What can be claimed on medicare

what can be claimed on medicare

8 Medicare Funded Chronic Disease Management (CDM) Allied Health Items

1 General

1.1 What are the GP Chronic Disease Management (CDM) items?

The CDM Medicare items are for GPs to manage the health care of people with chronic or terminal medical conditions and/or complex care needs. These questions and answers (Qs and As) provide guidance on the requirements relating to Medicare eligibility for the CDM items and the rules that apply for Medicare benefits.

A chronic medical condition is one that has been (or is likely to be) present for six months or longer, for example, asthma, cancer, cardiovascular disease, diabetes, musculoskeletal conditions and stroke. 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.

GPs are able to choose Medicare rebateable items for GP-managed care planning and/or team-assisted care planning, depending on the health needs of their patients.

Patients who have a chronic or terminal medical condition, with or without complex care needs, and who would benefit from a structured care approach, are eligible for a GP Management Plan (GPMP) (MBS item 721) providing they are not a public in-patient of a hospital or a care recipient of a residential aged care facility. The item enables GPs to provide GP-only care planning services for eligible patients.

Patients who have a chronic or terminal condition and complex care needs requiring ongoing care from a multidisciplinary team comprising their GP and at least two other health or care providers are eligible for a Team Care Arrangements (TCAs) service (MBS item 723), providing they are not a public in-patient of a hospital or a care recipient of a residential aged care facility.

While many patients will be eligible for both a GPMP and TCAs, the services can be provided independently. It is not mandatory to follow the preparation of a GPMP with the coordination of TCAs or to prepare a GPMP before coordinating TCAs.

There is a review item for patients who have a CDM plan or plans in place. MBS item 732 provides a rebate for a GP to review a GPMP and/or TCAs. The recommended frequency for review is every six months.

Using the CDM items, GPs can also contribute to other providers' care plans or to a review of these plans. MBS item 729 allows the GP to contribute to a multidisciplinary care plan or to a review of a multidisciplinary care plan prepared by another health or care provider for a patient who is not a resident of a residential aged care facility.

MBS item 731 allows for GPs to contribute to a multidisciplinary care plan for a resident of a residential aged care facility, or to a review of such a plan, where the care plan was developed by that facility. The GP’s contribution to the resident's care plan should be through direct collaboration with the residential aged care facility, at the request of the facility.

1.2 How can patients have access to allied health services through the Chronic Disease Management (CDM) items?

Once a GP Management Plan (GPMP) and Team Care Arrangements (TCAs) have been prepared, the patient may be eligible for access to certain individual allied health services (MBS items 10950 to 10970 inclusive) on referral from their GP. Residents of residential aged care facilities whose GP has contributed to a care plan prepared by the residential facility (item 731) may also have access to the allied health items.

The allied health services provided through these referrals must be directly related to the management of the patient’s chronic condition/s. Only the GP can determine whether the patient’s chronic condition would benefit from allied health services and the need for allied health services must be identified in the patient’s care plan.

Patients with a GPMP and type 2 diabetes can access Medicare rebates for group allied health services (MBS items 81100 to 81125) in addition to the individual allied health services.

The chronic disease care planning process is not simply a mechanism to provide Medicare rebates for allied health services. The CDM items were developed to provide GPs with a structured way of managing a wide range of chronic medical conditions and to assist them to plan and coordinate the care of patients with multidisciplinary care needs. Care planning can be used as a tool for organising the care a patient needs and help reduce the need for ad hoc, episodic consultations. A care plan is a useful mechanism for recording comprehensive, accurate and up-to-date information about the patient's condition and all of the treatment they are receiving. Development of a care plan can also help encourage the patient to take some responsibility for their care, including the identification of any actions the patient might take to help achieve the goals of the treatment.

1.3 What conditions must a patient have to be eligible for a Chronic Disease Management (CDM) service?

To be eligible for any of the CDM items, a patient must have a chronic or terminal medical condition. This is one that has been or is likely to be present for six months or longer and includes but is not limited to asthma, cancer, cardiovascular illness, diabetes mellitus, musculoskeletal conditions and stroke.

The Medicare Benefits Schedule (MBS) does not list all possible medical 'conditions' that are or are not regarded as chronic medical conditions for the purposes of the CDM items.

Whether a patient is eligible for a CDM service or services is essentially a matter for the GP to determine, using their clinical judgement and taking into account both the eligibility criterion and the general guidance. Where a patient’s ‘condition’ would not obviously come within the MBS definition, a GP may still consider the patient’s condition and circumstances are such that they require the preparation of a care plan because of such factors as non-compliance, inability to self-manage or functional disability.

