Contribution by a general practitioner — prepared by that facility, or to a review

Publication date: 1 November 2025

SUMMARY

Multidisciplinary care plans are part of the MBS framework for managing patients with chronic conditions (see AN.15.3 for an overview of MBS items that support the management of chronic conditions). Multidisciplinary care plans allow GPs (see GN.4.13) and prescribed medical practitioners (see AN.7.1) to contribute to a patient’s plan that is developed by another provider.

The multidisciplinary care plan items described in this note are available to patients who are a care recipient in a residential aged care facility. The items can be used to contribute to the preparation or review of a multidisciplinary care plan prepared by the facility, or another provider before the patient is discharged from a hospital. See AN.15.7 for multidisciplinary care plans for patients that are not care recipients of a residential aged care facility.

Care recipients of a residential aged care facility who have a multidisciplinary care plan may be eligible for MBS-supported allied health and Aboriginal and Torres Strait Islander health and wellbeing, and other services (see AN.15.3).

USE OF THE ITEMS

Multidisciplinary care plans are intended to support multidisciplinary care for patients with a chronic condition.

The Health Insurance (General Medical Services Table) Regulations 2021 (the Regulations) define a multidisciplinary care plan as a written plan that:

“(a) is prepared for the patient by:

(i) a general practitioner (for item 731 [and 92027]) or a prescribed medical practitioner (for item 232 [and 92058], in consultation with 2 other collaborating providers, each of whom provides a different kind of treatment or service to the patient, and one of whom may be another medical practitioner; or

(ii) a collaborating provider (other than a general practitioner or a prescribed medical practitioner, as the case may be), in consultation with at least 2 other collaborating providers, each of whom provides a different kind of treatment or service to the patient; and

(b) describes, at least, treatment and services to be provided to the patient by the collaborating providers.”

For the purpose of the multidisciplinary care plans, the Regulations specify that a collaborating provider is “a person, including a medical practitioner, who:

(a) provides treatment or a service to a patient; and

(b) is not an unpaid carer of the patient.”

Multidisciplinary care plan items 232, 731, 92027, 92058 allow the GP or prescribed medical practitioner to contribute to the plan, or review a plan prepared by:

• The residential aged care facility, or
  
  
• Before the patient is discharged from hospital, another provider.

The Regulations state that contributing to a multidisciplinary care plan includes the following:

“(a) preparing part of a multidisciplinary care plan and adding a copy of that part of the plan to the patient’s medical records;

(b) preparing amendments to part of a multidisciplinary care plan and adding a copy of the amendments to the patient’s medical records;

(c) giving advice to a person who prepares part of a multidisciplinary care plan and recording in writing, on the patient’s medical records, any advice provided to the person;

(d) giving advice to a person who reviews part of a multidisciplinary care plan and recording in writing, on the patient’s medical records, any advice provided to the person.”

What is a chronic condition?

For the purpose of multidisciplinary care plans, the Regulations define a chronic condition to be a medical condition that has been (or is likely to be) present for at least 6 months, or is terminal.

There is no list of eligible conditions. It is up to the GP or prescribed medical practitioner’s clinical judgment to determine whether an individual patient with a chronic condition requires multidisciplinary care to manage the condition.

The items are for collaborating to prepare a plan or its review. Who prepares the multidisciplinary care plan?

For care recipients of an aged care facility the multidisciplinary care plan is prepared by:

• The residential aged care facility, or
  
  
• If the service occurs before the patient is discharged from hospital, another provider.

Is there a maximum number of collaborating providers for a multidisciplinary care plan?

No, there is no maximum number of collaborating providers. However, a multidisciplinary care plan requires a minimum of three collaborating providers (including the GP or prescribed medical practitioner) supplying different types of services to the patient.

At least one of the collaborating providers must be a medical practitioner. A maximum of two medical practitioners can be counted in the minimum requirement of three collaborating providers. This means that if there are more than two medical practitioners collaborating on the plan (e.g. a GP, a geriatrician and a neurologist) there must also be at least one collaborating provider that is not a medical practitioner.

Do all collaborating providers have to be health care professionals?

No. Any person providing a treatment or service to the patient is a collaborating provider unless they are an unpaid carer of the patient. However, MBS benefits are only available for the GP or prescribed medical practitioner’s contribution to the multidisciplinary care plan.

Do all collaborating providers have to provide services under the MBS (e.g. allied health professionals)?

