Chronic Disease Management & MBS Item Numbers

July 2022

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
ACKNOWLEDGEMENTS:
Wentworth Healthcare acknowledges and thanks the organisations that contributed to the content
used in this Desktop Guide. They include PHNs, former Divisions of General Practice and
Medicare Locals, National Peak Organisations and Commonwealth Agencies.

INTRODUCTION:
This Desktop Guide is intended as a resource to assist General Practice staff to effectively
coordinate care for their patients with chronic conditions. It provides comprehensive information
regarding the MBS items relevant to the management of chronic diseases and other conditions
commonly treated in general practice. For current and comprehensive information about each MBS
item number, please refer to the Medicare Benefits Schedule at MBS Online. MBS Online is
frequently updated as changes to the MBS occur.

FEEDBACK/COMMENTS:
If you have any enquiries or would like to provide feedback or comments regarding information
provided in this Guide, please contact the General Practice Support Team.
P: 02 4708 8100

DISCLAIMER: whilst every effort has been made to ensure that the information included in this
Desktop Guide is current and up to date, you should exercise your own independent skill and
judgement before relying on it. Refer to MBS Online for current information.

CONTACT DETAILS:
Wentworth Healthcare
Werrington Park Corporate Centre, Level 1, Suite 1
14 Great Western Highway
Kingswood NSW 2747

P: 02 4708 8100
E: reception@[Link]
W: [Link]

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Table of Contents
TABLE OF CONTENTS................................................................................................................................................ 3
CHRONIC DISEASE MANAGEMENT ........................................................................................................................... 5
CHRONIC DISEASE OVERVIEW ................................................................................................................................................ 5
CHRONIC DISEASE MANAGEMENT AND HEALTH ASSESSMENTS FLOWCHART ........................................................... 6
........................................................................................................................................................................................ 7
PREPARATION OF A GP MANAGEMENT PLAN (GPMP) .............................................................................................................. 7
COORDINATION OF TEAM CARE ARRANGEMENT (TCA) .............................................................................................................. 8
REVIEWING A GPMP AND/OR TCA ........................................................................................................................................ 9
RECALL AND REMINDER SYSTEMS ......................................................................................................................................... 10
WORKFORCE INCENTIVE PROGRAM PRACTICE STREAM ............................................................................................................. 11
PRACTICE NURSES AND CHRONIC DISEASE MANAGEMENT..................................................................................... 11
Patient and claiming eligibility ................................................................................................................................. 11
CYCLES OF CARE FOR PATIENTS WITH ESTABLISHED DIABETES MELLITUS ...................................................................................... 14
Asthma Annual Cycle of Care ................................................................................................................................... 16
MULTIDISCIPLINARY CASE CONFERENCES ............................................................................................................................... 19
CANCER SCREENING............................................................................................................................................... 20
CERVICAL SCREENING ......................................................................................................................................................... 20
MBS Item Numbers for Under Screened Women ..................................................................................................... 20
HEALTH ASSESSMENTS .......................................................................................................................................... 21
How to Make Health Assessments Work for Your Practice ...................................................................................... 21
Health Assessment Target Groups ........................................................................................................................... 21
HEALTH ASSESSMENT ITEM NUMBERS ................................................................................................................................... 22
HEART HEALTH ASSESSMENT ............................................................................................................................................... 23
HEALTH ASSESSMENT FOR ABORIGINAL AND/OR TORRES STRAIT ISLANDER PEOPLE ........................................................................ 24
TYPE 2 DIABETES RISK 40 – 49 YEARS .................................................................................................................................. 25
HEALTH ASSESSMENT FOR 45 – 49‐YEAR‐OLDS ...................................................................................................................... 26
HEALTH ASSESSMENT FOR 75‐YEARS AND OLDER .................................................................................................................... 27
HEALTH ASSESSMENTS FOR GOVERNMENT HUMANITARIAN PROGRAM ........................................................................................ 28
HEALTH ASSESSMENTS FOR PEOPLE WITH AN INTELLECTUAL DISABILITY ....................................................................................... 28
SYSTEMATIC CARE CLAIMING RULES...................................................................................................................................... 29
INDIVIDUAL ALLIED HEALTH SERVICES UNDER MEDICARE .......................................................................................................... 30
RESIDENTIAL AGED CARE FACILITIES........................................................................................................ 31
HEALTH ASSESSMENT PROVIDED AS A COMPREHENSIVE MEDICAL ASSESSMENT FOR RESIDENTS OF RESIDENTIAL AGED CARE FACILITIES
...................................................................................................................................................................................... 31
COMMONLY USED ITEM NUMBERS ...................................................................................................................................... 32
ARRANGEMENTS FOR GP RACF SERVICES ............................................................................................................................ 33
New Items for Doctor’s RACF Services .................................................................................................................... 33
Call‐Out Fee ............................................................................................................................................................. 33
Billing ....................................................................................................................................................................... 33
RESIDENTIAL MEDICATION MANAGEMENT REVIEW (RMMR) ................................................................................................. 34
PRESCRIBING/HOME MEDICINES REVIEW .............................................................................................................. 35
DOMICILIARY MEDICATION MANAGEMENT REVIEW (DMMR) .................................................................................................. 35
MENTAL HEALTH ................................................................................................................................................... 37
MBS BETTER ACCESS INITIATIVE .......................................................................................................................................... 37
Short Term Psychological Therapies ........................................................................................................................ 37

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
 MENTAL HEALTH ITEM NUMBERS ........................................................................................................................................ 38
PREPARATION OF A MENTAL HEALTH TREATMENT PLAN ........................................................................................................... 39
REVIEW OF A MENTAL HEALTH TREATMENT PLAN ................................................................................................................... 41
GP MENTAL HEALTH CARE CONSULTATION............................................................................................................................ 41
CHECKLIST FOR GP MENTAL HEALTH TREATMENT PLAN ........................................................................................................... 43
VETERANS’ CARE ................................................................................................................................................... 44
COORDINATED VETERANS’ CARE PROGRAM (CVC) ................................................................................................. 44
CONTACT DETAILS FOR KEY ORGANISATIONS ......................................................................................................... 46

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Chronic Disease Management
Chronic Disease Overview
Our current health system is not optimally set up to effectively manage long term conditions.
Increased and poorly targeted service use is resulting in variable patient outcomes and significant
financial impacts across the entire health system. While not all hospital presentations for chronic or
other conditions can be prevented through primary health interventions, it may be possible to
prevent many.

• In 2017-18, Chronic conditions accounted for 46% of the 748000 potentially preventable
hospitalisations in Australia. Of this 50% were for chronic conditions such as congestive
cardiac failure, chronic obstructive pulmonary disease (COPD) and type 2 diabetes (AIHW,
2022)

• Nearly a quarter (23%) of people who visited an emergency department felt their care could
have been provided by a General Practitioner.

Chronic Disease in the Nepean Blue Mountains (NBM) Region

The NBM region covers almost 9179 square kilometres and aligns with the Nepean Blue
Mountains Local Health District. The region encompasses 4 Local Government Areas (LGAs) and
has a total population of over 380,000 people. The population is projected to grow by 17.6% by
2036 (Wentworth Healthcare Limited, 2021). By this time the region will have an additional 89 461
residents living in the area.
Chronic disease related hospitalisation rates were higher within the NBM region compared to
NSW. COPD was the fourth leading cause of death, accounting for 4.9% of preventable
hospitalisations in our region. An estimated 12% of the population within our region have diabetes,
61% of adults are overweight, and approximately 50% of the population do not get enough
exercise. These risk factors can result in a compromised state of health and wellbeing in relation to
chronic disease, especially among vulnerable population groups and mitigating these risk factors is
critical to further support general health and wellbeing within the NBM region. However, 17% of the
population with a chronic disease received a GP chronic management plan (2017-2018).

Chronic Disease Management Services

Chronic Disease Management (CDM) services have been established to assist eligible medical
practitioners (MPs) such as general practitioners (GPs) and non-vocationally recognised medical
practitioners (non-VR MPs) coordinate the necessary care for patients with chronic medical
conditions, thus better managing their conditions. The ‘usual’ GP co-ordinates the plan for a patient
with chronic diseases and ensures that each member of the multidisciplinary team has contributed
to the plan’s development or review. Where chronic conditions are defined as having been present
for at least six months and include but not limited to asthma, cancer, diabetes, cardiovascular
disease and kidney disease. For further information on Guidelines for Preventive Activities in
General Practice (9th Edition) and Putting Prevention into Practice (Third Edition) have been
developed to support evidence based preventative activities in primary care.
Please refer to Medicare Benefits Schedule (MBS) Quick Guide 2022 and Non-VR MBS Quick
Guide for a list of commonly used MBS Item Numbers in the treatment and management of CDM
in general practice. The General Practice MBS Calculator has been developed to provide the
potential financial contribution that can be made by the practice in CDM. Click here to download an
Excel version of the calculator. For further information on Chronic disease GP Management Plans
and Team Care Arrangements, click here. Refer to MBS Online for current information about item
numbers.

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Chronic Disease Management and Health Assessments Flowchart
Finding your way through the maze.

If your patient is of Aboriginal and/or Torres Strait Islander descent… Is your patient eligible for any health assessments? Brief health assessment of less than 30
minutes item 701.

Do an Aboriginal and Torres Strait Utilise item 109787 for follow-up If your patient is over 75 years… Do an over 75 health assessment
Islander Health Assessment Item 715. by PN or ATSI health worker. Standard health assessment lasting more than
30 minutes item 703.
If your patient was a serving member of the Do an ADF post-discharge GP health
If patient has a chronic or terminal illness, initiate a GPMP item 721 and TCA item ADF… assessment.
723 as appropriate. Long health assessment lasting more than 45
minutes item 705.

