MBSM12
July 2025
This module provides an understanding of your
obligations to comply with standard work practices and maintain a sound working
knowledge of the requirement of the Medical Benefits Schedule (MBS) relating to
GP Chronic Condition Management Plans.
GPCCMP
review (item 967, 393, 92030 or 92061)
General
assistance in preparing or reviewing a GPCCMP
Claiming limits for plan and review services
Access to
MBS allied health services
Individual
and group allied health services
By the end of this
module, you will understand:
·
what a GP Chronic Condition Management Plan (GPCCMP) is
·
which patients are eligible for a GPCCMP
·
the steps involved in preparing a GPCCMP
·
the specific MBS item numbers associated with a GPCCMP, and the
documentation required for accurate billing
·
the GPCCMP requirements and claiming limits
·
your role in initiating multidisciplinary care, including referring to
MBS funded allied health services
·
the assistance that practice nurses, Aboriginal
and Torres Strait Islander Health Practitioners and Aboriginal Health Workers
can provide for GPCCMP services.
For the purpose of this module the term:
·
General Practitioner
(GP) is used for a Medical Practitioner who either holds:
·
specialist registration in the specialty of General Practitioner with the
Australian Health Practitioner Regulation Agency (Ahpra), or
·
general registration as a GP on the Vocational Register.
·
Prescribed Medical
Practitioner (PMP) is a Medical Practitioner who is not a GP, Specialist, or
Consultant Physician.
·
Specialist is used to
mean a Medical Practitioner in a specialty other than general practice.
A GPCCMP allows you to collaboratively develop
and periodically review structured plans for patients with a chronic or
terminal medical condition. The MBS items allow you to work with your patients
to set:
•
the goals for the
treatment/management of their condition,
•
roles and
responsibilities, and
•
a structured plan for
their care.
A range of MBS-supported multidisciplinary
services may be available to patients with a GPCCMP, where those services are
consistent with the plan.
·
patients in the
community
·
private in-patients
(including private in-patients who are residents of a Residential Aged Care
Facility (RACF) who are being discharged from hospital.
A GPCCMP isn’t available to:
·
public in-patients being
discharged from hospital
·
care recipients in a
RACF.
In considering the need for a structured plan, GPs and PMP need to ensure
the service is clinically relevant, which is a requirement of the Health Insurance Act 1973.
Chronic medical condition
A chronic condition is a medical condition that has been (or is likely to
be) present for at least 6 months, or is terminal.
There is no list of eligible conditions. It is up to your clinical
judgment to determine whether an individual patient with a chronic condition
would benefit from a structured plan for the management of their condition.
GPCCMPs can be
claimed by GPs and PMPs, but not by a Specialist or Consultant Physician.
The term, GP in GP
Chronic Condition Management Plan is used as a generic reference to Medical
Practitioners able to claim these items.
GPCCMPs should be
provided by the patient’s usual Medical Practitioner.
Patients
registered under MyMedicare must access GP chronic condition management
services through the practice where they are registered.
Patients that are
not registered through MyMedicare can access the services through their usual
Medical Practitioner.
Usual Medical
Practitioner
The patient’s
usual Medical Practitioner means the GP or PMP who, or is located at a medical
practice, that:
·
has provided the majority of care to the patient
over the previous 12 months, and/ or
·
is likely to be providing the majority of care
to the patient over the next 12 months.
The term usual
Medical Practitioner wouldn’t generally apply to a practice that provides only
one specific chronic condition management service.
Before proceeding
with a GPCCMP or GPCCMP review, you must make sure that:
·
the steps involved in providing the service have been explained to your
patient and to your patient’s carer (if appropriate and with your patient’s
permission)
·
your patient’s agreement to proceed is recorded.
The following
steps are all GPCCMP requirements for claiming
item 965, 392, 92029 or 93060.
1.
Assess the patient
Assess your
patient to identify and, or confirm their health care needs, health problems
and conditions.
2.
Agree on goals
Develop health and
lifestyle goals with your patient.
3.
Patient actions
Identify actions
to be taken by your patient.
4.
Identify and arrange treatment and services
Identify treatment
and services for your patient and describe the treatments or services you will
refer them for and their purpose.
5.
Prepare written plan
Comprehensively
outline each of the previous steps and specify a date to review the plan.
6.
Obtain Consent
Seek and record your patient’s consent to
share relevant information and parts of the plan with members of the
multidisciplinary team.
7.
Offer copy of GPCCMP to patient
A copy must be
offered to your patient and or (with the permission from your patient) to your
patient’s carer, if appropriate. A copy must be added to your patient’s medical
records.
From 1 July 2025, GPCCMP review items 967,
393, 92030, 92061 are for patients who have a current GPCCMP (item 965, 392,
92029 and 93060) in place and who will benefit from a review of their
GPCCMP.
A review is the principal mechanism for making
sure that the GPCCMP and the management of your patient’s chronic condition is
still appropriate.
A benefit isn’t claimable, and an account
shouldn’t be rendered until all components of the GPCCMP review service have
been provided.
