MBS Chronic Condition Management Items: The Practice Nurse's Guide to the GPCCMP (965), Reviews (967) and Item 10997

If you're a practice nurse in an Australian GP clinic, chronic condition management is probably the backbone of your week — recalls, care plan paperwork, health assessments and follow-up appointments. Medicare used to call it chronic disease management (CDM); since the move to the GP Chronic Condition Management Plan, the item numbers on your day sheet have changed.

This guide walks through the items you'll touch most often: the GPCCMP (item 965), its review (item 967), health assessments (including item 715) and the practice nurse item — most importantly item 10997. It's written for nurses, not billing managers: the focus is on what you do at each step.

First, the ground rules: what a practice nurse can and can't bill

Medicare claims in general practice are made by medical practitioners (or by the practice on their behalf). Practice nurses don't hold their own Medicare provider numbers for these services. What nurses do have is a set of items the GP can claim for services you deliver on their behalf — item 10997 is the everyday example — and a huge amount of preparation work that makes GP items billable and audit-proof.

Three principles run through every CDM item:

• The GP stays clinically responsible. You work under their supervision and delegation, and they authorise the plan or service.
• Documentation carries the claim. If it isn't written in the record — patient consent, the plan content, reviews — the practice can't defend the claim.
• Items change. Descriptions, fees and rules are updated regularly (fees are typically indexed each 1 November). The MBS Online description for each item is the only authoritative source.

The chronic condition management items you'll see on the day sheet

Item	What it is	Your role as the nurse
965 — GPCCMP	The GP Chronic Condition Management Plan — the single plan that replaced the old GPMP (721) and TCA (723). Prepared by the GP for a patient with a chronic condition.	Pre-appointment: collect observations, pathology, history and current medications so the GP can finalise the plan efficiently. Book the dedicated, adequately long appointment.
967 — GPCCMP review	The GP's review of an existing GPCCMP — claimed by the GP, not the nurse.	Run the recall system so reviews aren't missed (commonly 3–6 monthly in many practices, per the GP's clinical judgement), and pre-populate the review data.
715 — Health assessment	Annual health assessment for Aboriginal and Torres Strait Islander patients.	Often nurse-led: complete the assessment components and flag the follow-up actions for the GP.
10997 — Practice nurse item	Lets the GP claim for an attendance you provide on their behalf for chronic condition management — the workhorse nurse item in general practice.	Deliver the service (wound care, chronic condition follow-up, education) under the GP's supervision, and document it as if the GP were in the room.

What happened to items 721, 723 and 10990?

If your practice software reports still print GPMP (721), TCA (723), review items 2755/2757 or the old nurse item 10990, that's the previous chronic disease management framework. Under Medicare's chronic condition management changes, the GPMP and TCA were folded into a single GP Chronic Condition Management Plan (item 965), plan reviews moved to item 967, and the practice nurse item became item 10997.

Three practical clean-ups for your workflow:

• Update billing templates and checklists that still say GPMP/TCA — the fastest source of billing confusion is staff picking a superseded item from an old template or nurse-clinic checklist.
• Expect legacy numbers in old paperwork. Letters, discharge summaries and older care plans reference the previous items — read them as "this patient has (or had) a plan" and confirm what's current in the record before claiming.
• Plan the cycle under the new items. When a plan is next due it's prepared as a GPCCMP — set the review recall at that visit so the 967 cycle starts on time.

Item 10997 in practice

Item 10997 is the reason a nurse-led chronic condition clinic can be sustainable for a practice. The core points to keep in mind:

• The service is provided by a practice nurse, on behalf of the GP, as part of the patient's chronic condition management.
• Check the current MBS Online note for item 10997 before you book — its eligibility conditions (including requirements around the patient's existing plan and prior services) are exactly what separates a clean claim from a rejection, and they shouldn't be assumed from how the old 10990 worked.
• You work under the supervision of the GP, and claim frequency limits apply — confirm the current count in the MBS note rather than a colleague's rule of thumb.

A practical habit: build a pre-appointment checklist in your practice software — "plan current? item conditions met? Y/N" — so the front desk doesn't have to guess at billing time.

The paperwork traps that cause claim rejections

• Missing or unsigned consent. CDM plans require the patient's agreement to be documented.
• Plans "finalised" without the GP. You can draft and gather, but the GP prepares and authorises the plan — keep your drafting separate from their sign-off in the record.
• Review dates never booked. The plan is only as good as its recall cycle. Book the review before the patient leaves.
• Same-day double-ups. Some services can't be claimed together on the same day — when in doubt, check the item's "restrictions" flags (the P/R/E codes) on MBS Online.

Where nurses add the most value in the CDM cycle

Practices that run CDM well treat it as a pipeline, not a set of one-off appointments: a recall list that never goes stale, pre-appointment data collection that shortens the GP's consult, team referrals actually followed up, and a review booked at every touchpoint. That pipeline work is nurse work — and it's where the paperwork side pays off fastest. Docsert AI turns scattered notes, summaries and extracts into tidy, structured care-plan documents in minutes, using smart templates that work with Best Practice — you review, edit and finalise every output. The ClinicIQ calculators and CDM checklists cover the rest of the workflow.

This article is general information for Australian practice nurses, not medical or billing advice. MBS item descriptions, fees and claim rules change — always confirm against the current MBS Online item descriptors and your practice software's billing guidance before claiming. Patient care decisions remain the responsibility of the treating practitioner.

Frequently asked questions

Can practice nurses claim Medicare items themselves?

No. Medicare claims in general practice are made by medical practitioners or by the practice on their behalf. Practice nurse services are billed under specific items — most commonly MBS item 10997 — which the GP claims for an attendance the nurse provides on their behalf, under the GP's supervision.

What is MBS item 10997?

Item 10997 lets a GP claim for an attendance provided by a practice nurse on the GP's behalf as part of a patient's chronic condition management. It replaced the old practice nurse item 10990 in the move to the GP Chronic Condition Management Plan. Check the current MBS Online note for the full descriptor, eligibility conditions and claim-frequency limits.

What happened to GPMP (721) and TCA (723)?

They were replaced by a single plan — the GP Chronic Condition Management Plan (GPCCMP, item 965) — with plan reviews under item 967. Old 721/723 references still appear in legacy records, letters and software reports, but new claims use the current item numbers.

Do practice nurses prepare the GPCCMP?

Nurses commonly collect the information and draft the content — observations, pathology, medications, patient goals and provider details — but the plan is prepared and authorised by the GP. Keep the drafting work and the GP's authorisation clearly documented as separate steps.

How often can item 10997 be claimed for a patient?

There are limits on the number of 10997 services per patient in a 12-month period, and the exact count has changed over time. Confirm the current limit in the MBS Online item note rather than relying on memory or practice folklore.

What changed in the MBS chronic condition items?

The GPMP (721) and TCA (723) were replaced by the single GPCCMP (965), plan reviews moved to item 967, and the practice nurse item 10990 became 10997. Fees are still typically indexed each 1 November — treat MBS Online (mbsonline.gov.au) as the source of truth and subscribe to its updates.