If your patient is 45-49 years with no

Do a 45-49 health check.
If your patient has a chronic condition that has been or will be in place diagnosed chronic condition…
for six months, or has a terminal illness… Prolonged health assessment lasting more
than 60 minutes item 707.
If your patient is 40-49 years and at ‘high
Do a type 2 diabetes risk evaluation.
Do a GPMP item 721. risk’ of diabetes…
Review after 3-6 months using item If your patient resides in an aged care facility…
732.

Utilise item 10997 for follow-up If your patient has an intellectual disability... Do an intellectual disability assessment.
by PN or ATSI health worker is Contribute to RACF Care Plan item 731. Review after 3-6
patient has a GPMP or TCA in months using item 731.
If your patient also has complex care place.
needs necessitating the involvement of If your patient resides in an RACF… Do a comprehensive medical assessment.
at least to other health can providers,
do a TCA item 723. If your patient also has complex care needs necessitating the
Review after 3-6 months using item Your patient is eligible to access involvement of at least two other health care professionals…
If your patient is a refugee or humanitarian Do a refugee or humanitarian entrant
732. allied health. entrant… assessment.

Your patient is eligible to access allied health.

If your patient has diabetes… If your patient has a mental health issue…

Could your patient be at high risk of developing type

Commence a Diabetes Cycle of Care. Prepare a GP Mental Health Treatment Plan item 2700 (if no MH skills training) or item 2715 (if MH 2 diabetes? Should your patient be referred to a
skills training) and review with item 2712. For ongoing management item 2713. lifestyle modification program?

Initiate a GPMP item 721 and TCA item 723 as appropriate.

If patient has an additional chronic illness, initiate a GPMP and TCA as appropriate. 1. If your patient is of Aboriginal and/or Torres Strait
Islander descent and aged 15-54 years, do an ATSI
If your patient has type 2 diabetes and has a GPMP in place, refer for group diabetes Health Assessment – use ausdrisk tool
education. Could your patient benefit from a medication review? 2. If your patient is 45-49 years with no diagnosed
chronic condition, do a 45-year health check – use
ausdrisk tool
3. If your patient is 40-49 years, use ausdrisk tool to
If your patient has moderate to severe asthma… Organise a home medication review item 900. determine diabetes type 2 risk. If patient is at high
risk’ do a diabetes type 2 risk evaluation

Commence an Asthma Cycle of Care and initiate a GPMP and TCA if necessary. Case conferencing
If your patient is found to be at ‘high risk’ of developing
type 2 diabetes, provide advice and information such
If patient has an additional chronic illness, initiate a GPMP and TCA as appropriate. Organise and coordinate a Case Conference item 735, 739 or 743. Participate in a Case Conference as My Health for Life program and/or information and
item 747, 750 or 758 with two or more health care providers. Consider contributing to a mutli- strategies to achieve lifestyle and behaviour changes.
disciplinary care plan if requested by another health provider item 729.

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Preparation of a GP Management Plan (GPMP)

Eligibility Criteria
• No age restrictions for patients
Item 721 • Patients with a chronic (present for or likely to persist 6
months or more) or terminal condition
• Patients who will benefit from a structured approach to their
Ensure patient eligibility care
• Not for public patients in a hospital or patients in a
Residential Aged Care Facility
• A GP Mental Health Treatment Plan (item 2702/2710) is
suggested for patients with a mental health disorder only

Clinical Content
• Explain steps involved in GPMP, possible out of pocket
Develop Plan
costs and gain patient’s consent
Nurse/Aboriginal Health • Assess health care needs, health problems, relevant
Worker or Health history, and conditions
Practitioner may collect • Agree on management and patient goals with the patient
information • Identify treatments and services required
GP must see patient • Arrangements for providing the treatments and services
• Arrangements for review using item 732 at least once over
the life of the plan (12-24 months)

Essential Documentation Requirements

• Record patient’s consent to GPMP
• Patients’ needs and goals, patient actions and
Complete relevant treatments/services required
activities and • Set review date
documentation • Offer copy to patient or carer, keep a copy in patient
records

Claiming
• All elements of the service must be completed to claim
• Requires personal attendance by GP
• Review using item 732 at least once during the life of the
plan (8 reviews over 24 months, more if clinically indicated)
Claim MBS item • MBS item 10991 (bulk billing incentive) may also be
claimed for eligible patients

Item Name Recommended Frequency

721 GP Management Plan Once every two years (min 12 monthly)

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Coordination of Team Care Arrangement (TCA)

Item 723 Eligibility Criteria

• No age restrictions for patients
• Patients with a chronic or terminal condition and complex
Ensure patient eligibility care needs
• Patients who need ongoing care from a team including the
GP and PN, and at least two other healthcare providers
• Not for patients in a hospital or patients in a Residential
Aged Care Facility

Clinical Content
• Explain steps involved in TCA, possible out of pocket costs,
Develop Plan gain and document patient’s consent
Nurse/Aboriginal Health • Treatment and service goals for the patient and actions to
Worker or Health be taken by the patient
Practitioner may collect • Discuss with patient which two providers the GP will
information collaborate with and the treatment/services the two
providers will deliver
GP must see patient • Gain patient’s agreement on what information will be
shared with other providers
• Ideally list all health and care services required by the
patient
• Obtain collaborating providers agreement to participate
• Obtain feedback on treatments/services two collaborating
Complete relevant providers will administer to achieve patient goals
activities and
documentation Essential Documentation Requirements
• Patient’s consent to TCA
• Goals, collaborating providers, treatments/services, actions
to be taken by patient
• Set review date
• Send copy of relevant parts to collaborating providers
• Offer copy to patient and/or carers, keep copy in patient
record
Claim MBS item
Claiming
• All elements of the service must be completed to claim
• Required personal attendance by GP with patient
• Review using item 732 at least once during the life of the
plan
• Claiming a GPMP and TCA enables patients to receive five
rebated services from allied health during one calendar
year
• NB – Indigenous patients, refer to 715 for additional TCA
eligibility
• MBS item 10991 (bulk billing incentive) may also be
claimed for eligible patients
Item Name Recommended Frequency
723 Team Care Arrangements Once every two years (min 12 monthly)

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Reviewing a GPMP and/or TCA

Item 732 Reviewing a GP Management Plan (GPMP)

Clinical Content
• Explain steps involved in the review and gain patient
GPMP Review consent
Nurse/Aboriginal health • Review all matters in plan
Worker or Health
Practitioner may collect Essential Documentation Requirements
information • Record patient’s agreement to review
• Make any required amendments to plan
GP must see patient • Set new review date
• Offer copy to patient and/or carers
• Keep copy in patient record

Revieing a Team Care Arrangement (TCA)

Clinical Content
• Explain steps involved in the review and gain consent
Claim MBS item • Consult with two collaborating providers to review all
matters in plan

Essential Documentation Requirements

• Record patient’s agreement to review
• Make any required amendments to plan
• Set new review date
• Offer copy to patient and/or carers
• Keep copy in patient record
• Send copy of relevant amendments of TCA to collaborating
TCA Review providers

Nurse/Aboriginal Health Claiming of GPMP and TCA Review

Worker or Health • All elements of the service must be completed to claim
Practitioner may collect • Item 732 should be claimed at least once over the life of
information the GPMP
• Cannot be claimed within three months of a GPMP (721)
except where there are exceptional circumstances arising
from a significant change in the patient’s clinical condition,
in this case the Medicare claim should be annotated as to
Claim MBS item why the service was required earlier
• Item 732 can be claimed twice on the same day is review
of both GPMP and TCA are completed. Medicare claim
should be annotated “Review of GPMP” for one item
number and “Review of TCA” for the other item number
• MBS item 10991 (bulk billing incentive) may also be
claimed for eligible patients

Item Name Recommended Frequency

732 Review of GP Management and/or Team Bi-annually (minimum three monthly)
Care

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Recall and Reminder Systems
Reminders are used to initiate a prevention activity, before or during the patient visit. They can be
either opportunistic or proactive. Recalls are a proactive follow up to a preventative or clinical
activity.
Prompts are usually computer generated through clinical information systems and designed to
opportunistically draw attention during the consultation to a prevention or clinical activity needed by
the patient. Using a recall system can seem complex, but there are three steps that can be taken:

• Be clear about when and how you want to use these flags.

• Explore systems used by other practices and those endorsed by information technology
specialists to ensure you get the correct system.

• Identify all the people who need to be recalled and place them in a practice register. This will
help to ensure that the recall process is both systematic and complete.

GP/Nurse puts patient’s reminder

on clinical system

Staff generate reminder list using

clinical systems recall tool

Staff either phone patient/career or

mail merge using relevant letter

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Practice Nurses and Chronic Disease Management

Workforce Incentive Program Practice Stream

The Workforce Incentive Program (WIP) provides targeted financial incentives to encourage
doctors to deliver services in rural and remote areas. The WIP also provides financial incentives to
support general practitioners to engage the services of nurses, Aboriginal and Torres Strait
Islander Health Practitioners and Health Workers, and eligible allied health professionals.
Some areas of the NBM region are classified as rural so this stream of the WIP is available to
some GPs in the region.
From early 2020, general practices participating in the Practice Nurse Incentive Program (PNIP)
automatically transitioned to the WIP. An up-to-date rural classification system is used to ensure
metropolitan areas are no longer able to access incentives intended for rural and remote Australia.

WIP – Practice Stream

Practice in all locations may be eligible for incentives to support the engagement of nurses, allied
health professionals, and Aboriginal and Torres Strait Islander Health Practitioners or Health
Workers. The WIP will expand eligibility for allied health to all areas of Australia and include
pharmacists (non-dispensing role) and Nurse Practitioners to support increased team-based care
arrangements. Practices will need to consider the needs of their community when determining
which health professionals or combination of health professionals to engage.

Patient and claiming eligibility

Care Plan preparation
Practice nurses as defined either as a registered or enrolled nurse may assist and deliver some
services either under the supervision of or on behalf of the GP in the preparation of a GPMP (item
721) or TCA (Item 723). This includes in patient assessment, identification of patient needs and
making arrangements for services. The GP must meet all regulatory requirements, personally
attend the patient, review, and confirm all elements of assistance provided on their behalf before
claiming the relevant item/s.

