GP Chronic Condition Management Plan — preparation

Professional attendance by a general practitioner to prepare a GP chronic condition management plan for a patient. Effective 1 July 2025, item 965 replaced the legacy GP Management Plan (item 721) and consolidated the Team Care Arrangement (item 723) collaborative-care function into a single preparation item. Patients with plans under the legacy framework can continue under those arrangements until 1 July 2027. Telehealth equivalent is item 92029. Where collaborative multidisciplinary care is required, multidisciplinary care plan items 231/729 (non-RACF) or 232/731 (RACF) are billed alongside 965.

Plain-English summary. See MBS Online for the verbatim descriptor of each item.

Time

Not specified

Frequency

Not capped

Referral

Not required

Profession

General Practitioner

Requirements to bill

Conditions imposed by the descriptor that must be met to claim this item.

1Patient has a chronic or terminal medical condition expected to last at least 6 months (or, where the patient has a terminal condition, the GP forms a clinical view that the plan is appropriate).
2GP prepares a documented chronic condition management plan covering the patient's health and care needs, agreed goals, the actions to be taken by the patient, the actions to be taken by the GP, and the treatment and services the patient requires (including from other providers where applicable).
3The plan is offered to the patient, the patient agrees to participate, and a copy is provided to the patient.
4A review timeframe is set for the plan (subsequent reviews are billed under item 967, not 965).
5A prescribed medical practitioner (PMP) cannot claim 965 — they use item 392 instead.

Your notes must show

Documentation tests — what clinical notes need to demonstrate to survive a PSR audit.

Confirmation of eligibility — chronic or terminal condition documented, with expected duration ≥6 months or terminal-condition rationale.
Patient health and care needs — specific to the patient, not templated boilerplate.
Goals — measurable and agreed with the patient.
Actions to be taken by the patient — specific behavioural / self-management commitments, not generic "lifestyle advice".
Actions to be taken by the GP — review schedule, monitoring, prescribing, referrals.
Treatment and services from other providers — named providers and roles where multidisciplinary input is part of the plan.
Distribution — confirmation that a copy was offered and provided to the patient (and to other providers where relevant).
Review timeframe — explicit date or interval for the next review (which will be billed under 967).
Where the patient is transitioning from a legacy 721/723 plan, evidence of the transition (date, what carried over, what changed).

Common audit failures

Patterns the Professional Services Review scheme and Medicare audits flag.

A plan that only lists medications, observations, and a review date — does not meet the descriptor (which requires patient and GP actions, agreed goals, and other-provider services).
Identical plan content across multiple patients (templated boilerplate, not individualised).
No evidence the plan was discussed with the patient, agreed, and provided to them.
No review timeframe set.
Item 965 claimed by a prescribed medical practitioner instead of a GP — PMPs use item 392.
Item 965 claimed where the patient does not have a chronic or terminal condition (e.g. acute presentations relabelled as "chronic management").
Pre-1 July 2025 patient still on a 721 plan billed as 965 — the transition arrangement allows the legacy plan to continue but doesn't convert it; the GP must prepare a new GPCCMP under 965 if claiming the new item.

Related MBS items

Level B GP consultation

Level C GP consultation

Level D GP consultation

967

GP Chronic Condition Management Plan — review (face-to-face)

92029

GP Chronic Condition Management Plan — preparation (video telehealth)

729

GP contribution to a multidisciplinary care plan (non-RACF, face-to-face)

231

PMP contribution to a multidisciplinary care plan (non-RACF, face-to-face)

Templates that document this item

Note templates inside Grounded Scribe that produce documentation aligned to this MBS item.

GP Chronic Condition Management Plan (965)

GP Chronic Condition Management Plan (MBS item 965) for patients with chronic and complex conditions. Documents the diagnoses, agreed goals, patient and GP actions, services from other providers, and a mandatory review date. Structured to satisfy the post-1-Jul-2025 GPCCMP framework that replaced the legacy GPMP (721) and TCA (723) items, and to support the patient's ongoing chronic care.

CDM Physiotherapy (10960)

Chronic Disease Management physiotherapy session (MBS item 10960). Documents the chronic condition being managed, treatment goals from the referring GPCCMP (item 965, post-1-Jul-2025; legacy GPMP plans continue under transition arrangements until 1 July 2027), intervention provided, response, and recommendations back to the GP. Structured to evidence the eligibility and content the item requires.

CDM Occupational Therapy (10958)

Chronic Disease Management occupational therapy session (MBS item 10958). Documents the chronic condition, functional goals from the referring chronic condition management plan (GPCCMP item 965 post-1-Jul-2025; legacy GPMP plans continue under transition arrangements until 1 July 2027), intervention provided (e.g. activity modification, equipment, energy conservation), and recommendations back to the GP. Structured for the Medicare claim and continuity of care.

CDM Speech Pathology (10970)

Chronic Disease Management speech pathology session (MBS item 10970). Documents the chronic condition (e.g. dysphagia, post-stroke communication), goals from the referring chronic condition management plan (GPCCMP item 965 post-1-Jul-2025; legacy GPMP plans continue under transition arrangements until 1 July 2027), intervention delivered, and feedback to the GP. Structured to satisfy the Medicare item content requirements.

CDM Dietetics (10954)

Chronic Disease Management dietetic session (MBS item 10954). Documents the chronic condition (e.g. diabetes, CKD, weight-related comorbidities), nutrition goals from the referring chronic condition management plan (GPCCMP item 965 post-1-Jul-2025; legacy GPMP plans continue under transition arrangements until 1 July 2027), dietary assessment and intervention, and feedback to the GP. Structured to satisfy the Medicare item requirements.

In-depth reading in the Library

Medicare Audit-Ready Documentation: A GP's Guide to MBS Item Number Compliance

Professional Services Review audits can result in repayment demands, exclusion from Medicare, and public referral. Your clinical notes are the primary evidence in any PSR investigation. This guide details exactly what your documentation must contain to withstand scrutiny.

Source authority

Documentation tests on this page reference the descriptor conditions and PSR-audit patterns covered in our existing Library guides. Always confirm current rules against the official descriptor.

Item 965 on MBS Online

Keep reading