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.

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

Chronic Disease Management services

Chronic Disease Management (CDM) services help eligible practitioners coordinate health care for patients with chronic or terminal medical conditions. These medical conditions are present or are likely to be present for 6 months or longer, or are terminal. Examples include:

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

Practitioners who can claim for CDM items include:

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

The patient's usual medical practitioner should provide CDM 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

Read more about CDM services on the MBS Online website.

Claiming CDM Items

CDM item descriptions and how frequently you can claim

The table below provides CDM service descriptions, item numbers and information about 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 a 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.

Information about specific items

GPMP and Review items 229, 721 or 233, 732

These services 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 230, 723 or 233, 732

These services are for patients with a chronic or terminal medical condition who require multidisciplinary, team-based care from a medical practitioner and at least 2 other professionals.

Multidisciplinary Care Plan items 231, 729 or 232, 731

These items are for contributing to or reviewing a Multidisciplinary Care Plan prepared by another health or care professional. Items 232 or 731 are only available to care recipients in a residential aged care facility.

Claiming restrictions for CDM items

CDM items are available to:

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

CDM items are not available to:

  • public in-patients of a hospital, or
  • care recipients in a residential aged care facility

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 prevents 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 the patient needs to see a different practitioner on the same day, we will pay benefits for both items.

Assisting with CDM items

Other health professionals can help eligible practitioners deliver some services, including:

  • CDM plan development
  • monitoring and support services - item 10997

The tables below give further details.

CDM plan development

Health professionals who can help Type of support they can give Requirements
  • Practice nurses
  • Aboriginal and Torres Strait Islander Health Practitioners
  • Aboriginal Health Workers
  • Other health professionals

Can help to prepare, contribute and review CDM items, including:

  • performing patient assessment
  • identifying patient needs
  • arranging for services

Eligible practitioners must meet all Medicare item requirements, including:

  • reviewing and confirming assessments
  • seeing the patient

Monitoring and support services item 10997

Health professionals who can help Type of support they can give 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 must be:

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

Referring patients to allied health services through CDM items

Practitioners can refer patients for services using the relevant referral forms available on the Department of Health website. They can also use a form that contains all the components in the referral forms.

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. Patients can see:

  • Aboriginal Health Workers or Aboriginal and Torres Strait Islander Health Practitioners - item number 10950
  • audiologists - item number 10952
  • chiropractors - item number 10964
  • diabetes educators - item number 10951
  • dietitians - item number 10954
  • exercise physiologists - item number 10953
  • occupational therapists - item number 10958
  • osteopaths - item number 10966
  • physiotherapists - item number 10960
  • podiatrists - item number 10962
  • psychologists - item number 10968
  • speech pathologists - item number 10970
  • mental health workers - item number 10956

Patients with type 2 diabetes

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

  • 1 assessment for group services per calendar year
  • up to 8 group services per calendar year

The allied health professionals who can offer the assessments are:

  • diabetes educators - item number 81100
  • exercise physiologists - item number 81110
  • dietitians - item number 81120

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

The allied health professionals who can offer the group services are:

  • diabetes educators - item number 81105
  • exercise physiologists - item number 81115
  • dietitians - item number 81125

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

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

Closing the gap on Indigenous health

These initiatives provide support for Aboriginal and Torres Strait Islanders to better manage chronic disease:

Case study

This case study focuses on an Indigenous patient. It provides 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.

His medical history includes:

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

As well as this, he:

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

Actions to develop the care plan

First visit

This visit you:

  • discuss the patient's health issues
  • outline
    • the potential benefits of a care plan
    • the process of putting a structured plan in place to better manage his chronic conditions
  • decide to develop a GPMP, items 229 or 721, and TCAs, items 230 or 723, to
    • manage the patient's care needs
    • collaborate with and coordinate treatment by a multidisciplinary team of health and care providers
  • tell the patient you'll
    • start developing the plan
    • discuss it further with them when they come back in a few days for wound review
  • ask if the patient minds if an Aboriginal and Torres Strait Islander Health Practitioner assists you
  • explain what is involved to the patient

The patient agrees to the plan.

Follow-up visit

The next visit you:

  • go through the draft plan
  • discuss
    • management goals and actions for the patient and the health care team
    • arrangements for services with allied health professionals
    • arrangements for specialist services at the local public hospital with a cardiologist, endocrinologist, renal physician and ophthalmologist
  • 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
  • explain that you can refer them for some Medicare-subsidised allied health services

The patient agrees with your decisions.

Referrals

You decide to refer your patient for allied health service, including:

  • 3 individual services with a podiatrist - item 10962
  • 2 individual services with an Aboriginal Health Worker - item 10950
  • 1 assessment for suitability for group education services with a diabetes educator - item 81100

Monitoring and support services

As well as these services, you ask the patient to attend services with the Aboriginal and Torres Strait Islander Health Practitioner. This will be under 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

More information

Read more about:

Contact us for MBS item interpretation.

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Page last updated: 24 August 2018