All information is current as at 1 November 2016.

Care planning - management of Chronic Disease conditions for patients living in the community

Service type Preparation of a GP Management Plan MBS 721
or
Review of a GP Management Plan MBS Item 732
and
Provision of monitoring and support for a person with a chronic disease by a practice nurse or Aboriginal and Torres Strait Islander health practitioner MBS Item 10997
Ensure patient / client eligibility Eligibility Criteria
MBS Item 721/732

Client has at least 1 medical condition that has been or is likely to be present for at least 6 months or is terminal.
or
MBS item 10997
Client has a GP Management Plan, Team Care Arrangements or Multidisciplinary Care Plan in place; and the service is consistent with the GP Management Plan, Team Care Arrangements or Multidisciplinary Care Plan.
Obtain patient consent Explaining the service any other associated costs with the client, gaining and recording consent to proceed.
Role of the GP Ultimate responsibility for delivery of the service, which must include a personal attendance by a medical practitioner with the client which may or may not include the clients carer or representative as necessary.
Role of the PN or AHW To assist in client assessment, identification of client needs and coordinating care and services.
Develop a plan Assess the client to identify and confirm needs, problems and conditions. Agree on management goals with the client for changes to be achieved by the treatment and services identified in the plan. Preparation of a comprehensive written plan describing the client's needs, goals, proposed actions, treatment and services and setting a review date.
Frequency of service MSB item 721
Maximum of 1 per client in a 12 month period.
The recommended frequency is every two year, with 6 monthly reviews.
MBS item 732
Maximum of 1 per client in a three month period.
The recommended frequency is every six months
MBS Item 10997
Maximum of 5 services per patient in a calendar year.
Associated MBS items Item 723 Coordination of Team Care Arrangements; Item 732 Coordinate a review of Team Care Arrangements.
More information MBS Online - Medicare Benefits Schedule
Australian Department of Health - Primary care (GP, nursing, allied health)
Australian Department of Human Services - Education services for health professionals

Care planning - management of Chronic Disease conditions for patients living in the community

Service type MBS Item 723
GP to coordinate the development of Team Care Arrangements

Or
MBS Item 732
Coordinate a review of Team care Arrangements

Ensure patient / client eligibility Eligibility Criteria
The patient has at least one medical condition that has been present for at least six months; or is terminal, and requires ongoing care from at least three collaborating health or care providers, each of whom provides a different kind of treatment or service to the patient, and at least one of whom is a GP.
Obtain patient consent Initial explanation of the service and any other associated costs to the client, gaining and recording consent to proceed by the GP.
Role of the GP Consult with at least two collaborating providers, each of whom will provide a different kind of treatment or service to the patient, preparation of  a document ( see below) Explaining the steps involved in the development of the arrangements to the patient and the patient's carer; discusses with the patient the collaborating providers who will contribute to the development of the TCAs and provide treatment and services to the patient under those arrangements; and  record the patient's agreement to the development of TCAs; give copies of the relevant parts of the document to the collaborating providers; offer a copy of the document to the patient and the patient's carer (if any), and adds a copy of the document to the patient's medical records.
Role of the PN or AHW May assist in patient assessment, identification of patient needs and making arrangements for services.
Prepare documentation
Prepare a document that describes:
A) treatment and service goals for the patient;
B) treatment and services that collaborating providers will provide to the patient;
 C) actions to be taken by the patient; and D)arrangements to review.
Frequency of service MSB item 723
Maximum of 1 per client in a 12 month period.
MBS item 732
Maximum of once per client in a three month period.
May be claimed every 12 months
Associated MBS items MBS Item 721 Preparation of a GP management Plan; MBS item 732 Review of a GP Management plan; MBS Item 10997 Monitoring and Support by PN or AHW; MBS Item 10950- 10970 Individual Allied health Services for Chronic Disease Management
More information MBS Online - Medicare Benefits Schedule
Australian Department of Health - Primary care (GP, nursing, allied health)
Australian Department of Human Services - Education services for health professionals

GP care planning - management of Chronic Disease conditions for patients living in the community

Service type MBS Item 729
Contribution by a GP to a Multidisciplinary Care Plan, or to a Review of a Multidisciplinary Care Plan, prepared by another provider.
or
MBS Item 731
Contribution to a Multidisciplinary Care Plan, or to a review of a multidisciplinary care plan, for a resident in an aged care facility (RACF).
Ensure patient / client eligibility Eligibility Criteria
Patient has at least 1 medical condition that has been or is likely to be present for at least 6 months or is terminal.
MBS Item 729
Available to: patients in the community; both private and public in-patients being discharged from hospital.
It is not available to patients in a residential aged care facility
Or
MBS item 731
Available to residents in a residential aged care facility only.
Obtain patient consent Explaining the service any other associated costs with the patient, gaining and recording consent to proceed.
Role of the GP Prepare part of the plan or amendments to the plan and documenting in the patient's medical records; or to give advice to a person who prepares or reviews the plan and documents advice given in the patient's medical notes.
Develop a plan Developing a written plan for a patient that describes treatment and services to be provided to the patient by the collaborating providers
Item 729