The steps in reviewing a GPCCMP must include:
1.
explaining the steps involved in reviewing the GPCCMP with your patient
and/or your patient’s carer (where appropriate and with your patient’s
permission) and recording your patient’s agreement to proceed
2.
reviewing all matters set out in the plan and making required amendments,
including reviewing information provided by members of the multidisciplinary
team and the progress made towards meeting goals
3.
adding a new review date
4.
obtaining and recording your patient’s consent to share relevant
information with members of the multidisciplinary team
5. offering a copy of the
reviewed GPCCMP to your patient and or your patient’s carer (where appropriate
and with your patient’s permission)
6.
adding a copy of the amended document to your patient’s records.
A practice nurse,
Aboriginal Health Worker, or Aboriginal and Torres Strait Islander Health
Practitioner can assist you in preparing or reviewing a GPCCMP as long as it’s accepted medical practice and under your
supervision. You must be comfortable the assisting health worker has the right
skills, expertise and training.
This can include assistance with:
·
assessing the patient,
·
identifying patient needs,
·
arranging necessary services.
Ongoing monitoring
and support for patients already under a GPCCMP may also involve these health
professionals, and services can be claimed under items such as 10997
(face-to-face), 93201 (video), or 93203 (phone), provided they align with the
plan’s management goals and are conducted under your direction.
Assistance in
development of GPCCMP
Items 10997, 93201 and 93203 may not be claimed for assistance by a
practice nurse or Aboriginal and Torres Strait Islander Health Practitioner in
the development of a GPCCMP (item 392, 965,
92029 or 92060).
The assistance is
provided on behalf of the Medical Practitioner and not as a separate Medicare
service. Item 10997, 93201 or 93203 can only be claimed where your patient already
has an existing GPCCMP in place.
Item description
example – item 10997
Group M12,
Services provided by a practice nurse or Aboriginal and Torres Strait Islander
Health Practitioner on behalf of a Medical Practitioner
Subgroup 3,
Services provided by a practice nurse or Aboriginal and Torres Strait Islander
Health Practitioner on behalf of a Medical Practitioner
Service provided
to a person with a chronic condition by a practice nurse or an Aboriginal and
Torres Strait Islander Health Practitioner if:
a)
the service is provided on behalf of and under the supervision of a
Medical Practitioner, and
b)
the person isn’t an admitted patient of a hospital, and
c)
the person has a GP Chronic Condition Management Plan, or
Multidisciplinary Care Plan in place, and
d)
the service is consistent with the GP Chronic Condition Management Plan,
or Multidisciplinary Care Plan
to a maximum of 5
services per patient in a calendar year.
GPCCMP (item 965, 392, 92029
or 92060)
There
is a minimum claiming
interval of 12 months for a GPCCMP.
A Medicare benefit won’t be
paid within 3 months of item 231, 232, 729, 731, 92026, 92027, 92028, 92057, or
92058 other than in exceptional circumstances, such as
repeated discharges from hospital.
GPCCMP review (item 967, 393, 92030 or 92061)
There is a minimum claiming
interval of 3 months.
MBS definition of
exceptional circumstances
Provision for
claims to be made earlier than these minimum intervals are in place for
exceptional circumstances.
Exceptional
circumstances apply where there has been a significant change in the patient’s
clinical condition or care circumstances that require a new GPCCMP or GPCCMP
review service to be developed rather than amending the existing GPCCMP.
Where a service is
provided in exceptional circumstances, your patient’s invoice/account or
Medicare voucher (assignment of benefit form) should
be annotated or text included for online claims, to indicate the reason why the
service was required earlier than the minimum time interval for the relevant
item.
The annotation or
text included for online claims should be factual, for example:
·
exceptional circumstances
·
significant change in clinical conditions.
Adequate and
contemporaneous clinical notes should be recorded in your patient’s file at the
time of consultation outlining the need for the GPCCMP or GPCCMP review service
to be provided within the minimum time interval.
Under a GPCCMP,
your patient can be referred to member of a multidisciplinary team for
management of their chronic condition:
A
multidisciplinary team includes:
·
the patient’s usual Medical Practitioner
·
other collaborating health or care providers.
Each person in the
team must provide 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 isn’t counted as part of this team.
The GPCCMP should
set out the multidisciplinary services that your patient will be referred to.
There is no requirement for a provider to agree to accept the referral prior to
the plan/review being finalised. Activities or services not covered by the MBS
can be included in your patients GPCCMP, but patients must be informed when
such services are part of their care.
For example
Your patient has
type-2 diabetes and osteoarthritis, you develop a GPCCMP for ongoing care with
an Exercise Physiologist and a Dietitian – both covered under the MBS.
As part of your
patient’s broader health goals, they are also interested in attending
hydrotherapy classes run by a local physiotherapy clinic. You know the clinic
doesn’t offer MBS-rebatable sessions, and the classes are privately billed. You
include the hydrotherapy in your patients GPCCMP because it aligns well with
their health goals. While it’s not funded under the MBS, you explain this
clearly to your patient. This ensures transparency and supports shared
decision-making.
