Education guide - 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.

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.

Chronic Disease Management items

Chronic Disease Management (CDM) items enable general practitioners (GPs) to plan and coordinate health care for patients diagnosed with chronic or terminal medical conditions. A chronic medical condition is one that has been present or is likely to be present for 6 months or longer, or is terminal. For example:

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

The patient's usual GP should provide CDM items. Usual GP means the medical practitioner or medical practitioner in the same practice who has provided the majority of services to the patient in the past 12 months, and is likely to provide the majority of services in the following 12 months.

CDM items are not available to public in-patients of a hospital or care recipients in a residential aged care facility, except before discharge from a hospital or an approved day-hospital facility.

Read more about CDM services on the MBS Online website.

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: with chronic disease management (CDM) 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

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.

Claiming frequency

This table provides the CDM service descriptions, item numbers and minimum claiming periods.

Service description Item number Minimum claiming period
Preparation of a GP Management Plan (GPMP) 721 12 months
Coordinate the development of Team Care Arrangements (TCAs) 723 12 months
Contribution to a Multidisciplinary Care Plan or to a Review of a Multidisciplinary Care Plan, for a patient who isn’t a care recipient in a residential aged care facility 729 3 months
Contribution to a Multidisciplinary Care Plan, or to a Review of a multidisciplinary care plan, for a resident in an aged care facility 731 3 months
Review of either a GPMP or TCA 732 3 months

CDM services may be provided more frequently in exceptional circumstances—such as when there is a significant change in a patient's clinical condition or care requirements and you may need to perform a service earlier than the minimum claiming period. For billing purposes, include the reason on the patient’s account or in the claim.

GPMP and Review items 721 and 732 respectively

GPMPs and Review items are for patients with a chronic or terminal medical condition who will benefit from a structured approach to managing their care needs.

TCA and Review items 723 and 732 respectively

TCA and Review items are for patients with a chronic or terminal medical condition who require multidisciplinary, team-based care from a GP and at least 2 other health or care professionals.

Multidisciplinary care plan items 729 and 731

These items are available for contributing to or reviewing a multidisciplinary care plan prepared by another health or care professional. Item 731 is available to care recipients in a residential aged care facility only.

Helping GPs with CDM items

These health professionals can help GPs with:

CDM plan development

Health professionals Type of support Requirements
  • practice nurses
  • Aboriginal and Torres Strait Islander health practitioners
  • Aboriginal health workers
  • other health professionals
Help GPs to prepare, contribute and review CDM items, including:
  • patient assessment
  • identifying patient needs
  • making arrangements for services
GPs must meet all Medicare item requirements, including:
  • review and confirm assessments
  • see the patient

Monitoring and support services item 10997

Health professionals Type of support Requirements
  • 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 is:

  • provided on behalf of and under the supervision of the GP and
  • consistent with the patient's CDM plan

Accessing allied health services through CDM items

GPs referring for allied health services

GPs may determine their patients being managed through relevant CDM item(s) would benefit from and be suitable for allied health individual and/or group services and refer eligible patients with:

Complex care needs - individual allied health services

Service limits Health professionals Item numbers Claiming period Written reporting required for GP
Up to 5 individual services in total from a range of allied health professionals Aboriginal health worker or Aboriginal and Torres Strait Islander health practitioners 10950 per calendar year
  • after the first and last service
  • more often - if clinically necessary
Audiologist 10952
Chiropractor 10964
Diabetes educator 10951
Dietitian 10954
Exercise physiologist 10953
Occupational therapist 10958
Osteopath 10966
Physiotherapist 10960
Podiatrist 10962
Psychologist 10968
Speech pathologist 10970
Mental health worker – includes Aboriginal health workers and Aboriginal and Torres Strait Islander health practitioners, mental health nurses, occupational therapists, psychologists and some social workers 10956

Type 2 Diabetes - group allied health services

Service limits Health professionals Item numbers Claiming period Written reporting required for GP
1 assessment for group services from a diabetes educator, an exercise physiologist or a dietitian Diabetes Educator 81100 per calendar year after the assessment service
Exercise Physiologist 81110
Dietitian 81120
up to 8 group services in total from a diabetes educator, exercise physiologist, dietitian Diabetes Educator 81105 per calendar year after the last service in the group services program - prepare or contribute to the written report
Exercise Physiologist 81115
Dietitian 81125

Type 2 Diabetes assessment and group services are payable in addition to the 5 individual allied health services per calendar year for patients who have Type 2 Diabetes.

Additional resources

GPs can refer their eligible patients for services recommended in the care plan using the relevant referral forms available on the Department of Health website or a form that contains all the components in the referral forms.

Closing the Gap (CTG) on Indigenous health

The Practice Incentive Program (PIP), Indigenous Health Incentive and CTG Pharmaceutical Benefits Scheme (PBS) Co-payment Measure also provides support for Aboriginal and Torres Strait Islanders to better manage chronic disease.

Read more about the Practice Incentives Program.

Read more about the Closing the Gap Pharmaceutical Benefits Scheme Co-payment Measure.

Case study

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

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

Medical history includes:

  • hypertension and high cholesterol
  • mild renal impairment
  • myocardial infarction
  • Type 2 Diabetes
  • increasing circulation concerns with associated foot issues

Other health information:

  • has a family history of heart disease
  • smokes
  • has a poor diet
  • seldom seeks medical attention
  • usually attends every 6 months for script renewals
  • isn't effectively managing their chronic conditions

Actions are needed to develop the care plan.

The table below shows what you do on this visit.

This visit you Patient
  • discuss the patient's health issues
  • outline:
    • potential benefits
    • process of putting a structured plan in place to better manage their chronic conditions
agrees to this
  • decide to develop a GPMP (item 721) and TCAs (item 723) in order to provide both a structured approach to:
    • managing the patient's care needs, as well as
    • collaborating with and coordinating treatment from a multidisciplinary team of health and care providers
  • tell the patient you'll:
    • start developing the plan
    • discuss it further with the patient when they come back in a few days for wound review
  • ask if the patient minds if the Aboriginal and Torres Strait Islander health practitioner employed by the practice assists you with some of this work
  • explain to the patient what is involved
agrees to this

The table below shows what you do on the next visit.

Next visit you Patient
  • go through the draft plan
  • discuss
    • management goals and actions identified for the patient and the health care team
    • arrangements for services with collaborating allied health professionals
    • arrangements for specialist services at the local public hospital with a cardiologist, endocrinologist, renal physician and ophthalmologist
agrees to this
  • 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
agrees to this
  • explain to the patient that now the plan is in place, you can refer them for some Medicare subsidised allied health services as described in the plan
agrees to this

Referring the patient for allied health services.

Type of service Allied health professional Item numbers
3 individual allied health services podiatrist 10962 x 3
2 individual allied health services Aboriginal health worker 10950 x 2
1 assessment for suitability for group education services to manage their Type 2 Diabetes diabetes educator 81100

A total of 5 individual allied health services are payable per calendar year.

Referring for group allied health services

Where the patient is deemed suitable for group education services, they can access up to 8 group services in total per calendar year from a:

  • diabetes educator
  • exercise physiologist
  • dietitian, or
  • combination of these allied health professionals

Monitoring and support services on your behalf

In addition to the patient getting treatment from you, specialists and allied health professionals you also ask they return for regular monitoring and support services with your Aboriginal and Torres Strait Islander health practitioner using MBS item 10997.

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

Up to 5 services per calendar year are payable under item 10997.

More information


Contact us at MBS item interpretation.

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Page last updated: 5 July 2018