Home > For Health Professionals > Services > MBS Primary Care Items

MBS Primary Care Items

Chronic Disease Management (CDM) Medicare Items

Fact Sheet

Printable version of Fact sheet - Chronic Disease Management (CDM) Medicare items

This fact sheet must be read in conjunction with the item descriptors and explanatory notes for items 721-732 (as set out in the Medicare Benefits Schedule).

The Chronic Disease Management (CDM) Medicare items are for GPs to manage the health care of patients with chronic or terminal medical conditions, including patients with these conditions who require multidisciplinary, team-based care from a GP and at least two other health or care providers.

Eligibility

Patients who have a chronic or terminal medical condition (with or without multidisciplinary care needs) can have a GP Management Plan (GPMP) service.

Patients with a chronic or terminal medical condition and complex care needs requiring care from a multidisciplinary team can have a GPMP and Team Care Arrangements (TCAs).

A ‘chronic medical condition’ is one that has been or is likely to be present for at least six months, including but not limited to asthma, cancer, cardiovascular disease, diabetes mellitus, musculoskeletal conditions and stroke.

These items are designed for patients who require a structured approach to their care.

Overview of the items

There are six CDM items that provide rebates for GPs to manage chronic or terminal medical conditions by preparing, coordinating, reviewing or contributing to CDM plans.

The CDM items are intended to be provided by the patient’s usual GP, that is, the GP who has provided the majority of care to the patient over the previous 12 months and/or will be providing the majority of care to the patient over the next 12 months.

A review item is the key component for assessing and managing the patient’s progress once a GPMP or TCAs have been prepared.

GPMPs and TCAs can be reviewed by a GP from the same practice or, if the patient changes practices, by their new GP. Using the CDM items, GPs can contribute to other provider’s multidisciplinary care plans and to a review of these plans. GPs can be assisted by practice nurses, Aboriginal and Torres Strait Islander health practitioners, Aboriginal health workers and other health professionals in preparing and reviewing the CDM items.

The items

Preparation of a GP Management Plan
(GPMP - item 721)

• Provides a rebate for a GP to prepare a management plan for a patient who has a chronic or terminal medical condition with or without multidisciplinary care needs.
• The minimum claiming period is once every twelve months, supported by regular review services.
• Involves the GP assessing the patient, agreeing management goals with the patient, identifying actions to be taken by the patient, identifying treatment and ongoing services to be provided, and documenting these and a review date in the GPMP.

Review of a GP Management Plan (Item 732)

• Provides a rebate for a GP to review a GP Management Plan (see above).
• The minimum claiming period is once every three months; can be earlier if clinically required.
• Involves reviewing the patient’s GP Management Plan, documenting any changes and setting the next review date.

Coordination of Team Care Arrangements (TCAs - item 723)

• Provides a rebate for a GP to coordinate the preparation of TCAs for a patient who has a chronic or terminal medical condition and also requires ongoing care from a multidisciplinary team of at least three health or care providers.
• In most cases the patient will already have a GPMP in place (but this is not mandatory).
• The minimum claiming period is once every twelve months, supported by regular review services.
• Involves the GP collaborating with the other participating providers on required treatment/services, agreeing the arrangements with the patient, documenting the arrangements and a review date in the patient’s TCAs, and providing copies of the relevant document to the collaborating providers.

Coordination of a Review of Team Care Arrangements (Item 732)

• For patients who have current TCAs and require a review of their TCAs.
• The minimum claiming period is once every three months; can be earlier if clinically required.
• Involves the GP (who may be assisted by their practice nurse or other) collaborating with the participating providers on progress against treatment/services and documenting any changes to the patient’s TCAs.

Contribution to a multidisciplinary care plan being prepared by another health or care provider (Item 729)

• For patients who are having a multidisciplinary care plan prepared or reviewed by another health or care provider (other than their usual GP).
• The minimum claiming period is once every three months; can be earlier if clinically required.
• Involves the GP (who may be assisted by their practice nurse or other) collaborating with the providers preparing or reviewing the plan and including their contribution in the patient’s records.

Contribution to a multidisciplinary care plan being prepared for a resident of an aged care facility (Item 731)

• This is for patients in residential aged care facilities and is otherwise identical to Item 729 (immediately above).

Access to allied health items

Patients who have both a GPMP (item 721) and TCAs (item 723) have access to the individual allied health services on the Medicare Benefits Schedule.

Similarly, residents of aged care homes whose GP has contributed to a care plan prepared by the residential aged care facility (item 731) may also have access to these allied health items.

Eligible patients can claim a maximum of five (5) allied health services per calendar year (MBS items 10950-10970).

Patients with a GPMP (item 721) and type 2 diabetes can also access Medicare rebates for allied health group services (MBS items 81100 to 81125).

Patients need to be referred by their GP for services recommended in their care plan, using the referral form issued by the Department or a form that contains all the components of the Department’s form.

Practice Nurse Monitoring and Support

Patients with either a GPMP or TCAs can also receive monitoring and support services from a practice nurse or Aboriginal and Torres Strait Islander health practitioner on behalf of the GP (MBS item 10997).

More information

More detailed information on the CDM items is available at

Alternatively, contact Medicare Australia on 132 150 (for GPs) or 132 011 (for patients).