Care Plan Monitoring

Patients being managed under a GPMP/TCA may receive ongoing support and monitoring from
practice nurses, up to five times per year, on behalf of the GP who prepared the plan. MBS nurse
item 10997 applies. Item 10997 may not be claimed in the development of a GPMP and can only
be claimed where your patient already has an existing GPMP, TCA or multidisciplinary care plan in
place. Here, the GP is not required to see the patient or be present with the practice nurse when
the chronic disease monitoring and support is undertaken. It is up to the GP to decide whether they
need to see the patient, and where a consultation with the patient occurs, the GP is entitled to
claim a Medicare item for the time and complexity of their personal attendance on the
patient. Please refer to explanatory note MN. 12.4 for more information.
GPs and nurses should read the relevant MBS items before providing a primary care service: see
MBS Online and MBS Education for Health Professionals.

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Diabetes
It is not necessary for a doctor to perform each step for the Diabetes Cycle of Care. For example, a
doctor may assess a patient’s condition, monitor, and prescribe relevant medications. An
appropriately trained and skilled practice nurse, under GP supervision, can undertake checks such
as blood pressure, BMI, feet examination and review the patient’s diet and exercise. The nurse will
then report back to the doctor who must note that the elements of the annual diabetes care have
been provided.

Asthma
A GP is expected to provide the majority of care for the Asthma Cycle of Care, however, under
doctor’s supervision, an appropriately skilled practice nurse can be utilised to measure vital signs,
assess the patient’s health care needs, provide information and reinforce key messages on asthma
education, ensure the patient’s record is up to date including medications, and undertake
spirometry or peak flow testing.

Cervical Screening
A practice nurse can take a cervical smear if they have undertaken appropriate training. The doctor
should review the pathology results. The service can be covered by WIP funding along, or the GP
can see the patient at the conclusion of the test and claim for the length of time that the GP saw
the patient.

Health Assessments
A suitably qualified practice nurse can assist the GP to conduct an annual health assessment for a
patient over 75 years, a chronic disease 45–49-year check, a 40–49-year diabetes evaluation, or a
Comprehensive Medical Assessment for a patient in Residential Aged Care. The nurse can collect
information for the assessment, provide lifestyle advice and education, as well as facilitate
appropriate referral pathways inclusive of a multidisciplinary team. Such assistance must be
provided in accordance with accepted medical practice and under the supervision of the GP. MBS
items 701-707 apply (time-based). Item number 699 is not time based.
The MBS item 10987 can also be claimed by the practice nurse for health assessment follow up for
ATSI People who have received a health assessment, including a 715 for up to 10 times per
patient per calendar year. Please refer to Practice Nurse Items for more information.

Mental Health
A GP Mental Health Treatment Plan can only be provided by a GP registered with Medicare
Australia; a practice nurse does not take part in delivery of this service.

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Practice Nurse Activity – Item Number Income Estimator
The Practice Nurse item number calculator (reproduced in this guide) provides information
regarding the financial contribution practice nurses can make when involved in providing care for
patients with common chronic conditions. This calculator can be downloaded from our website.

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Cycles of Care
Cycles of Care for Patients with Established Diabetes Mellitus
The aim of the Diabetes Cycle of Care is to enhance prevention, diagnosis, and management of
people with diabetes. The GP is the coordinator of the patient care who ensures that all aspects of
the Annual Cycle of Care are completed.

Patient Register/Recall and Reminder System

Recall system must include:

• A list of all known patients who have diabetes attending the practice, by name, contact number
and file number.

• An active patient recall/reminder system, electronic or paper based.

New MBS Pathology Item for Diagnostic HbA1c

Medicare Benefits Schedule (MBS) pathology item 66841 was introduced on 1 November 2014:

• Quantitation of HbA1c (glycated haemoglobin) performed for the diagnosis of diabetes in

asymptomatic patients at high risk.
When a patient is unlikely to do an OGTT or is reluctant to fast, GPs now have the option of
ordering HbA1c as a screening tool.

• If the HbA1c is within normal limits no further testing is required.

• If the HbA1c is ൒ 48 mmol/mol (6.5%) diabetes is likely.

The RACGP recommends two tests on separate occasions before a diagnosis is confirmed,
however, under item 66841 each patient is entitled to only one Medicare-funded HbA1c diagnostic
test in a 12-month period [Rule p12.1, 25.c applies]. Therefore, confirm the diagnosis either by
ordering the second HbA1c test as ‘management’ of a patient with diabetes* or by ordering a
Fasting Blood Glucose (FBG) or Oral Glucose Tolerance Test (OGTT).

• Path items 66551 (or 66554 if patient is pregnant) can be claimed up to 4 times in a 12-month
period by the same patient.

• For diagnostic purposes this must be notated on the pathology request form.
Note: All visits should be billed under the normal attendance items with the exception of the visit
that completes all the minimum requirements of the Diabetes Cycle of Care. These MBS specific
diabetes item numbers (2517 – 2526) are to be used once all components of the diabetes annual
cycle of care are completed.

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
 Eligibility Criteria
• No age restriction for patients
Ensure patient • Patients with established diabetes mellitus
eligibility • For patients in the community and Residential Aged Care
Facilities
Essential Clinical Documentation Requirements
• Explain Annual Cycle of Care process, gain and record
Care Requirements patient’s consent

This item certifies that Essential Requirements

the minimum
Six Monthly
requirements of the
annual cycle of care
• Measure height, weight and calculate BMI, waist
circumference
have been completed
• Measure BP
• Foot assessment (high risk: every 1 – 3months, low risk:
yearly)
Yearly
• Measure HbA1c, total cholesterol, triglycerides, and HDL
cholesterol and eGFR
• Test for micro albuminuria
• Provide patient education regarding diabetes management
including self-care education
• Review diet and levels of physical activity – reinforce
information about appropriate dietary choices and levels of
physical activity
• Check smoking status – encourage smoking cessation
• Review medication – consider Home Medicine Review
Two yearly
• Comprehensive eye examination by ophthalmologist or
optometrist to detect and prevent complications – requires
dilation of pupils
All elements of the Cycle of Care should be completed every 12 months. Completion item numbers
below.

Item Name Frequency Rebate

2517 Diabetes: Level B Standard Consult + Level B
2521 Diabetes: Level C Long Consult 11 – 13 monthly + Level C
2525 Diabetes: Level D Prolonged Consult + Level D
MBS Item 10991 (bulk billing incentive) may also be claimed for eligible patients.

Patient education
A range of Diabetes-related information for patients is available at The National Diabetes Services
Scheme – About Diabetes page.

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Asthma Annual Cycle of Care
Patient Eligibility
Patients must have moderate to severe asthma:

• Frequency of episodes

• Frequency of use of medication

• Bronchodilator use > three times per week

• Hospital attendance following acute attack

Completion of the Asthma Cycle of Care

• The patient is required to attend two asthma-related consultations; one visit is opportunistic
and is to be recorded, and the second visit is a planned visit for the asthma action plan to be
completed.

• Consultations are attended at a minimum over a four-week period and not greater than 12
months for the cycle to be complete.
The visits must include:

• Diagnosis and assessment of severity

• Review of medication

• Written asthma action plan and education of the patient

Two Step Asthma Visit Example

Visit 1:
This visit is best attended as an opportunistic visit. The clinician assesses the patient’s asthma
severity and knowledge of their condition. Questions that are commonly asked include:

• How do you feel your asthma is currently managed?

• How often do you take your preventative or reliever medications?

• What conditions trigger your asthma symptoms?

• Do you suffer from a persistent cough?

• Do your asthma symptoms prevent you from participating in any activities?

• Do your asthma symptoms cause you to wake up at night?

The patient can be encouraged to keep a symptom diary for review at next visit. This visit is
recorded in the patient’s file and the patient is then invited to return for a thorough assessment and
development of an Asthma Action Plan.
Visit 2:
The patient is booked in for a 30–40-minute visit and is advised to come to the visit having avoided
any asthma-related medications on the day prior to the visit.

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
 • A pre and post peak-flow or spirometry is attended. This is a system to both monitor lung
function and to assess medication delivery technique. The patient is educated and supported
in relation to medication delivery and the best techniques to maximize effectiveness of the
medications.

• Review of symptom diary from visit 1.

• GP review peak-flow or spirometry results.

• Asthma Action Plan completed using the clinical software program. The action plan must be in
written format and the patient must be supplied with a copy of the action plan.

• Plan is signed off by GP.

New Patient:

• Ascertain status, including history, medication, and management.

Existing Patient:

• Assess present situation, including review of medical records and consolidation/collection of

information on history, medication, and management.

Asthma may be treated in General Practice using either the Asthma Cycle of Care or the
GPMP. Both schemes should not be claimed in the same 12 months for the patient due to
overlap in the two services. If, however, the patient has other chronic health conditions or
complex care needs requiring a GPMP and TCA this can be attended in addition to the Asthma
Cycle of Care. The two cannot be billed with less than three months interval between claims.
Refer to MBS Online for further information.