Examples of people
who may be part of a multidisciplinary team include but aren’t limited to those
listed below. These may differ depending on your patient’s care needs.
•
Aboriginal Health Workers
•
Aboriginal and Torres Strait Islander Health Practitioners
•
Asthma Educators
•
Audiologists
•
Dental Therapists
•
Dentists
•
Diabetes Educators
•
Dietitians
•
home and community service providers, or care organisers, such as:
o education providers
o Meals on Wheels providers
o personal care workers, who’re paid to provide
care services
o probation officers
•
Mental Health Workers
•
Nurse Practitioners
•
Occupational Therapists
•
Optometrists
•
Orthopedists
•
Orthoptists
•
Orthotists
•
Prosthetists
•
Pharmacists
•
Physiotherapists
•
Podiatrists
•
Psychologists
•
Registered Nurses
•
Social Workers
•
Speech Pathologists.
The allied health services must be recommended
in your patient’s plan.
Patients being managed under the prerequisite
CCM items may be eligible for:
•
5 individual allied health services per calendar year items,10950 to 10970 (excluding 10955, 10957 and
10959, 93000 and 93013); and
•
one patient suitability assessment for allied
health group services for the management of type 2 diabetes, items 81100,
81110, 81120, 93284 and 93286,
•
8 group allied health services for people with type
2 diabetes per calendar year, items 81100, 81105, 81115, 81125 and 93285.
If your patient is of Aboriginal
or Torres Strait Islander descent, they may be eligible for 10 individual
allied health services per calendar year (items 81300 to 81360, 93048 and 93061). For more information refer to Indigenous health
assessments eLearning module.
Definitions of individual and group allied
health services are explained in more detail below.
Individual allied
health services
To be
eligible for these individual allied health services, your patient must have
one of the following in place a:
·
GPCCMP - item 965, 392, 92029, 93060 or
review item 967, 393, 92030, 92061; or
·
multidisciplinary care plan prepared for them by the RACF (item 232, 731,
92027 or 92058) for patients who are permanent residents of a RACF (their
Medical Practitioner must have contributed to, or contributed to a review of
the multidisciplinary care plan); or
·
Health Care Home shared care plan.
Group allied
health services for people with type 2 diabetes
To be eligible for
these group allied health services, your patient must have one of the following
in place a:
·
GPCCMP - item 965, 392, 92029, 93060, 229, 721, 92024 or 92055 (or review
item 967, 393, 92030, 92061, 233, 732, 92028 or 92059 for a review of a
GPCCMP); or
·
multidisciplinary care plan prepared for them by the RACF (item 232, 731,
92027 or 92058) for patients who are permanent residents of a RACF (their
Medical Practitioner must have contributed to, or contributed to a review of
the multidisciplinary care plan); or
·
Health Care Home shared care plan.
Generally,
patients of a RACF rely on the facility for assistance to manage
their type 2 diabetes. Therefore, the resident may not need to be referred for
group allied health services under these items, as the self-management approach
offered in group services may not be appropriate.
Unlike the individual allied health services
under items 10950 to 10970, 93000 and 93013, there’s no additional requirement
for a GPCCMP (item 965, 392, 92029, 93060) in order for
your patient to be referred for group allied health services.
Use the MBS items online
checker
to check eligibility. Alternatively, you can call Medicare provider enquiries
to check eligibility for MBS items that you intend to use.
Follow this link for an Access to
Mental Health Services for eligible Medical Practitioners eLearning module transcript.
Follow this link for a Benefits to using HPOS Infographic.
Follow this link for
an MBS items online checker Simulation.
Follow this link for a View
patient care plan history in HPOS Simulation.
Follow this link
for a GP Chronic Condition Management
Plan (GPCCMP) Referred Allied Health Services Infographic.
Follow this link for a
Multidisciplinary Case Conferences eLearning module.
Follow this link for an Indigenous
health assessments eLearning module.
Follow this link
for an MBS items online checker Infographic.
Follow this link for
a View patient care plan history in HPOS Infographic
Follow this link
for an Eligibility for mental health treatment services Infographic.
Additional Medicare Benefits Schedule
education resources including eLearning modules, Infographics and Simulations
are available from the Medicare Benefits Schedule tile on the Health Professional Education Resources website.
Glossary
Ahpra Australian Health Practitioner Regulation Agency
CCM Chronic Condition Management
GP General Practitioner
GPCCMP GP Chronic Condition Management Plan
HPOS Health Professional Online Services
MBS Medicare Benefits Schedule
PMP Prescribed Medical Practitioner
RACF Residential Aged Care Facility
MBS items online checker in HPOS
Benefits to using HPOS
Infographic
MBS items online checker Simulation
View patient care plan history in HPOS Simulation
GP Chronic Condition Management Plan (GPCCMP) Referred
Allied Health Services Infographic
Indigenous health assessments eLearning module
MBS items online checker Infographic
View patient care plan history
in HPOS Infographic
Eligibility for mental health
treatment services Infographic
Multidisciplinary
Case Conferences eLearning module
Access
to Mental Health Services for eligible Medical Practitioners eLearning module
Feedback
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