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

the patient’s eligible practitioner
at least 2 other collaborating health or care providers, 1 of whom may be another medical practitioner.

Each person in the team must be providing a different type of ongoing treatment or service. They do not need to be Medicare eligible providers.

A patient's informal or family carer does not count as a healthcare provider.

When preparing the TCAs:

discuss the steps involved in developing the TCAs with your patient
record whether your patient’s agrees to proceed
discuss the multidisciplinary team who will 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.

Determining patient eligibility for GPMPs and TCAs

Determining patient eligibility for GPMP item 721 and TCAs item 723.

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

To be eligible for TCAs, the patient must have a chronic or terminal medical condition that requires ongoing treatment from a multidisciplinary team.

While many patients will be eligible for both a GPMP and TCAs, practitioners can provide the services independently. Practitioners don’t have to coordinate TCAs after preparing a GPMP or prepare a GPMP before coordinating TCAs.

GPMP items 229 or 721 and TCAs items 230 or 723 are available to both:

patients in the community
private in-patients of a hospital who are being discharged, including private in-patients who are residents of aged care facilities.

Items 229, 230, 721 and 723 are not available to either:

public in-patients of a hospital
care recipients in a residential aged care facility.

Items 232 or 731 are available to care recipients in a residential aged care facility

Checking patient eligibility

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
calling us.

Claiming Chronic Disease Management items

Chronic Disease Management item descriptions and how frequently you can claim

The table below provides Chronic Disease Management (CDM) service descriptions, item numbers and information about how claiming frequency.

Service description	Item number	Claiming frequency
Preparation of a GPMP	229, 721	Once every 12 months
Coordination of the development of TCAs	230, 723	Once every 12 months
Contribution to a Multidisciplinary Care Plan or to a review for a patient who isn’t in a residential aged care facility	231, 729	Once every 3 months
Contribution to an Multidisciplinary Care Plan or to a review for a resident in an aged care facility	232, 731	Once every 3 months
Review of either a GPMP or TCAs	233, 732	Once every 3 months

You can provide CDM services more frequently in exceptional circumstances. For example, when there is a significant change in a patient's condition, you may need to provide a service more than once. For billing purposes, include the reason on the patient’s account or in the claim.

MBS review items 233 or 732 are for reviewing GPMPs and TCAs. Practitioners can claim items 233 or 732 twice on the same day. One claim will be for a review of a GPMP and one for a review of TCAs. They will need to fill in the MBS item descriptions and explanatory notes correctly.

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

CDM items claiming restrictions

Medical practitioners shouldn’t bill CDM items and attendance items for the same patient on the same day. The table below shows which attendance and CDM items practitioners shouldn’t claim together.

This restriction prevent co-claiming these attendance items	with these CDM items
3, 4, 23, 24, 36, 37, 44, 47, 52, 53, 54, 57, 58, 59, 60, 65, 179, 181, 185, 187, 189, 191, 203, 206, 585, 588, 591, 594, 599, 600, 733, 737, 741, 745, 761, 763, 766, 769, 5000, 5003, 5020, 5023, 5040, 5043, 5060, 5063, 5200, 5203, 5207, 5208, 5220, 5223, 5227, 5228	229, 230, 233, 721, 723, 732

If a practitioner claims both items for the same patient on the same day, they will only receive benefits for the CDM item.

If patients need to see a different practitioner on the same day, we will pay benefits for both consultations.

Eligible practitioners referring for allied health services

Eligible practitioners may decide that a patient would benefit from allied health services.

Allied health professionals must write a report for the referring practitioner at least after the first and last individual service. They can write more reports if necessary.

Allied health professionals have to write a report for the referring practitioner after the last group service.

Patients with complex care needs

Following a GPMP and TCAs, eligible practitioners can refer patients with complex care needs for up to 5 individual services per calendar year. These services can include individual allied health services, items 10950-10970.

Patients with type 2 diabetes

Following a GPMP, eligible practitioners can refer patients with type 2 diabetes for group services including:

1 assessment for group services per calendar year - item 81100, 81110 or 81120
up to 8 group allied health services per calendar year - item 81105, 81115 or 81125.

Patients with type 2 diabetes can access these services and the 5 individual allied health services each calendar year.