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
 Eligibility Criteria

• No age restrictions for patients

Ensure patient eligibility

• Patients with moderate to severe asthma

• Available to patients in the community and in Residential

Aged Care Facilitates
Essential Requirements

• At least two asthma consultations within 12 months

Note • One of the consultations must be for a Review

A specialist consultation • Review must be planned during previous consultation

does not constitute one
Clinical Content
of the two visits – both
must be with the same • Explain Cycle of Care process and gain patient’s consent
GP or in exceptional
circumstances with • Diagnosis and assessment of level of asthma related
another GP from the medication and devices
same practice.
• Give patient written Asthma Action Plan (if the patient is
\
unable to use a written Asthma Action Plan, discussion with
the patient about an alternative method of providing an
Asthma Action Plan)

• Provide patient self-management education

• Review of written or documented Asthma Action Plan

Essential Documentation Requirements

• Record patient’s consent to Cycle of Care

• Document diagnosis and assessment of level of asthma

control and severity

• Include documentation of the above requirements and

clinical content in the patient file, including clinical content
of the patient held written Asthma Action Plan

Item Name Frequency Rebate

2546 Asthma: Level B Standard Consult + Level B
2552 Asthma: Level C Long Consult 12 monthly + Level C
2558 Asthma: Level D Prolonged Consult + Level D
MBS item 10991 (bulk billing incentive) may also be claimed for eligible patients

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Multidisciplinary Case Conferences
Patients with a chronic or terminal medication condition and complex care needs requiring care or
services from their usual GP and at least two other health or care providers are eligible for a case
conference service. There is no list of eligible conditions, however, the CDM items are designed for
patients who require a structured approach and to enable GPs to plan and coordinate the care of
patients with complex conditions requiring ongoing care from a multidisciplinary team.
Case conferences can be undertaken for patients in the community, for patients being discharge
into the community from hospital and for people living in Residential Aged Care Facilitates.

When are patients most likely to benefit from a Case Conference?

• When there is a need to develop immediate solutions in response to a recent change in the
patient’s condition or circumstances, e.g., death of a carer or unexpected event such as a
stroke.

• To facilitate ongoing management such as sharing of information to develop or communicate

goals for patient care or define relevant provider contributions to care.

How can a GP be involved in a Case Conference?

Prepare and co-ordinate a case conference

• For patients living in the community

• For private patients on discharge from hospital

• For patients in a Residential Aged Care Facility; not those receiving nursing home level care
Participate in a case conference

• For patients living in the community

• For public or private patients on discharge from hospital

• For patients in a Residential Aged Care Facility; not those receiving nursing home level care
A case conference can occur face-to-face, by phone or by video conference, or through a
combination of these. A minimum of three care providers (including the GP) must be in
communication with each other throughout the conference. Examples of persons who may be
included in a multidisciplinary care team are:

• Allied health professionals;

• Home and community service providers;

• Care organizers such as education providers, “meals on wheels” providers, personal care
workers and probation officers.

MBS item numbers for Case

GP Prepares and Co-ordinates GP Participates
Conferences
Community Case Conference 15-20 20-40 >40 mins 15-20 20-40 >40 mins
mins mins mins mins
735 739 743 747 750 758
Discharge Case Conference (At the For Private Patients For Public and Private Patients
invitation of the hospital) 735 739 743 747 750 758
RACF Case Conference 735 739 743 747 750 758

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Cancer Screening
Cervical Screening
Human Papillomavirus (HPV) is a common infection that can cause cervical cell changes that may
lead to cervical cancer. Cervical cancer is one of the most preventable cancer types therefore,
routine cervical screening is the best protection against cervical cancer. Previously, the Pap test
was used to detect cell changes in the cervix. In In December 2017, this was replaced with the
Cervical Screening Test (CST). CST is more effective than the Pap Test at preventing cervical
cancer because it detects the HPV, whereas the Pap Test looked for cell changes in the cervix
which may take a longer period to discover. The new test is only required to be completed every
five years rather than every two and is expected to protect up to 30% more women (Department of
Health and Aged Care, 2022).

Patient Eligibility
• Women aged between 25 and 74

• ‘Under screened’ women who have not had a cervical smear in the last four years

Self-Collection
Self-collection of a sample for screening is available for women between the ages of 30 and 74
years of age who are overdue for screening by two or more years (i.e., being 4 years since their
last Pap Test). Self-collection should only be offered to an eligible person who refuses to have their
sample collected by their requesting practitioner.

Cervical Screening Resources

Resource Details Publication Details
Various Information resources NSW Cervical Screening Program
P: 131 556

National Cancer Screening register National Cervical Screening Program

P: 1800 627 701

MBS Item Numbers for Under Screened Women

Item Name Description
2497 Level A Cervical Screening Short surgery consultation
2501 < 20 min surgery consultation
Level B Cervical Screening
2503 < 20 min out of surgery
2504 > 20 min surgery consultation
Level C Cervical Screening
2506 > 20 min out of surgery
2507 > 40 min surgery consultation
Level D Cervical Screening
2509 > 40 min out of surgery

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Health Assessments
How to Make Health Assessments Work for Your Practice
Take a systematic approach to health care in your practice. Designate the task of setting up the
health assessment process in the practice:

• Obtain a list of appropriate patients (database search) that have been seen by the GP over the
last 12 months
• Ensure all patients are eligible for a Health Assessment
• Set up a process for contacting patients (phone or mail)
• Ensure adequate time is allowed for each assessment; 30-90 minutes (longer for home
assessments – these require a more thorough approach)
• Identify and discuss the benefits of a Health Assessment with each patient
• Obtain patient consent
• Findings and outcomes must be discussed with the patient (and carer where appropriate)
• The GP prepares a written summary which that patient signs, including outcomes and
recommendations – a copy should be offered to the patient
• Keep a copy of each assessment in patient’s records
• Use a Practice Nurse to help conduct the assessments if available
If a third person is undertaking the information collection component, the GP must ensure that this
person has suitable skills, experience, and qualifications.

Health Assessment Target Groups

Medical practitioners may select one of the MBS Health Assessment items to provide a Health
Assessment service to a member of any of the target groups listed. The Health Assessment item
that is selected will depend on time taken to complete the Health Assessment service. This is
determined by the complexity of the patient’s presentation and the specific requirements that have
been established for each target group eligible for Health Assessments.
This excludes the Heart Health Check item number 699, which must be at least 20 minutes.
Type 2 Diabetes Risk Evaluation
Provision of lifestyle modification advice and interventions for patients aged 40-49 years who score
> 12 on AUSDRISK. Once every three years.
45-49-year-old
Once only Health Assessment for patients 45-49 years who are at risk of developing chronic
disease.
75 Years and Older
Health Assessment for patients aged 75 years and older. Once every 12 months.
Comprehensive Medical Assessment
Comprehensive Medical Assessment for permanent residents of Residential Aged Care Facilitates.
Available for new and existing residents. Not more than once a year.
For Patient with an Intellectual Disability
Health Assessment for patients with an intellectual disability. Not more than once a year.
For Refugees and Other Humanitarian Entrants
Once only health assessment for new refugees and other humanitarian entrants, as soon as
possible after their arrival (within 12 months of arrival).

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Health Assessment Item Numbers
Item Name Description/Recommended Frequency
699 Heart Health Check ൒ 20 mins
a. Collection of relevant information, including taking a
patient history that is aimed at identifying cardiovascular
disease risk factors, including diabetes status, alcohol
intake, smoking status, and blood glucose.
b. A physical examination, which must include recording of
blood pressure and cholesterol status.
c. Initiating interventions and referrals to address the
identified risk factors.
d. Implementing a management plan for appropriate
treatment of identified risk factors.
e. Providing the patient with preventative health care advice
and information, including modifiable lifestyle factors.
701 Brief Health < 30 mins
Assessment a. Collection of relevant information, including taking a
patient history.
b. A basic physical examination.
c. Initiating interventions and referral as indicated.
d. Providing the patient with preventative health care advice
and information.
703 Standard Health 30 – 45 mins
Assessment a. Detailed information collection, including taking a patient
history.
b. An extensive physical examination.
c. Initiating interventions and referrals as indicated.
d. Providing a preventative health strategy for the patient.
705 Long Health 45 – 60 mins
Assessment a. Comprehensive information collection, including taking a
patient history.
b. An extensive examination of the patient’s medical
condition and physical function.
c. Providing a basic preventative health care strategy for the
patient.
707 Prolonged Health > 60 mins
Assessment a. Comprehensive information collection, including taking a
patient history.
b. An extensive examination of the patient’s medical
condition and physical and social function.
c. Initiating interventions and referrals as indicated.
d. Providing a comprehensive preventative health care
management plan for the patient.
715 Aboriginal and No designated time or complexity requirements
Torres Strait Aboriginal and/or Torres Strait Islander Child
Islander Health For patients 0-14 years old. Not available to inpatients of a
Assessment hospital or RACF. Not more than once every nine months.
Aboriginal and/or Torres Strait Islander Adult
For patients 15-54 years old. Not available to inpatients of a
hospital or RACF. Not more than once every nine months.
Aboriginal and/or Torres Strait Islander Older Peoples
For patients 55 years and over. Not available to inpatients of a
hospital or RACF. Not more than once every nine months.

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Heart Health Assessment
Item 699
Eligibility Criteria
Perform records search • Adults who are aged 30 years and above
to identify ‘at risk’ • The absolute cardiovascular disease risk must be calculated as
patients per the Australian Absolute Cardiovascular Disease Risk
Calculator which can be viewed at CVD Check

• Not for patients in hospital

Risk Factors
Identify risk factors • Lifestyle: smoking, physical inactivity, poor nutrition, alcohol use,
biomedical, high cholesterol, high BP, impaired glucose
metabolism or excessive weight
• Family history of chronic disease
Clinical Content
Mandatory
• Explain Health Assessment process and gain consent
• Collection of relevant information including taking a patient
history that is aimed at identifying cardiovascular disease risk
factors, including diabetes status, alcohol intake, smoking status,
cholesterol status (if not performed within the last 12 months) and
blood glucose
Perform Health Check • A physical examination, which must include recording of blood
pressure
Nurse may collect • Initiating interventions and referrals to address the identified risk
information. GP must see factors
patient. • Implementing a management plan for appropriate treatment of
identified risk factors
• Providing the patient with preventative health care advice and
information, including modifiable lifestyle factors

Non-mandatory
• Written patient information is recommended
Essential Documentation Requirements
• Record patient’s consent to Health Assessment
• Record the Health Assessment and offer the patient a copy
Claiming
Claim MBS item
• All elements of the service must be completed to claim
Item Name Age Range Recommended Frequency
699 Heart Health • Adults over 30 years Annually
Assessment

You cannot bill a heart health check item for your patient if in the last 12 months have had another
health assessment under Items 701 – 715.

