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GPCCMP FAQ - Staff Roles & Responsibilities

Categories:

Understanding GPCCMP & Key Changes – Overview of the GP Chronic Care Management Program and what’s new under GPCCMP.

Transitioning Existing Patients & Plans – How to move existing care plan patients smoothly into GPCCMP.

Specific Patient Groups & Edge Cases – Advice for managing complex patients and uncommon GPCCMP scenarios.

Practice Management & Clinical Software – Guides for using clinical software and Cubiko tools to support GPCCMP workflows.

Patient Communication & Operational Planning – Templates and tips for engaging patients and planning care delivery efficiently.

MyMedicare Requirements – What practices and patients need to know about MyMedicare registration and eligibility.

MBS Item Numbers & Billing – Understand which MBS items apply, how to claim correctly and avoid common billing errors.

GPCCMP Plan Creation & Reviews – Step-by-step guidance for creating, reviewing and updating GP Chronic Care Management Plans.

Financial Strategy & Practice Efficiency – Practical tips to improve billing accuracy, profitability and workflow efficiency.

Compliance & Quality Assurance – Stay compliant with RACGP, Medicare and MyMedicare requirements when delivering care plans.

Allied Health Referrals Under GPCCMP – How to manage allied health referrals linked to GP Chronic Care Management Plans.

 

Which practice staff can help with GPCCMP preparation and reviews?

The Bottom Line:

The good news is that various practice staff members can assist GPs and Prescribed Medical Practitioners with both the preparation and review of GPCCMPs. Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners, and Aboriginal Health Workers are all explicitly able to help, giving you flexibility to use your team effectively while maintaining clinical oversight. Their assistance is now formally recognised in the new framework.
 

The Facts:

  • Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners, and Aboriginal Health Workers can assist a GP or prescribed medical practitioner in preparing or reviewing a GPCCMP
  • The GPCCMP is a plan between the GP/prescribed medical practitioner and their patient - it is a requirement that the GP/prescribed medical practitioner sees the patient as part of the service, and they are responsible for the service
  • The changes recognise the importance of practice nurses, Aboriginal and Torres Strait Islander Health Practitioners, and Aboriginal Health Workers in the management of chronic conditions within primary care
Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 1, 2; Upcoming Changes to the Chronic Disease Management Framework – What Do the Changes Mean for Practice Nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers? – Factsheet, pages 1, 2, 3; MBS Online explanatory note AN.0.47
 

Links and Resources:

Are there any restrictions on which staff can help with GPCCMPs?

The Bottom Line:

While various staff can assist with GPCCMP preparation and reviews, the GP or Prescribed Medical Practitioner remains ultimately responsible for billing the GPCCMP items. The assistance provided by practice nurses, Aboriginal and Torres Strait Islander Health Practitioners, and Aboriginal Health Workers is formalised under the new framework, ensuring clear roles and clinical oversight. You'll find this gives you good flexibility while maintaining proper accountability.
 

The Facts:

  • GPCCMP items may be billed by General Practitioners and Prescribed Medical Practitioners only
  • The clinical roles authorised to assist a GP or prescribed medical practitioner in preparing or reviewing a GPCCMP include Practice Nurses, Aboriginal and Torres Strait Islander Health Practitioners, and Aboriginal Health Workers
  • The ability for these roles to assist has been specified in the regulatory arrangements for the new items
  • It is a requirement that the GP/prescribed medical practitioner sees the patient as part of the service, and they are responsible for the service
  • The items for preparing and reviewing a GPCCMP are complete medical services - they provide the full MBS benefit for the services
  • Practice nurses are defined as "a registered or an enrolled nurse who is employed by, or whose services are otherwise retained by, a general practice"
  • Nurse practitioners are registered nurses with an endorsement - provided they are working in general practice, they meet the definition of a practice nurse for these items
Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 1, 2; Upcoming Changes to the Chronic Disease Management Framework – What Do the Changes Mean for Practice Nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers? – Factsheet, pages 1, 2; MBS Online explanatory note AN.0.47; MBS Online explanatory note MN.12.4
 

Links and Resources:

Official Information:
Role-Based Implementation Guides:

What is the minimum GP time requirement if nurses prepare the GPCCMP?

The Bottom Line:

There's no specified minimum GP time requirement when nurses assist with GPCCMP preparation or reviews. However, you still need to meet all MBS requirements, including seeing the patient, discussing the plan with them, and ensuring they understand and agree with what's proposed. The actual time will depend on your patient's complexity and needs.
 

The Facts:

  • There is no minimum amount of time required to spend with the patient when staff assist with GPCCMP preparation or review
  • All MBS requirements must be met including that the GP or prescribed medical practitioner must attend the patient, have a discussion with them about the plan, and be satisfied that the patient understands and agrees with the plan (including actions they are to take)
  • Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners, and Aboriginal Health Workers can assist the GP or prescribed medical practitioner in preparing or reviewing a GPCCMP
  • Several factors determine how long the consultation will take, including the complexity of their condition(s), whether this is the patient's first plan, whether their condition is stable or has changed significantly, and whether their treatment goals remain the same
Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, page 1; Upcoming Changes to the Chronic Disease Management Framework – What Do the Changes Mean for Practice Nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers? – Factsheet, page 1; MBS Online explanatory note AN.0.47
 

Links and Resources:

Official Information:
Role-Based Implementation Guides:

How do I document staff contributions to GPCCMP preparation and review?

