Chronic disease management (CDM) is one of the most impactful clinical and financial opportunities in general practice. With chronic conditions accounting for a significant proportion of GP consultations, implementing a structured CDM program allows your practice to deliver better patient outcomes, access dedicated Medicare item numbers, and build long-term patient relationships that drive practice sustainability.
Talk with our Regulatory Growth team to set up a comprehensive chronic disease management program for your practice.
What Are Chronic Disease Management Plans?
Chronic disease management plans are structured care plans developed by GPs for patients with chronic or terminal medical conditions. Under Medicare, these plans are formalised through specific MBS items that fund the GP’s time in developing, coordinating, and reviewing the plan. The plans are designed to improve health outcomes through proactive, coordinated care rather than reactive, episodic treatment.
CDM plans are particularly relevant for patients with conditions such as diabetes, cardiovascular disease, chronic respiratory conditions (asthma, COPD), mental health conditions, musculoskeletal conditions, and cancer. Any patient with a chronic condition that has been present (or is expected to be present) for at least six months is potentially eligible.
Key MBS Items for Chronic Disease Management
GP Management Plan (Item 721)
Item 721 covers the preparation of a GP Management Plan for a patient with a chronic medical condition. The plan must document the patient’s health problems, treatment goals, actions to be taken by the patient and the GP, and arrangements for review. Item 721 attracts a higher rebate than standard consultation items and can be claimed once every 12 months per patient (with some exceptions for significantly changed circumstances).
The clinical documentation for Item 721 must demonstrate that the GP has assessed the patient’s chronic condition(s), identified treatment goals in collaboration with the patient, outlined specific management actions, and scheduled a review date.
Team Care Arrangement (Item 723)
Item 723 covers the coordination of a Team Care Arrangement (TCA) for patients who require care from a multidisciplinary team. The TCA must involve at least two other healthcare providers (in addition to the GP) who contribute to the patient’s care. These providers may include practice nurses, physiotherapists, dietitians, psychologists, podiatrists, and other allied health professionals.
The TCA documents each team member’s role, the services they will provide, and how care will be coordinated. Item 723 can be claimed on the same day as Item 721, and patients with a TCA in place can access Medicare-funded allied health services under Items 10950 to 10970 (up to five individual allied health services per calendar year).
Practices that employ allied health professionals through the Workforce Incentive Program (WIP) can deliver these allied health services in-house, creating a streamlined patient experience and additional revenue streams.
Review of GP Management Plan (Item 732)
Item 732 covers the review of an existing GP Management Plan. Reviews should assess progress toward treatment goals, update the plan based on the patient’s current condition, and adjust management actions as needed. Item 732 can be claimed every three months (minimum), making it a regular touchpoint for patients with chronic conditions and a consistent revenue source for the practice.
Implementing a CDM Program in Your Practice
Identify Eligible Patients
Use your practice management software to identify patients with chronic conditions who do not currently have a GP Management Plan. Common search criteria include patients with diagnoses of diabetes, hypertension, heart failure, COPD, asthma, depression, or arthritis who have had three or more consultations in the past 12 months. Many practices underestimate the number of eligible patients in their existing database.
Develop Standardised Templates
Create CDM plan templates within your practice management software for the most common chronic conditions. Templates should include pre-populated sections for the specific condition, standard treatment goals, common management actions, and typical team members. Templates save significant time during the consultation and ensure consistent, compliant documentation.
Establish Recall Systems
Effective CDM programs require systematic recall of patients for plan reviews (Item 732). Set up automated recalls in your practice management software to contact patients when their review is due. A well-managed recall system ensures patients receive timely reviews and the practice captures the associated Medicare revenue. Without active recall, many patients will not return for reviews, resulting in both poorer outcomes and lost billing opportunities.
Train Your Team
CDM programs work when the entire practice team understands the system. Practice nurses play a critical role in patient assessment, care coordination, and plan preparation. Reception staff need to understand booking requirements for CDM appointments (which typically require longer consultation slots). GPs need to be confident with the MBS item descriptors and documentation requirements to ensure compliant billing.
Financial Impact of CDM Programs
A well-implemented CDM program can significantly increase practice revenue. The rebates for Items 721, 723, and 732 are substantially higher than standard consultation items, and the quarterly review cycle creates a predictable, recurring revenue stream. Practices that systematically identify eligible patients and maintain active recall systems routinely report CDM revenue that represents 15 to 25 per cent of total Medicare billings.
Beyond direct Medicare revenue, CDM programs improve patient retention (patients with active care plans are more engaged with the practice), support PIP Quality Improvement data reporting requirements, and generate allied health referrals that can be delivered by your in-house team.
Medicare Compliance for CDM Items
CDM items are among the most scrutinised by the Professional Services Review (PSR). Common compliance issues include claiming CDM items for patients without a genuine chronic condition, failing to document the minimum required elements of the plan, claiming reviews (Item 732) more frequently than every three months, creating TCAs that do not involve genuine collaboration with at least two other providers, and using templates that contain identical content across multiple patients without personalisation.
To maintain compliance, ensure every CDM plan is individualised to the patient, document all consultations thoroughly, verify the frequency of claims against MBS rules, and conduct regular internal audits of CDM billing patterns. Your practice management software should flag when a CDM item is being claimed outside the eligible timeframe.
How HCPA Supports CDM Implementation
As Regulatory Growth Consultants, the HCPA team helps GP practices establish and optimise their chronic disease management programs. We provide support with patient identification and eligibility assessment, template development and practice management software configuration, staff training on CDM workflows and MBS compliance, recall system setup and management, billing audit and compliance review, and integration with billing systems and workforce planning.
Our consultants understand how CDM programs integrate with your broader practice operations. A well-designed CDM program improves clinical outcomes, increases revenue, and supports your accreditation and PIP obligations simultaneously.
Explore our GP clinic registration services for a complete overview of our practice setup and clinical program support.
Talk with our consultants to build a chronic disease management program that delivers results for your patients and your practice.