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Health Assessment for Aboriginal and/or Torres Strait Islander
People
Item 715 Eligibility Criteria
• Patients 0-14 years use “child” assessment
• Patients 15-54 years use “adult” assessment
Ensure patients eligibility • Patients 55+ years use “older adult” assessment
• May be provided once every nine months
Clinical Content
Mandatory
• Explain Health Assessment process and gain parents’/carers
Note consent
• Information collection - taking patient history and undertake or
It may take several arrange examinations and investigations as required
shorter sessions to • Overall assessment of patient
complete the full Health • Recommended appropriate interventions
Assessment with an • Provide advice and information
Aboriginal and/or Torres • Keep a record of the health assessment and offer a copy of the
Strait Islanders Patient. assessment with recommendations about matters covered to the
The Practice cannot patient and/or carer
claim the 715 until all
components are Non-mandatory
completed • Discuss eating habits, physical activity, speech and language
development, fine and gross mottos skills, behavior, and mood
• Oher examinations considered necessary by GP/Practice Nurse
Essential Documentation Requirements
• Record parent’s/carer’s consent to Health Assessment
• Record the Health Assessment and offer the parent/carer a copy
Complete documentation • Update parent held child record for children under 5 years of age
• Record immunisations provided
Claiming
• All elements of the service must be completed to claim
• May be completed over several sessions but do not claim 715
until all components are complete
Claim MBS item NB: Once the patient has had a 715 Health Assessment, they are
eligible for ten follow ups by the practice nurse (item number 10987)
and five “at risk” allied health visits (separate/additional to the five
allied health visits under TCA if the patient is diagnosed with a
chronic disease)

A health assessment referral form for follow-up allied health services

is available on the Department of Health and Aged Care website.

Item Name Age Range Recommended Frequency

715 Aboriginal and/or Torres Strait Islander 0-14 years Every 9 months
Health Assessment 15-54 years
55+ years

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Type 2 Diabetes Risk 40 – 49 Years
Item 701/703/705/707 Eligibility Criteria
To reduce the risk of Type • Non-Indigenous patients aged 40 – 49 years (inclusive)
2 Diabetes
• Patients must score > 12 point on Australian Type 2
Diabetes Risk Assessment Tool (AUSDRISK)

Ensure patient eligibility • GP must exclude diabetes via glucose tolerance test
Age and AUSDRISK • Document outcomes

• Determine if diabetes prevention / lifestyle modification or

diabetes management is required based on the outcomes
of glucose tolerance test.

Attend Health
Assessment

Claim MBS item

Common diabetes
prevention or commence
diabetes management

Item Name Age Range Recommended Frequency

701/703/705/707 Health Assessment: Type 2 40-49 years Once every 3 years
Diabetes Risk Evaluation
23 Consulting at consultation room
Level B: if referral not taken-up
within 2 months by the patient –
must be annotated with the
original item number claimed
when the original referral was
written
MBS item 10991 (bulk billing incentive) may also be claimed for eligible patients.

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Health Assessment for 45 – 49-Year-Olds
Item 701/703/705/707 Eligibility Criteria
• Patients aged 45 to 49 years (inclusive)
• Must have an identified risk factor for chronic disease
Perform record search to • Not for patients in hospital
identify ‘at risk’ patients
Risk Factors
• Lifestyle: smoking, physical inactivity, poor nutrition, alcohol
use
• Biomedical: high cholesterol, high BP, excess weight,
impaired glucose metabolism
Identify risk factors • Family history of chronic disease
Clinical Content
Mandatory
• Explain Health Assessment process and gain consent
• Information collection - take patient history, examinations
and investigations as clinically required
• Overall assessment of patient’s health, including their
Perform Health Check readiness to make lifestyle changes
Nurse may collect • Initiate interventions and referrals as clinically indicated
information • Advice and information about Lifestyle Modification
Program and strategies to achieve lifestyle and behavior
GP must see patient changes
Non-mandatory
• Written patient information such as the Lifescripts
resources are recommended
Essential Documentation Requirements
• Record parent’s consent to Health Assessment
• Record the Health Assessment and offer the parent a copy
Claim MBS item Claiming
• All elements of the service must be completed to claim
• Requires personal attendance by GP with patient

Item Name Age Range Recommended Frequency

701/703/705/707 Health Assessment: 45–49- 45 – 49 years Only once
year-old
MBS item 10991 (bulk billing incentive) may also be claimed for eligible patients.

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Health Assessment for 75-Years and Older
Item 701/703/705/707 Eligibility Criteria
• Patients aged 75 years and older
• Patients seen in consulting rooms and/or at home
Establish a patient
• Not for patients in hospital or a Residential Aged Care
register and recall when
Facility
due for assessment
Clinical Content
Mandatory
• Explain Health Assessment process and gain
patient’s/carer’s consent
• Information collection - take patient history, examinations
and investigations as clinically required
• Measurement of BP, pulse rate and rhythm
Perform Health Check • Assessment of medication, continence, immunisation
status for influenza, tetanus, and pneumococcus
Allow 45 – 90 minutes • Assessment of physical function including activities of daily
living and falls in the last three months
Nurse may collect
information
• Assessment of psychological function including cognition
and mood
GP must see patient • Assessment of social function including availability and
adequacy of paid and unpaid help and the patient’s carer
responsibilities
• Overall assessment of patient
• Recommend appropriate interventions
• Provide advice and information
• Discuss outcomes of the assessment and any
recommendations with the patient
Non-mandatory
• Consider the need for community services, social isolation,
oral health and dentition, and nutrition status
Claim MBS item • Additional matters as relevant to the patient
Claiming
• All elements of the service must be completed to claim
• Requires personal attendance by GP with patient

Item Name Age Range Recommended Frequency

701/703/705/707 Health Assessment: 75 75 years and older Once every 12 months
years and older
MBS item 10991 (bulk billing incentive) may also be claimed for eligible patients.

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Health Assessments for Government Humanitarian Program
Items 701, 703, 705 and 707 may be used to undertake a Health Assessment for refugees and
other humanitarian entrants.
The purpose of this Health Assessment is to introduce new refugees and other humanitarian
entrants to the Australian primary health care system as soon as possible after their arrival in
Australia (within 12 months of arrival).
In addition to general requirements for Health Assessments, the assessments must include
development of a management plan addressing the patient’s health care needs, health problems
and relevant conditions.
The Health Assessment applied to humanitarian entrants who are residents in Australia with
access to Medicare services. This includes refugees, Special Humanitarian Program and
Protection Program entrants.
Patients should be asked to provide proof of their visa status and date of arrival in Australia.
Alternatively, medical practitioners may telephone Medicare Australia on 132 011, with the patient
present, to check eligibility.
The medical practitioner and patient can use the service translator by accessing the
Commonwealth Government’s Translating and Interpreting Service (TIS) on 131 450.
A Health Assessment for refugees and other humanitarian entrants may only be claimed once by
an eligible patient.

Health Assessments for People with an Intellectual Disability

Items 701, 703, 705 and 707 may be used to undertake a Health Assessment for people with an
intellectual disability.
A person is considered to have an intellectual disability if they have significantly sub-average
general intellectual functioning (two standard deviations below the average intelligence quotient
and would benefit from assistance with daily living activities. Where medical practitioners wish to
confirm intellectual disability and a patient’s need for assistance with activities of daily living, they
may seek verification from a paediatrician registered to a practice in Australia or from a
government-provided or funded disability service that has assessed the patient’s intellectual
function.
The Health Assessment provides a structured clinical framework for medical practitioners to
comprehensively assess the physical, psychological, and social function of a patient with
intellectual disability and to identify any medical intervention and preventive health care required.
A Health Assessment for people with an intellectual disability may be claimed once every 12
months.

28
Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Systematic Care Claiming Rules
For the most up to date information refer to the Medicare Benefits Schedule online at
[Link]/mbsonline or phone Medicare Australia Schedule Interpretation Team on 132
150.

Item
Service Brief Guide Claim Period
Number
Preparation of a General 2 yearly
Patients with a chronic or
721 Practitioner Management (minimum 12
terminal medical condition
Plan (GPMP) months)
Patients with a chronic
2 yearly
Coordination of a Team disease who require
723 (minimum 12
Care Arrangement (TCA) ongoing care from a
months)
multidisciplinary team
Chronic Disease Management

Systematic review of the

Review of GPMP patient’s progress against
6 monthly
GPMP goals
732 (minimum 3
Systematic team-based
months)
Review of TCA review of the patient’s
progress against TCA goals
Contribution to care plan
6 monthly
or to review the care plan Not available to patients of
729 (minimum 3
being prepared by the RACF
months)
other provider
Contribution to care plan 6 monthly
Plan prepared by such a
731 or to review the care plan (minimum 3
facility
for patient of RACF months)
Assessment, diagnosis
and development of a Children aged under 13
139 treatment and years with an eligible Once only
management plan for a disability
disability
12 months
Domiciliary Medication
except in
Medication reviews

Management Review Assessment, referral to a

900 circumstances
(DMMR) for patient living community pharmacy
with significant
in the community setting
change
12 months
Residential Medication For new or existing except in
903 Management Review residents of Residential circumstances
(RMMR) Aged Care Facilities with significant
change
Monitoring and support for
715 Health Assessment for Maximum 10 per
10987 a person who has had a
Practice

ATSI people patient per year

Nurse

715-health assessment
Monitoring and support for Patient must have a GPMP, Maximum of 5
10997 a person with a chronic TCA or multidisciplinary times per patient
disease care plan in place per calendar year
Restrictions of Co-claiming of Chronic Disease and General Consultation Items
Co-claiming of GP consultation items 3, 4, 23, 24, 36, 37, 44, 47, 52, 54, 57, 58, 59, 60, 63, 65, 597, 598, 599, 600,
5000, 5003, 5020, 5023, 5040, 5043, 5060, 5063, 5200, 5203, 5207, 5208, 5220, 5223, 5227, and 5228 with chronic
disease management items 721, 723, or 732 is not permitted for the same patient on the same day.