This is  prepared by a either GP in consultation with two other collaborating providers, each of whom provides a different kind of treatment or service to the patient, and one of whom may be another GP; or
a collaborating provider in consultation with at least two other collaborating providers, each of whom provides a different kind of treatment or services to the patient;
Item 731
This is prepared by a collaborating provider, in consultation with at least two other collaborating providers, each of whom provides a different kind of treatment or services to [...?]
Frequency of service MSB item 729
Minimum claiming period every 3 months
MBS 731
Minimum claiming period every 3 months
More information MBS Online - Medicare Benefits Schedule
Australian Department of Health - Primary care (GP, nursing, allied health)
Australian Department of Human Services - Education services for health professionals

GP care planning - Group Allied Health Services for people with Type 2 Diabetes

Service type Assessment for Group Services for the Management of Type 2 Diabetes
Diabetes education  provided to a person by an eligible provider for the purposes of ASSESSING a person's suitability for group services for the management of type 2 diabetes, including taking a comprehensive patient history, identifying an appropriate group services program based on the patient's needs, and preparing the person for the group services.
MBS Item 81100 (Diabetes Education Service) MBS Item 81110 (Exercise Physiology) MBS Item 81120 (Dietetics Service)
Ensure patient / client eligibility Eligibility Criteria
The service is provided to a person who has type 2 diabetes; and is being managed by a GP under a GP Management Plan [ie item 721 or 732], or if the person is a resident of an aged care facility, their GP has contributed to a multidisciplinary care plan item 731.
Obtain patient consent Initially explanation of the service and any other associated costs to the client, gaining and recording consent to proceed by the GP, reiterated and confirmed by the Allied health care provider.
Role of the GP To manage the person using a GP Management Plan (Item 721 or 732), or to contributed to a multidisciplinary care plan for those living in a RACF (Item 731).
To refer the eligible patient to an eligible provider using a referral form that contains all the key components of the form issued by the Department of Health & Human Services.
Role of the AHP Assessing a person's suitability for group services for the management of type 2 diabetes, including taking a comprehensive patient history, identifying an appropriate group services program based on the patient's needs, and preparing the person for the group services.
Feedback and contribution Following the service the eligible provider after the service gives a written report to the referring GP.
Frequency of service MSB item 81100; 81110 and 81120
Maximum of 1 per client in a calendar year.
Associated MBS items Item 721 Preparation of a General Practice management Plan: Item 723 Coordination of Team care Arrangements; Item 732 Review of a GP Management Plan and/or Coordinate a review of Team Care Arrangements; Item 731 Contribution by a GP to a MD care plan for a patient in a RACF.
More information MBS Online - Medicare Benefits Schedule
Australian Department of Health - Primary care (GP, nursing, allied health)
Australian Department of Human Services - Education services for health professionals

Service type Diabetes Education Service- Group Services for the Management of Type 2 Diabetes
MBS Item 81105 (Diabetes Educator) MBS Item 81115 (Exercise Physiology) MBS Item 81125 (Dietetics Service)

Diabetes education health service provided to a person by an eligible provider as a GROUP SERVICE for the management of type 2 diabetes.
Ensure patient / client eligibility Eligibility Criteria
The person has been assessed as suitable for a type 2 diabetes group service under assessment item 81100, 81110 or 81120; and the service is provided to a person who is part of a group of between 2 and 12 people.
Obtain patient consent

Initially explanation of the service and any other associated costs to the client, gaining and recording of consent during the assessments phase, reiterated and confirmed by the Allied health care provider facilitating the group sessions.

Role of the GP To manage the person using a GP Management Plan (Item 721 or 732) or to contributed to a multidisciplinary care plan for those living in a RACF (Item 731). To refer the eligible patient to an eligible provider using a referral form that contains all the key components of the form issued by the Department of Health. There is no additional requirement for a Team Care Arrangement (item 723) in order for the patient to be referred for group allied health services.
Role of the AHP Group allied health service providers are strongly encouraged to deliver multidisciplinary group services programs that allow patients to benefit from a range of interventions designed to assist in the management of their type 2 Diabetes. On completion of the group services program, each allied health professional must provide, or contribute to, a written report back to the referring GP in respect of each patient.  The report should describe the group services provided for the patient and indicate the outcomes achieved.
Feedback and contribution On completion of the group services program, each allied health professional must provide, or contribute to, a written report back to the referring GP in respect of each patient.  The report should describe the group services provided for the patient and indicate the outcomes achieved.
Frequency of service

Patients are eligible for up to eight group allied health services in total (items 81105, 81115 and 81125 inclusive) per calendar year.

Associated MBS items

Item 721 Preparation of a GP Management Plan; Item 732 Review of a GP Management Plan; Item 731 Contribution by a GP to a Multidisciplinary care plan for a patient in a RACF.

More information MBS Online - Medicare Benefits Schedule
Australian Department of Health - Primary care (GP, nursing, allied health)
Australian Department of Human Services - Education services for health professionals