The Bottom Line:

While the MBS factsheets confirm that various staff can assist with GPCCMP preparation and reviews, they don't provide specific details on how to document staff contributions. What's clear is that maintaining comprehensive medical records is essential, and adding a copy of the plan to the patient's medical records is a required part of the process.
 
 

The Facts:

  • The process of developing and finalising a GPCCMP must include adding a copy of the plan to the patient's medical records
  • The process of reviewing a GPCCMP must include adding a copy of the updated plan to the patient's medical records
  • Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners, and Aboriginal Health Workers can assist a GP or prescribed medical practitioner in preparing or reviewing a GPCCMP
  • Providers are responsible for ensuring services claimed from Medicare using their provider number meet all legislative requirements and they may be required to submit evidence for compliance checks
  • Practitioners should ensure they keep adequate and contemporaneous records
Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 3, 4, 5; Upcoming Changes to the Chronic Disease Management Framework – What Do the Changes Mean for Practice Nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers? – Factsheet, page 1; MBS Online explanatory note MN.12.4
The MBS factsheets don't provide specific information about documenting staff contributions to GPCCMP work.
 

Links and Resources:

Can I claim item 10997 when a practice nurse assists with GPCCMP preparation or review?

The Bottom Line:

In general you can't co-claim item 10997 (or its telehealth equivalents 93201, 93203) when a practice nurse assists with preparing or reviewing a GPCCMP. The GPCCMP items are complete medical services that provide the full MBS benefit. Co-claiming may be appropriate where the service provided by the practice nurse or Aboriginal and Torres Strait Islander health practitioner is separate from, but consistent with the patient's plan development or review.
 
Examples of appropriate co-claiming scenarios include:
  • Review and wound treatment (e.g., diabetic wounds) - where the nurse provides separate wound care on the same day
  • Plan/review and immunisation - where the nurse administers vaccines identified in the GPCCMP
  • Plan/review and administration of parenteral medication (e.g., B12 injection) - where separate medication administration occurs

The Facts:

  • Item 10997 (and its telehealth equivalents) cannot be used when a practice nurse or Aboriginal and Torres Strait Islander health practitioner assists with the preparation or review of a GPCCMP
  • The items for preparing and reviewing a GPCCMP are complete medical services and provide the full MBS benefit for the services - you cannot co-claim a second item for the provision of these services
  • Co-claiming may be appropriate where the service provided by the practice nurse or Aboriginal and Torres Strait Islander health practitioner is separate from, but consistent with the patient's plan development or review
  • Examples of appropriate co-claiming scenarios include:
  • Review and wound treatment (e.g., diabetic wounds) - where the nurse provides separate wound care on the same day
  • Plan/review and immunisation - where the nurse administers vaccines identified in the GPCCMP
  • Plan/review and administration of parenteral medication (e.g., B12 injection) - where separate medication administration occurs
Sources: MBS Online explanatory note AN.0.47; MBS Online explanatory note MN.12.4

Links and Resources:

Billing Support:
Role-Based Implementation Guides:

What training should I provide to different staff members for GPCCMP implementation?

The Bottom Line:

Educating your team is highly encouraged for a smooth transition to the new Chronic Condition Management framework. The practical reality is that training GPs, practice nurses, and other relevant staff on the new GPCCMP requirements and referral processes will make this transition much easier for everyone. Support resources are available to help your practice prepare effectively.
 

The Facts:

  • Practices are encouraged to provide training for GPs, practice nurses, and other relevant staff on the new chronic condition management plan requirements and referral processes
  • Practices can seek support and resources from their local Primary Health Networks (PHNs) to assist with the transition and participate in available training or informational sessions
Source: Preparing for Chronic Condition Management Changes in Bp Premier, page 3
 

What are the item numbers for nurse services and what can be included in these calls?

The Bottom Line:

Patients with a GPCCMP can continue accessing practice nurse services using items 10997 (face-to-face), 93201 (telehealth), and 93203 (phone). The good news is that the nature of these services hasn't changed under the new framework - nurses can provide the same scope of services they did previously, but the item descriptors have been updated to reflect the transition to GPCCMPs.
 

The Facts:

  • Patients with a GPCCMP will be able to access services provided by a practice nurse or Aboriginal and Torres Strait Islander Health Practitioner on behalf of a medical practitioner using items 10997, 93201 and 93203
  • Patients with a GPMP and/or TCA in place prior to 1 July 2025 can continue to access these services under those plans until 30 June 2027
  • There are changes to the item descriptors for these items due to the removal of GPMPs and TCAs, and commencement of GPCCMPs
  • The nature of the services that can be provided using items 10997, 93201, 93203 are not changing as part of these reforms
  • Patients are eligible for up to 5 services per calendar year in total - the 5 services can be made up of any combination of 93201, 93203 and 10997
  • Fee: $14.00 Benefit: 100% = $14.00 for item 10997 (face-to-face services)
Sources: Upcoming Changes to the Chronic Disease Management Framework – What Do the Changes Mean for Practice Nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers? – Factsheet, page 2; MBS Online explanatory note MN.12.4
 

Links and Resources:

Official Information:
Role-Based Implementation Guides:
Billing Support:
 

Disclaimer: This FAQ is for general information only and reflects our understanding of upcoming changes to chronic disease management frameworks at the time of publication. For the most accurate and up-to-date guidance, please refer to official sources such as the Department of Health and Aged Care or Medicare. Cubiko is not responsible for any actions taken based on this information.