Note: CDM services can also be provided more frequently in circumstances where there has been a significant change in
the patient’s clinical condition or care circumstances that require a new GPMP/TCA or review service. You must mark the
Medicare claim as “exception circumstances” or “clinically indicated”.

29
Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Individual Allied Health Services Under Medicare
Summary
• A Medicare rebate is available for a maximum of five services per patient each calendar year.
Additional services are not possible under any circumstances.

• If a provider accepts the Medicare benefit as full payment for the services, there will be no out-
of-pocket cost. If not, the patient will have to pay the difference between the fee charged and
the Medicare rebate.

• Patients must have a GP Management Plan and Team Care Arrangement prepared by their
GP or be residents of a Residential Aged Care Facility who are managed under a
multidisciplinary care plan.

• Referrals to allied health providers must be from GPs.

• Allied health providers must report back to the referring GP.

Eligible Patients
Community-based patients may be eligible if they have a chronic (or terminal) medical condition,
and their GP has provided the following Chronic Disease Management (CDM) services:

• A GP Management Plan (GPMP) item 721

• Team Care Arrangements (TCA) item 723

Residents of a Residential Aged Care Facility may be eligible if their GP has contributed to a
multidisciplinary care plan prepared for them by the aged care facility or to a review of the
multidisciplinary care plan (item 731).

Item Name Recommended Frequency

10950 Aboriginal Health Worker Services
10951 Diabetes Educator Services
10952 Audiologist Services Five allied health services per calendar year.
10953 Exercise Physiologist Can be five sessions with one provider or a
10954 Dietician Services combination (e.g., three dietician and two
10958 Occupational Therapist Services diabetes education sessions). Referral for allied
10960 Physiotherapist Services health services under Medicare form for each
10962 Podiatrist Services provider. Allied health provider must be
10964 Chiropractor Services Medicare registered.
10966 Osteopath Services
10970 Speech Pathologist Services
10956 Mental Health Worker Services • Better access to metal health care items:
ten sessions
10968 Psychologist Services • GPMP and TCA for chronic medical
conditions: five sessions

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Residential Aged Care Facilities
Health Assessment Provided as a Comprehensive Medical
Assessment for Residents of Residential Aged Care Facilities
Items 701, 703, 705 and 707 may be used to undertake a Comprehensive Medical Assessment
(CMA) of a resident of a Residential Aged Care Facility.
This requires an assessment of the resident’s health and physical and psychological functioning,
and must include:

• Making a written summary of the CMA.

• Developing a list of diagnoses and medical problems based on the medical history and
examination.

• Providing a copy of the summary to the Residential Aged Care Facility.

• Offering the resident a copy of the summary.

A Residential Aged Care Facility is a facility in which residential care services, as defined in the
Aged Care Act 1997, are provided. This includes facilities that were formerly known as Nursing
Homes and Hostels. A person is a resident of a Residential Aged Care Facility if they have been
admitted as a permanent resident of that facility.
This Health Assessment is available to new residents on admission. It is recommended that new
residents should receive the Health Assessment as soon as possible after admission, preferably
within six weeks following admission into a Residential Aged Care Facility.
A Health Assessment for the purpose of a CMA of a resident of a Residential Aged Care Facility
may be claimed for an eligible patient:

• On admission to a Residential Aged Care Facility, provided that a CMA has not already been
provided in another Residential Aged Care Facility within the previous 12 months.

• At 12-month intervals thereafter.

Can a GP Charge for a Consultation as well as the CMA?

Medical practitioners should not conduct a separate consultation for any other health-related issue
in conjunction with a Health Assessment unless it is clinically necessary (i.e., the patient has an
acute problem that needs to be managed separately from the assessment).
The only exceptions are:

• The CMA, where, if this Health Assessment is undertaken during the course of a consultation
for another purpose, the Health Assessment item and the relevant item for the other
consultation may both be claimed.

• Use of a specific form to record the results of the CMA is not mandatory. A Health Assessment
provided as a CMA may be claimed annually to an eligible patient.

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Commonly Used Item Numbers
Comprehensive Medical Assessment GP Contribution or Review of a Multidisciplinary Care
Item 701/703/705/707 Plan Prepared by a RACF
Item 731
A full systems review of a permanent resident in a
Residential Aged Care Facility (RACF) For patients in RACFs with a chronic or terminal condition
and complex care needs requiring ongoing care from a
Activities: team including the GP and at least two other health or
Time based, see MBS for complexity of care care providers. Involves GP contributing to, or reviewing,
requirements for each item. a Multidisciplinary Care Plan prepared by the RACF, at
the request of the facility. The plan must describe, at
CMA requires assessment of the resident’s health and least, treatment and services to be provided to the patient
physical and psychological function and must include: by the collaborating providers. Item number 731 enables
Commonwealth funded patients who are classified as low
• Obtain and record resident’s consent. care residents to receive five rebated allied health
• Information collection, including taking patient services per calendar year. The need for allied health
history and undertaking or arranging services must be identified in the Care Plan
examinations and investigations as required.
• Making an overall assessment of the patient. Activities:
• Recommending appropriate interventions. • Obtain and record the resident’s consent.
• Providing advice and information to the patient. • Prepare part of the plan or amendments to the
• Keeping a record of the Health Assessment and plan and add a copy to the patient’s medical
offering the patient a written report about the records.
Health Assessment, with recommendations • Give advice to a person (e.g., nursing staff in
about matters covered by the Health Assessment. RACF) who prepares or reviews the plan and
• Providing a written summary of the outcomes of record in writing, on the patient’s medical records,
the Health Assessment for the resident’s records any advice provided.
and to inform the provision of care for the
resident by the RACF and assist in the provision
of Medical Management Review services for the
resident.
GP Multidisciplinary Case Conference Residential Medication Management Review (RMMR)
Item 735-758 Item 903

For patients in RACFs or the community or on discharge For permanent residents (new or existing) of RACFs. A
from hospital, with a chronic or terminal condition and RMMR is a review of medications, in collaboration with
complex care needs requiring ongoing care from a pharmacist, for patients at risk of medication related
multidisciplinary case conference team including the GP misadventure or for whom quality use of medicines may
and at least two other health or care providers. A carer be an issue.
can be included as a formal member of the team but
does not count towards the minimum of three providers. Activities:
• Obtain and record resident’s consent.
Activities:
Time based items 735-743 require:
• Collaborate with reviewing pharmacist. Provide
input from the resident’s CMA or relevant clinical
• Obtain and record resident’s consent. information for RMMR and resident’s records.
• Recording meeting details including date, start • Participate in post-review discussion with
and end time, location, participants names, all pharmacist (unless exceptions apply) regarding
matters discussed and identified by the team. the findings, medication management strategies,
• Discuss outcomes with patient and carer and issues, implementation, follow up and outcomes.
offer a summary of the conference to them and • Develop and/or revise Medication Management
team members. Plan and finalise plan after discussion with
• Keep record in the patient’s medical file. resident.
• Offer copy of Medication Management Plan to
Time based items 747-758 participation required: resident/carer, provide copy for resident’s records
• Above activities excluding discussion of and for nursing staff of RACF, discuss plan with
outcomes with patient/career and offering nursing staff is necessary.
summary to patient/carer and team members.

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Arrangements for GP RACF Services
New Items for Doctor’s RACF Services
On 1 March 2019, the Government introduced new MBS items for professional services provided
by a general practitioner (GP) or medical practitioner at a RACF. The new items include a call-out
fee to cover doctors’ costs of travel to a RACF (MBS items 90001 and 90002), and new (standard
level A to D) attendance items.
The new items simplify claims for RACF services and replace the derived fee payment model.

Call-Out Fee
The call-out items apply to a doctor’s initial attendance at a RACF and are billable only for the first
patient seen on a RACF visit. Once a call-out item is billed, doctors may then bill an applicable
attendance item for each of the RACF patients they see. The fees for the call-out items are $58.15
for GPs.

Item number Fee

90001 $58.15
90020 $18.20
90035 $39.75
90043 $76.95
90051 $113.30

Billing
The RACF items are only for Medicare-eligible GP and other medical practitioners providing
primary care services in RACFs. Doctors employed by RACFs cannot claim the items, nor can
specialists, consultant physicians, nurses and other allied health professionals.

Item Restrictions
In general, the call-out fee is intended as a one-off payment to help reimburse travel expenses, but
if a doctor must return to a RACF, on the same day and the attendances are not a continuation of
an earlier episode of treatment, another call-out fee would apply per subsequent RACF visit.

