GP Chronic Condition Management Plans (MBS Note AN.0.47)
Overview
- Chronic condition management (CCM) plans help structure care for patients with chronic or terminal conditions.
- These plans replaced GP Management Plans and Team Care Arrangements from 1 July 2025.
- CCM plans are not available to residents of residential aged care facilities (they may instead be eligible for multidisciplinary care plans).
Eligible Practitioners
- GPs (Vocationally Registered)
- Non-VR GPs (Medical practitioners not on the vocational register but authorised to bill CCM items)
Eligible Patients
- Must have at least one chronic or terminal condition expected to last 6 months or more.
- Must be living in the community (or a private hospital inpatient for face-to-face services).
- Must be seen by their MyMedicare-registered or usual provider.
- No specific diagnosis is required—clinical judgement applies.
When to Use Chronic Condition Management Plans
- When the patient would benefit from a structured, documented approach to managing their condition.
- Plans include:
- Goals and actions
- Treatments and referrals
- Consent and review arrangements
MBS Items
| Service | GP (VR) | Non-VR GP |
|---|---|---|
| Prepare Plan (Face-to-Face) | MBS Item 965 | MBS Item 392 |
| Review Plan (Face-to-Face) | MBS Item 967 | MBS Item 393 |
| Prepare Plan (Telehealth) | MBS Item 92029 | MBS Item 92060 |
| Review Plan (Telehealth) | MBS Item 92030 | MBS Item 92061 |
Preparing a Plan (Items 965, 392, 92029, 92060)
Must include:
- Description of the condition
- Patient-developed goals
- Actions, treatments, and services required
- Referrals (if needed) to allied health or multidisciplinary providers
- Review schedule
- Patient consent and copy of plan offered
- Documented in the medical record
Reviewing a Plan (Items 967, 393, 92030, 92061)
Must include:
- Discussion of progress towards goals
- Reassessment of goals and care needs
- Updates based on feedback from team members
- Updated referrals and review schedule
- Patient consent and updated copy offered
- Documentation in the medical record
Frequency of Services
- Prepare a new plan: once every 12 months (minimum 3 months after last review)
- Review a plan: every 3 months
- Earlier services allowed in exceptional circumstances, e.g. significant change in condition
Multidisciplinary Team
- Must involve two or more different providers (excluding unpaid carers), e.g.:
- Allied health professionals
- Medical specialists
- Disability or aged care support workers
- Team agreement is not required before billing the plan or review
Referrals and Allied Health Services
- A current plan or review within the last 18 months is required to access allied health services
- Patients can access:
- Up to 5 individual allied health sessions per calendar year (10 for First Nations patients)
- Up to 5 practice nurse or Aboriginal health worker services
- Diabetes-related services (if eligible): 1 assessment + up to 8 group sessions
- A standard referral letter can replace the old EPC form.
Telehealth
- Telehealth items are available for both GPs and non-VR GPs
- Can only be billed if patient is not an admitted hospital patient
- Same rules apply regarding MyMedicare registration and usual provider
Administrative Requirements
- Plans do not expire, but need to be updated/reviewed at least every 18 months
- Unused allied health sessions do not roll over into the next year
- Social prescribing (non-MBS services) can be included in the plan, with patient awareness
- Upload to My Health Record is encouraged, but not mandatory
Assisting with the Plan
- Practice nurses or Aboriginal health workers may assist
- The GP or non-VR GP must still see the patient and is responsible for the service
- Item 10997 cannot be co-claimed if the nurse assists with the CCM plan
Co-Claiming Restrictions
You cannot bill a CCM plan or review on the same day as standard attendance items (e.g. 23, 36, 44, etc.)
Record-Keeping
- Must keep adequate clinical records
- Any written plan must be retained for 2 years
- Providers may be asked to justify claims in Medicare audits