The Department has received queries about whether the following are chronic medical conditions for the purposes of the items: alcohol or other substance abuse; smoking; obesity; unspecified chronic pain; hypertension, hypercholesterolemia, or syndrome X; impaired fasting glucose tolerance or impaired glucose tolerance; pregnancy. In some cases these would

not be commonly regarded as chronic medical conditions in themselves: some may more accurately be regarded as risk factors for development of chronic conditions; some possibly relate more to personal choice/behavioural issues; and some (pregnancy without complications) could be regarded as a normal part of life.

The Department recognises, however, that conditions such as these can occur across a wide spectrum of severity and in a broad range of circumstances, with, for example, some patients with one (or more) of the above conditions being unable to self-manage or comply with care and treatment, being functionally disabled by their condition etc. In many cases a patient may have complications or comorbidities that may be a result of or exacerbated by such conditions or risk factors and would make them eligible for CDM services.

In these cases, the GP should satisfy themselves that their peers would regard the provision of a CDM service as appropriate for that patient, given the patient’s needs and circumstances. Top of page

1.4 Is there an age restriction on Chronic Disease Management (CDM) services?

No. Patients need to have a chronic or terminal condition and their GP has to determine that the patient’s condition would benefit from a CDM service or services, regardless of age.

1.5 Do ‘chronic conditions and complex care needs’ include people with severe disabilities for the purpose of the Chronic Disease Management (CDM) items?

If patients with severe disabilities have a chronic medical condition, they could be eligible for a GP Management Plan (GPMP). If they have a chronic condition and complex care needs, they could also be eligible for Team Care Arrangements (TCAs).

1.6 Who determines whether a patient is eligible for a Chronic Disease Management (CDM) service?

Whether a patient is eligible for a CDM service or services is essentially a matter for the GP to determine, using their clinical judgement and taking into account both the eligibility criterion and the general guidance.

This is also the case for CDM allied health services. Only the GP can determine whether a patient’s chronic condition would benefit from Medicare rebateable allied health services, and the need for these services must be identified in the patient’s care plan.

1.7 Who can provide Chronic Disease Management (CDM) services?

The GP items are intended to be provided by the patient’s usual GP (see section 1.8).

GPs are required to collaborate with two or more other health or care providers in the development of Team Care Arrangements (TCAs). To be one of the minimum three members of a TCAs team, a provider should have an ongoing role and involvement with the patient. In addition to the patient’s usual GP, the team can be comprised of health or care providers such as allied health providers, home or community service providers and medical specialists.

Other GPs would not usually be a team member.

Only one specialist or consultant physician can be counted towards the minimum of two contributing team members who, with the coordinating GP, make up the core TCAs team.

Persons who may be included in a team are discussed more fully in section 3.

1.8 What is meant by the term ‘usual GP’?

The patient’s ‘usual GP’ means:
  • a GP who has provided the majority of care to the patient over the previous twelve months; or
  • a GP who will be providing the majority of care to the patient over the next twelve months; or
  • a GP who is located at a medical practice that provided the majority of services to the patient in the past twelve months or is likely to provide the majority of services in the next twelve months.

1.9 Who can assist a GP with services covered by the Chronic Disease Management (CDM) items?

General assistance

A practice nurse, Aboriginal and Torres Strait Islander health practitioner, Aboriginal health worker or other health professional may assist a GP with the CDM items (e.g. in-patient assessment, identification of patient needs and making arrangements for services). However, the GP must review and confirm all assessments and arrangements, and see the patient.

A GP’s receptionist could assist with the logistics but it would not be appropriate for a receptionist to assess the patient or identify their health and care needs.

Medicare rebateable assistance

Item 10997 may be claimed under Medicare for monitoring or support services provided to a person with a chronic condition by a practice nurse or Aboriginal and Torres Strait Islander health practitioner if:
  • the patient has a GPMP, TCAs or multidisciplinary care plan in place; and
  • the service is provided on behalf of and under the supervision of the GP; and
  • the service is consistent with the patient’s care plan/s;
to a maximum of five services per patient in a calendar year.

As the service is being provided on behalf of, and under the supervision of the GP, the GP retains responsibility for the health, safety and clinical outcomes of the patient. This does not mean that the GP is required to see the patient or be present with the practice nurse or Aboriginal and Torres Strait Islander health practitioner 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. The time the patient spends receiving a service from the practice nurse or Aboriginal and Torres Strait Islander health practitioner is itemised separately under item 10997 and should not be counted as part of the Medicare item claimed for time spent with the GP.Top of page

1.10 Must the patient be offered a signed copy of the GP Management Plan (GPMP) or Team Care Arrangements (TCAs) document?

Yes. The patient must be offered a copy of the GPMP and the TCAs and a copy must be added to the patient’s medical records.

1.11 What are the recommended frequencies and claiming rules for the Chronic Disease Management (CDM) items?

The recommended frequency and minimum claiming periods for the CDM items are set out in the following table.

Source: www.health.gov.au

Category: Insurance

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