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Residential Medication Management Review (RMMR)
Item 903 Eligibility Criteria
• New residents on admission into a RACF
• Existing residents on an ‘as required’ basis every 12-
Ensure patient eligibility months or if there is a significant change in medical
condition or medication regimen
• Not for respite patients in a RACF (eligible for Domiciliary
Medicines Review when they are living in the community
setting)

GP Initiates Service
First GP Visit • Explain RMMR process and gain resident’s consent
Discussion and referral to • Send referral to accredited pharmacist to request
pharmacist collaboration in medication review
• Provide input from Comprehensive Medical Assessment or
relevant clinical information for RMMR and the resident’s
records

Accredited Pharmacist Component

• Review resident’s clinical notes and interview resident
RMMR review • Prepare Medication Review report and send to GP
Conducted by accredited
GP and Pharmacist Post Review Discussion
pharmacist
• Discuss findings and recommendations of the pharmacist
• Medication management strategies, issues,
implementation, follow up, outcomes
• If no (or only minor) changes recommended a post review
discussion is not mandatory

Essential Documentation Requirements

Claim MBS item • Record resident’s consent to RMMR
• Develop and/or revise Medication Management Plan which
should identify medication management goals and
medication regime
• Finalise plan after discussion with resident
• Offer copy of plan to resident/carer
• Provide copy for resident’s records, discuss plan with
nursing staff if necessary

Claiming
• All elements of the service must be completed to claim
• Derived fee arrangement does not apply to RMMRs
Item Name Recommended Frequency
903 Residential Medication As required (payable once in a 12-month period – unless the
Management Review medical practitioner believes there has been a significant
change to a patient’s condition or medicine regimen)

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Prescribing/Home Medicines Review
Domiciliary Medication Management Review (DMMR)
Targeted at patients living in the community who are likely to benefit from a review and may be at
risk of medication misadventure because of risk factors such as:

• Co-morbidities

• Age or social circumstances

• Characteristics of their medicines

• Complexity of their medication regime

• Lack of skills or knowledge to use medicines to their best effect

Examples of risk factors include:

• Currently taking five or more medications

• Taking more than 12 doses of medication per day

• Medications with a narrow therapeutic index or medications requiring therapeutic monitoring

• Significant changes to medication treatment in the last three months

• Suspended non-compliance

• Difficulty managing medication dues to literacy difficulties, cognitive difficulties, or physical

difficulties

• Recent discharge from a facility/hospital (in the last four weeks)

In conducting a DMMR, a medical practitioner must:

• Assess a patients medication management need

• Following that assessment, refer the patient to a community pharmacy or an accredited

pharmacist for DMMR

• With the patient’s consent, provide relevant clinical information required for the review

• Discuss with the reviewing pharmacist the results of that review, including suggested
medication management strategies

• Develop a written medication management plan following discussion with the patient

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
 Eligibility Criteria
Item 900
• Patients at risk of medication related problems or for whom
quality use of medicines may be an issue
• Not for patients in a hospital or Residential Aged Care
Ensure patient eligibility Facility

GP Initiates Service
• Explain purpose, possible outcomes, process, information
sharing with pharmacist
• Gain and record patient’s consent to DMMR
First GP Visit • Inform patient of need to return for second visit
• Complete DMMR referral and send to a pharmacy or an
Discussion and referral to accredited pharmacist
pharmacist
DMMR Interview
• Pharmacist holds review in patient’s home unless prior
approval is sought by the pharmacist
• Pharmacist prepares a report and sends to the GP
covering review findings and suggested medication
management strategies
DMMR review
• Pharmacist and GP discuss findings and suggestions
Conducted by accredited
pharmacist Second Visit
• Develop summary of findings as part of draft Medication
Management Plan
• Discuss draft plan with patient and offer copy of complete
plan
• Send copy of completed, agreed plan to pharmacist
Claim MBS item
Claiming
• All elements of the service must be completed to claim
• Patient must be seen by the GP at the time of claiming

Item Name Recommended Frequency

900 Domiciliary Medication Once every 12 months (unless the medical practitioner
Management Review believes there has been a significant change to a patient’s
condition or medicine regimen)
CP42 Medication Review of a Once every six months GP is required to ring Veterans Affairs
DVA Patient Pharmaceutical Advisory Centre (VAPAC) 1800 552 580 for
Authority Prescriptions for 6 months of DVA service and
discuss suitability with pharmacist or an accredited pharmacist

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Mental Health
MBS Better Access Initiative
The Better Access initiative aims to improve outcomes for people with a clinically diagnosed mental
disorder through evidence-based treatment. Under this initiative, Medicare rebates are available to
patients for selected mental health services provided by eligible general practitioners (GPs),
psychiatrists, psychologists (clinical and registered) and social workers and occupational
therapists.

What Medicare Services can be Provided Under the Better Access Initiative?
Medicare rebates are available for up to ten individual* and ten group allied mental health services
per calendar year to patients with an assessed mental disorder who are referred by:

• A GP managing the patient under a GP Mental Health Treatment Plan

• Under a referred psychiatrist’s assessment and management plan

• A psychiatrist or paediatrician
*From 9 October 2020 until 31 December 2022, 10 additional individual psychological therapy
sessions, previously available only to people whose movement was restricted by a state or territory
public health order, are now available each calendar year to all eligible patients under the existing
Better Access to psychiatrists, psychologists, and general practitioners through the MBS (Better
Access) initiative. Full change descriptor can be found here.

Short Term Psychological Therapies

Description of Services
There are three categories of services available for short term psychological therapies.

• Short term psychological therapies provided to people who have mild to moderate mental
illness, or are at risk of suicide or self-harm

• Group therapy programs for people with mild to moderate mental illness who would benefit
from group therapy. Available groups include: Perinatal depression, Dialectical Behavioral
Therapy for young people and adults and Hoarding Disorder treatment.

• Short term psychological therapies for people from a Chinese background, including
culturally appropriate services in English, Cantonese, Mandarin and Shanghainese.

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Mental Health Item Numbers
Item Name Description/Recommended Frequency
2700 GP Mental Health Treatment Assessment of patient taking between 20-39 minutes.
Plan (prepared by a GP who Not more than once yearly
2701 has not undertaken Mental Assessment of patient taking more than 40 minutes. Not
Health Skills Training) more than once yearly
2715 GP Mental Health Treatment Assessment of patient taking between 20-39 minutes.
Plan (prepared by GP who Not more than once yearly
2717 has undertaken Mental Assessment of patient taking more than 40 minutes. Not
Health Skills Training) more than once yearly
2712 Review of GP Mental Health Plan should be reviewed every one – six months
Treatment Plan
2713 Consult > 20 minutes for the ongoing management of a
GP Mental Health
patient with a mental disorder. No restrictions on the
Consultation
number of these consultations per year
2721 GP focused Psychological 30-40 minutes
Strategies (provision of
2723 focused psychological Out of surgery consultation. 30 – 40 minutes
2725 strategies by an appropriately > 40 minutes
trained and registered GP
2727 working in an accredited Out of surgery consultation. > 40 minutes
practice)

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Preparation of a Mental Health Treatment Plan
Items 2700, 2701, 2715 and 2717
Preparation of a GP Mental Health Treatment Plan involves both assessing the patient and preparing the GP
Mental Health Treatment Plan document.

What must be Included in the Assessment?

Assessment of a patient for the GP Mental Health Treatment Plan must include:
• Recording the patient’s agreement for the GP Mental Health Treatment Plan service
• Taking relevant history (biological, psychological, social) including the presenting complaint
• Conducting a mental state examination
• Assessing associated risk and any co-morbidity
• Making a diagnosis and/or formulation
• Administering an outcome measurement tool, except where it is considered clinically inappropriate

A formulation is important for the development of a GP Mental Health Treatment Plan and includes an
assessment of the biological, psychological, and social factors predisposing, precipitating and/or protecting
against a mental health problem.

Where the patient has a carer, the GP may find it useful to have the carer present for the assessment or
components thereof (subject to patient agreement). The assessment can be part of the same consultation in
which the GP Mental Health Treatment Plan is developed, or they can be undertaken in different visits.
Where separate visits are undertaken for the purpose of assessing the patient and developing the GP Mental
Health Treatment Plan, they are part of the GP Mental Health Treatment Plan service and are included in
items 2700, 2701. 2715, or 2717. A benefit is not claimable, and an account should not be rendered until all
components of the relevant item have been provided (see Associated Note 0.56 for more details).

What must a GP Mental Health Treatment Plan Include?

The development of a mental health plan must include:
• Discussion of the assessment with the patient, including the mental health formulation and/or diagnosis
• Identifying and discussing referral and treatment options with the patient, including appropriate support
services
• Agreeing goals with the patient – what should be achieved by the treatment – and any actions the
patient will take
• Provision of psychoeducation
• A plan for crisis intervention and/or for relapse prevention, if appropriate at this stage
• Making arrangements for required referrals, treatment, appropriate support services, review and follow
up
• Documenting this in the patient’s GP Mental Health Treatment Plan
• Offering a copy of the written GP Mental Health Treatment Plan to the patient and/or carer (with patient’s
agreement)

A GP Mental Health Treatment Plan sample template for the Better Access Program can be accessed here.

Can a Practice Nurse Assist with the Plan?

All consultations conducted as part of the GP Mental Health Care items must be rendered by the GP. A
specialist mental health nurse, other allied health practitioner or Aboriginal Health Worker with appropriate
mental health qualifications and training may provide general assistance to GPs in provision of mental health
care where the GP considers that they have skills appropriate to the assistance required.

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Item Eligibility Criteria
2700/2701/2715/2717/2712 • No age restrictions for patient
• Patients with a mental disorder, excluding dementia,
2700/2701 prepared by a
delirium, tobacco use disorder and mental retardation
GP who has not undertaken
Mental Health Skills • Not for patients in a hospital or a Residential Aged Care
Training Facility
2715/2717 prepared by a
Clinical Content
GP who has undertaken
Mental Health Skills
• Explain steps involved, possible out of pocket costs and
gain patient’s consent
Training
• Relevant history: biological, psychological, social and
presenting complaint
• Mental state examination, assessment of risk and co-
Ensure patient eligibility morbidity, diagnosis of mental disorder and/or formulation
• Outcome measurement tool score (e.g., K10), unless
clinically inappropriate
• Provide psychological education
• Plan for crisis intervention/relapse prevention, if appropriate
• Discuss diagnosis/formulation, referral, and treatment
options with the patient
Develop plan • Agree on management goals with the patient and confirm
actions to be taken by the patient
Only a specialist Mental
Health Nurse may assist
• Identify treatments/services required and make
arrangements for these
in the development of the
plan
Essential Documentation Requirements
• Record patient’s consent to the GP Mental Health
Treatment Plan
• Document diagnosis of mental disorder
• Results of outcome measurement tool
• Patient’s needs and goals, patient actions and
treatments/services required
Complete document
• Set review date
• Offer copy to patient (with consent, offer to carer) keep
copy in file

Claiming
Claim MBS item • All elements of the service must be completed to claim
• Review using 2712 at least once during the life of the plan
• Requires personal attendance by GP with patient
• Claiming a 2700/2701/2712/2717 enables patients to
receive up to ten rebated individual and up to ten group
psychology services per calendar year

Item Name Recommended Frequency

2700/2701/2015/2017 GP Mental Health Treatment Plan Not more than once yearly

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Review of a Mental Health Treatment Plan
Item 2712

The review is the key component for assessing and managing the patient’s progress once a GP Mental
Health Treatment Plan has been prepared, along with ongoing management through the GP Mental Health
Consultation item and/or standard consultation items. A patient’s GP Mental Health Treatment Plan should
be reviewed at least once.

