Education guide - Chronic disease GP Management Plans and Team Care Arrangements
Information for general practitioners about GP Management Plans (GPMP), Medicare item 721 and Team Care Arrangements (TCAs), Medicare item 723.
This information should be used as a guide only and be read together with the Medicare Benefits Schedule (MBS) item descriptors and explanatory notes available on the MBS Online website.
A chronic medical condition is a condition that has been, or is likely to be, present for at least 6 months. Including, but is not limited to:
- cardiovascular disease
- diabetes mellitus
- musculoskeletal conditions, and
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 TCA, the services can be provided independently. It is not mandatory to follow the preparation of a GPMP with the coordination of TCAs or to prepare a GPMP before coordinating TCAs.
|Patients criteria||MBS item||Once you have completed||Refer patients|
|Chronic or terminal medical condition||GPMP item 721||A GPMP||With type 2 diabetes for individual assessment for group allied health services.|
|Medical or terminal condition and require ongoing treatment from a multidisciplinary team.||
||Both a GPMP and TCAs||For individual allied health services.|
GPMP item 721 and TCAs item 723 are available to patients in the community, and private patients who are being discharged from hospital.
- items 721 and 723 are not available to public in-patients of a hospital or care recipients in a residential aged care facility
- item 731 is available to care recipients in a residential aged care facility
GPMPs and TCAs are not designed simply as mechanisms to provide Medicare rebates for allied health services. They are tools to coordinate the care of people with chronic conditions and help to reduce the need for ad hoc consultations. A care plan is a useful mechanism for recording comprehensive, accurate and up-to-date information about your patient's condition and all of the treatment they are receiving. Development of a care plan can also help encourage your patient to take some responsibility for their care, including the identification of any actions your patient might take to help achieve the goals of the treatment.
GPMP item 721 requirements
Preparing a GPMP involves explaining to your patient the steps involved in preparing the plan and recording their agreement to proceed. A written plan is then developed that describes:
- the patient's health care needs, health problems and relevant conditions
- management goals and actions to be taken with your patient
- treatment and services that your patient will need
- arrangements for providing the treatment and services that your patient will need; and
- arrangements to review the plan
Once the GPMP plan has been agreed upon offer a copy of the plan to your patient and add a copy to the patient's medical record.
TCAs item 723 requirements
When coordinating the development of TCAs you must consult with at least two other health professionals. Each health professional will provide a different kind of treatment or service for your patient and will make arrangements for the multidisciplinary care of your patient.
As part of preparing the TCA discuss with your patient:
- the steps involved in the development of the TCAs and record their agreement to proceed
- the collaborating providers who will contribute to the TCAs and provide treatment and services
When documenting the TCA include the following:
- treatment and service goals for the patient
- treatment and services that collaborating providers have agreed to give
- actions to be taken by the patient; and
- TCA review date(s) specify a date to review the TCAs
Once the TCA document has been completed offer a copy of it to the patient, give copies of the relevant parts of the document to the collaborating providers and add a copy of the document to the patient's medical record.
Multidisciplinary team for the purpose of TCAs
Patients eligible for a TCA services (MBS item 723) are those who have a chronic or terminal condition and complex care needs requiring ongoing care from a multidisciplinary team. Patients must not be a public in-patient of a hospital or a care recipient of a residential aged care facility.
A multidisciplinary team includes the patient’s GP andat least 2 other collaborating health or care providers, 1 of whom may be another medical practitioner, who will be providing ongoing treatment or services for the patient.
Each of the health or care providers must be providing a different type of ongoing treatment or service. The non-GP collaborating providers need not be providers of Medicare eligible services.
A patient's informal or family carer does not count as 1 of the other 2 health or care providers but can be involved in the process.
GPMP and TCAs should be undertaken by the patient's usual GP. The patient's usual GP is considered to be the GP, or a GP working in the medical practice, who has provided the majority of care to the patient over the previous 12 months or will be providing the majority of GP Services to the patient over the next 12 months.
CDM items claiming restrictions
General practitioners are restricted from billing Chronic Disease Management (CDM) items and GP attendance items for the same patient, on the same day.
This restriction prevents co-claiming GP attendance items:
3, 4, 23, 24, 36, 37, 44, 47, 52, 53, 54, 57, 58, 59, 60, 65, 597, 599, 598, 600, 5000, 5003, 5020, 5023, 5040, 5043, 5060, 5063, 5200, 5203, 5207, 5208, 5220, 5223, 5227 and 5228
with chronic disease management (CDM) items:
721, 723, or 732
If a GP claims both an attendance item and a chronic disease management item for the same patient on the same day, benefits will only be paid for the chronic disease management item.
If the patient needs to see a different GP on the same day, Medicare benefits will be paid for that consultation.
The recommended frequency and minimum claiming periods for the CDM items are set out in the following table.
|Name||Item no.||Minimum claiming period*|
|Preparation of a GP Management Plan||721||12 months|
|Coordinate the development of Team Care Arrangements||723||12 months|
|Review of a GP Management Plan and/or review of Team Care Arrangements||732||3 months|
|Contribution to a multidisciplinary care plan prepared by another provider||729||3 months|
|Contribution to a multidisciplinary care plan prepared by a residential aged care facility||731||3 months|
CDM services can be provided more frequently in ‘exceptional circumstances’, i.e. where there has been a significant change in the patient’s clinical condition or care circumstances (such as development of co-morbidities or complications, deteriorating condition, illness/death of carer etc), that require a new GPMP, TCAs or review service.
In general, a new GPMP or TCAs should not be prepared unless required by the patient's condition, needs and circumstances. The minimum claiming period is 12 months. Where there has been a significant change in the patient's clinical condition or care circumstances, more frequent claims can be made. If you are unsure whether the patient currently has a GPMP and or TCAs in place, contact us.
We suggest that practices create a system to call and encourage patients to attend an appointment for a review of their care plan. The MBS review item is 732 for reviewing a GPMP and TCAs. Item 732 can be claimed twice on the same day for a review of a GPMP and for a review of TCAs, as long as the MBS item descriptor and explanatory notes for item 732 are met.
- MBS Online to view the Schedule
- The Department of Health for resources on chronic disease management
- Education services for health professionals to access other education resources
Contact us for Medicare provider enquiries.
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