No. At least one of the collaborating providers must be the GP or prescribed medical practitioner that bills the multidisciplinary care item. Other collaborating providers may provide MBS services (e.g. a specialist or allied health providers), but it could also include providers that do not provide services under the MBS e.g. a registered nurse at the residential aged care facility that is preparing the plan.

Do all collaborating providers have to meet the MBS item requirements?

The GP or prescribed medical practitioner who bills the multidisciplinary care plan item must meet the requirements of the item.

Other collaborating providers are not able to bill these MBS items and are therefore not required to comply with the item requirements.

How often can the patient have a multidisciplinary care plan?

Multidisciplinary care plan items 232, 731, 92027 and 92058 can be provided once in a 3 month period. However, they cannot be provided if the patient has had a GP chronic condition management plan or review (see AN.0.47) within the last 3 months.

My patient’s clinical condition has changed unexpectedly and their plan should be updated. Can an update ever be done sooner than 3 months?

Yes, the Regulations provide for multidisciplinary care services to be provided to a patient sooner if exceptional circumstances apply. The Regulations define exceptional circumstances as “there has been a significant change in the patient’s clinical condition or care circumstances that necessitates the performance of the service for the patient”. The reasons for exceptional circumstances should be documented in the patient’s notes.

Services Australia needs to be advised that exceptional circumstances apply to pay a benefit sooner than is generally allowable. To facilitate this the patient's invoice, Medicare voucher or the digital claim should indicate that exceptional circumstances are in play, no further explanation is required to support payment.

Can patients with a multidisciplinary care plan access allied health and Aboriginal and Torres Strait Islander health and wellbeing services?

Care recipients of a residential aged care facility with a multidisciplinary care plan may be eligible to access a range of services, including up to 5 (10 for patients of Aboriginal or Torres Strait Islander descent) MBS-supported individual allied health and Aboriginal and Torres Strait Islander health and wellbeing services per calendar year (see AN.15.4 for further details).

Does the patient need a referral to access allied health and Aboriginal and Torres Strait Islander health and wellbeing services?

Yes, a referral is required for the patient to access MBS-supported allied health and Aboriginal and Torres Strait Islander health and wellbeing services. See AN.15.6 for information on referrals for these services.

ELIGIBLE PATIENTS

Patients are eligible for a multidisciplinary care plan items 232, 731, 92027 and 92058 if they:

• have at least one medical condition that has been (or is likely to be) present for at least 6 months, or is terminal

• are care recipients in a residential aged care facility

• require ongoing care from at least three collaborating providers, each of whom provides a different kind of treatment or service to the patient, and at least one of whom is a medical practitioner. At least one collaborating provider must be a provider who is not a medical practitioner, and

• for items 92027 and 92058 only, the patient must have an established clinical relationship with the medical practitioner providing the service (see AN.1.1). While the face to face items can be used prior to the patient being discharged from a hospital, consistent with the general rules applying to telehealth services items 92027 and 92058 cannot be used when the patient is an admitted patient of a hospital

ELIGIBLE PRACTITIONERS

Multidisciplinary care plan items are available for different practitioner types:

• general practitioner items can be claimed by GPs only (see GN.4.13).
  
  
• prescribed medical practitioner items can be claimed by prescribed medical practitioners only (see AN.7.1).

Noting that, under certain circumstances a multidisciplinary care plan can be provided to a patient in a hospital, multidisciplinary care plan items can only be used by medical practitioners that:

• are not employed by the proprietor of a public hospital, or
  
  
• is employed by the proprietor of a public hospital but the service is provided otherwise than in the course of employment by that proprietor.

RECORD KEEPING AND REPORTING REQUIREMENTS

As outlined above, the Regulations require that contributions to a patient’s multidisciplinary care plan, including any advice, be added to the patient’s medical records.

Clause 4.3 of the Health Insurance Act 1973 specifies that, where an item specifies the creation of a document (however described) and a document is created, the document must be retained for the period of 2 years.

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 related to Medicare claims. Practitioners should ensure they keep adequate and contemporaneous records. For information on what constitutes adequate and contemporaneous records see GN.15.39.

RELEVANT LEGISLATION

Details about the legislative requirements of the MBS item(s) can be found on the Federal Register of Legislation at www.legislation.gov.au. Multidisciplinary care plan items are set out in two regulatory instruments:

• Health Insurance (General Medical Services Table) Regulations 2021 – 232, 731
• Health Insurance (Section 3C General Medical Services – Telehealth Attendances) Determination 2021 - 92027, 92058