What must the Review Include?

The review stage must include:
• Recording the patient’s agreement for the service
• Reviewing the patient’s progress against the goals outlined in the GP Mental Health Treatment Plan
• Modifying the plan, if required
• Checking, reinforcing, and expanding education
• A plan for crisis intervention and/or relapse prevention, if appropriate and if not previously provided
• Re-administration of the outcome measurement tool used in the assessment stage, except where
considered clinically inappropriate.

Note: This review is a formal review point only and it is expected that in most cases there will be other
consultations between the patient and the GP as part of the ongoing management.

When should a Review of the GP Mental Health Care Plan be Done?

The initial review should take place a minimum of four weeks and a maximum of six months after the
completion of a GP Mental Health Treatment Plan. If required, an additional review three months after the
first review is allowed within a 12-month period.

GP Mental Health Care Consultation

Item 2713

When can I use the GP Mental Health Care Consultation Item?

The GP Mental Health Care Consultation item applies to surgery consultations, which are of at least 20
minutes duration and where the primary treating problem is related to a mental disorder.

This item is for the ongoing management of patients with a mental disorder, including patients being
managed under a GP Mental Health Treatment Plan, however, it can be used whether or not a patient has a
Mental Health Treatment Plan. This item should not be used for the patient assessment or preparation of a
GP Mental Health Treatment Plan. There are no restrictions on how often this item can be used.

What must a GP Mental Health Care Consultation Include?

• Taking relevant history and identifying the patients presenting problem(s) if not previously documented
• Providing treatment, advice and/or referral for other services or treatment
• Documenting the outcomes of the consultation in the patient’s medical records and other relevant mental
health plan (where applicable)

A patient may be referred from a GP Mental Health Care Consultation for other treatment and services as
per normal GP referral arrangements. This does not include referral for Medicare rebate-able services by
focused psychological services, clinical psychology, or other allied mental health services, unless the patient
is being managed by the GP under a GP Mental Health Treatment Plan or under a referred psychiatrist
assessment and management plan (item 291).

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Item 2712 Clinical Content
Review of a GP Mental
• Explain steps involved, possible out of pocket costs and
Health Treatment Plan
gain patient’s consent

• Review patient’s progress against goals outlines in the GP

Mental Health Treatment Plan

• Check, reinforce and expand psychological education

Reviewing the Plan
• Plan for crisis intervention and/or relapse prevention is
Only a specialist Mental appropriate and if not previously provided
Health Nurse may assist in
the review of the plan • Re-administered the outcome measurement tool used
when developing the GP Mental Health Treatment Plan,
except where considered clinically inappropriate
Essential Documentation Requirements

• Record patient’s consent to review

• Results of re-administered outcome measurement tool

• Document relevant changes to GP Mental Health

Treatment Plan
Complete documentation
• Offer copy to patient (with consent, offer to carer), keep
copy in patient file
Claiming

• All elements of the service must be completed to claim

• Requires personal attendance by GP with patient

• Claiming a 2712 enables patients to receive a second set

Claim MBS item of six individual or six group psychology services

• Item 2712 should be claimed at least once over the life of

the GP Mental Health Treatment Plan

• A review can be claimed one to six months after completion

of the GP Mental Health Treatment Plan if required and
additional review can be performed three months after the
first review

Item Name Recommended Frequency

2712 Review of GP Mental Health Treatment Plan 1-6 months after GP Mental Health
Treatment Plan

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Checklist for GP Mental Health Treatment Plan
Assessment •Patient’s agreement for the GP Mental Health Treatment Plan
(As part of a GP Mental service
Health Treatment Plan) • Relevant History
• Mental state examination
• Assess risk and co-morbidity
• A diagnosis and/or formulation
• Administer outcome measurement tool (unless clinically
inappropriate)
Plan • Discussion of the assessment with the patient, including the
mental health formulation and/or diagnosis
• Identifying and discussing referral and treatment options with
the patient
• Agreeing on goals with the patient
• Provision of psychoeducation
• Crisis intervention and/or relapse prevention plan if appropriate
• Referrals, treatment, appropriate support services, review, and
follow-up
• Documenting results in the patient’s GP Mental Health
Treatment Plan
• Offer a copy of the plan to the patient
Review • Recording the patient’s agreement for this service
• Review patient’s progress against the goals outlined in the GP
Mental Health Treatment Plan
• Modify GP Mental Health Treatment Plan if required
• Check, reinforce and expand education
• Crisis intervention and/or relapse prevention plan if appropriate
and if not previously provided
• Re-administration of the outcome measurement tool (unless
clinically inappropriate)
The Review is conducted one month to six months from when
the GP Mental Health Treatment Plan was prepared
Consultation • Taking relevant history and identifying the patient’s presenting
problem(s) (if not previously documented)
• Providing treatment, advice and/or referral for other services of
treatment
• Documenting the outcomes of the consultation in the patient’s
medical records and other relevant mental health plan (where
applicable)

Mental State Examination

Appearance and General Behaviour Mood (Depressed/Labile)
Thinking (Content/Rate/Disturbances) Affect (Flat/Blunted)
Perception (Hallucinations etc.) Appetite (Disturbed eating patterns)
Cognition (Level of Sleep (Initial insomnia/Early morning
consciousness/Delirium/Intelligence) wakening)
Attention/Concentration Motivation/Energy
Memory (Short and long term) Judgement (Ability to make rational decisions)
Insight (Capacity to organise and understand Anxiety Symptoms (Physical and emotional
problem, symptom, or illness)
Orientation (Time/Place/Person) Speech (Volume/Rate/Content)

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Veterans’ Care
Coordinated Veterans’ Care Program (CVC)
About the CVC Program
The Department of Veterans’ Affairs (DVA) new Coordinated Veterans’ Care Program commenced
on 1 May 2011. The CVC Program:

• Uses a proactive approach to improve the management of participant’s chronic diseases and
quality of care
• Involves a care team of a general practitioner plus a nurse coordinator who work with the
participant (and their carer if applicable) to manage their ongoing care
• Provides new payments to GPs for initial and ongoing care

Eligibility
The program is aimed at veterans who are at risk of unplanned admission to the hospital and hold
either:

• A Veteran Gold Card and have a chronic health condition

• A Veteran White Card and have a DVA-accepted mental health condition

A DVA-accepted mental health condition means DVA has accepted it as being related to a
veteran’s military service.
GPs can enrol participants in the program if they:

• Pass an eligibility assessment

• Give their informed consent to be involved in the program

Payments for GPs

By participating in the program, GPs can claim the following payments through existing payment
arrangements with Medicare Australia:

• Initial assessment and program enrolment (UP01 or UP02)

• Quarterly Care Payments for ongoing care (UP03 or UP04)

Guide for General Practice

The DVA has developed a guide to help with the implementation of the CVC. It can be downloaded
here. The CVC Program items are DVA only items and do not appear in the MBS Schedule.

UP01 Initial Payment – LMO/GP with Practice Nurse Coordinator

Item Description Business Rules
The payment is to an LMO/GP, with a Practice Nurse coordinator, for This item will be claimed on
enrolling a person in the CVC Program and having done all things enrolment of a participant in the
necessary for the enrolment as described in the guide for General CVC Program.
Practice or notes for CVC Program Providers and summarised as
follows: Only one claim of either UP01 or
• The LMO/GP has made any required changes to the practice UP02 will be paid per participant
before enrolling the participant in the Program regardless of change in
• The participant has been assessed by the LMO/GP as meeting LMO/GP or in Practice Nurse
the eligibility criteria for participation in the Program arrangements. Where a person
ceases to be a participant and
• The LMO/GP has explained the Program and the person has
later re-enters the Program, the
provided informed consent to being enrolled in the Program and
initial incentive payment (UP01
to the sharing of health and medical information
or UP02) will not be payable.

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
• A care coordinator employed by the general practice has been
appointed The date of service is the date
• A comprehensive needs assessment of the participant has been of enrolment in the Program
carried out by the care coordinator or the LMO/GP which is the date that all steps
necessary for enrolment in the
• A care plan (GPMP) has been prepared and agreed with the
Program have been completed.
participant and a patient friendly copy provided to the participant
and any carer/family as agreed

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022
Contact Details for Key Organisations
Asthma
National Asthma Council
W: [Link]
T: 03 8699 0476 / 1800 032 495
Best Practice
W: [Link]
T: (07) 4155 8888
Cancer Screening
W: [Link]
Diabetes Australia NSW
W: [Link]
T: 1300 342 238
Immunisation
Australian Immunisation Register (AIR) Immunisation Information
T: 1800 653 809
My Health Record
W: [Link]
T: 1800 723 471
Medical Director
W: [Link]
T: 1300 300 161
National Cervical Screening Program
W: [Link]
NBMPHN Health Pathways
W: [Link]
NSW Cervical Screening Program
W: [Link]
detection/cervical-screening
Practice Incentive Program (PIP)
W: [Link]
T: 1800 222 032
Quality Use of Medicines
NPS MedicineWise
W: [Link]
T: (02) 8217 8700
Services Australia
W: [Link]
T: 132 150

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Wentworth Healthcare Limited (ABN 88 155 904 975) provider of the Nepean Blue Mountains PHN. 30/07/2022