From Standard Consult to Chronic Care Review: Ethically Using Item 965 & 967 to Improve Patient Outcomes
A practical guide for Australian GPs on ethically identifying opportunities to transition standard consultations into structured chronic care reviews using MBS Item 965 and 967. Improve outcomes through proactive care conversations.
From Standard Consult to Chronic Care Review: Ethically Using Item 965 & 967 to Improve Patient Outcomes
Most chronic disease deterioration does not occur because patients avoid doctors.
It happens because consultations focus only on the presenting complaint.
A patient may attend a standard consultation billed under:
- MBS item 23
- MBS item 36
The presenting issue may be simple:
- script renewal
- sore throat
- blood test review
- skin lesion
But within the medical record are chronic conditions such as:
- asthma
- diabetes
- hypertension
- depression
- osteoarthritis
Without periodic review, chronic disease management slowly slips through the cracks.
The opportunity is not to “upsell” services.
The opportunity is to deliver better long-term care.
Table of Contents
- The Missed Opportunity in Standard Consultations
- Understanding Medicare Items for Chronic Care
- Why Chronic Disease Often Slips Through the System
- Reactive Care Is Expensive Care
- The Ethical Transition Conversation
- Structuring a Chronic Disease Review
- Why Patients Value Structured Reviews
- Turning Everyday Consults Into Preventive Medicine
- Documentation and Compliance
- The Bigger Picture: Chronic Care as a System
- Final Thoughts
- Explore AI Tools for Structured Chronic Care
The Missed Opportunity in Standard Consultations
In a typical GP consultation billed under MBS item 23 or 36, time pressure is real.
Doctors naturally focus on the presenting problem.
But a small conversational pivot can transform the encounter.
Examples:
“By the way, how has your asthma been lately?”
“I see you have diabetes and high blood pressure — do you mind if we quickly review how things are going?”
“We haven’t reviewed your chronic conditions for a while — should we update them today or book a dedicated review?”
This is preventive medicine, not marketing.
When clinically appropriate, these discussions may lead to structured chronic care planning, supported by Medicare items such as 965 and 967.
Understanding Medicare Items for Chronic Care
Australia’s Medicare Benefits Schedule (MBS) supports structured chronic care through several items.
Relevant categories include:
Standard GP consultations
| Item | Description |
|---|---|
| 23 | Standard GP consultation |
| 36 | Longer GP consultation |
Official reference: MBS Online - Medicare Benefits Schedule Item 23
Mental Health Care Plan items
| Item | Description |
|---|---|
| 2715 | GP Mental Health Treatment Plan |
| 2717 | Mental Health Treatment Plan Review |
More information: Services Australia – Eligibility for Mental Health Treatment Plan
Chronic condition management items
| Item | Description |
|---|---|
| 965 | GP Chronic Condition Management Plan |
| 967 | GPCCMP Review |
Reference: Services Australia – GP Chronic Condition Management Plans
Health assessment items
| Item | Description |
|---|---|
| 703 | Brief health assessment |
| 705 | Standard health assessment |
| 707 | Long health assessment |
| 715 | Aboriginal and Torres Strait Islander health assessment |
Reference: Services Australia - Health assessments
Chronic disease care planning items
| Item | Description |
|---|---|
| 695 | Care planning |
| 697 | Care plan review |
| 699 | Care coordination |
Understanding how these items interact helps clinicians deliver structured and compliant care.
Why Chronic Disease Often Slips Through the System
Patients rarely book appointments saying:
- “Review my diabetes control”
- “Check my inhaler technique”
- “Reassess my cardiovascular risk”
Instead they attend for:
- script renewal
- acute symptoms
- administrative requests
Without proactive review:
- HbA1c gradually rises
- blood pressure remains uncontrolled
- inhaler technique deteriorates
- medication adherence declines
This is exactly why structured chronic disease management plans exist.
Reactive Care Is Expensive Care
Delayed chronic disease review leads to:
- hospital admissions
- complications
- fragmented care
- increased anxiety
- reduced quality of life
Preventive medicine works best when chronic disease management is structured and proactive.
This philosophy underpins:
- MBS item 965 – GP Chronic Condition Management Plan
- MBS item 967 – Review consultation
The Ethical Transition Conversation
Moving from a standard consultation to a chronic care review should feel natural and patient-centred.
Asthma example
“By the way, how has your asthma been recently? Have you needed your reliever more often?”
If control appears suboptimal:
“Would you mind if we take a few minutes to review your asthma management and inhaler technique?”
Diabetes example
“I notice your HbA1c has crept up slightly. Would you like us to review your diabetes management today?”
Multiple chronic conditions
“You have a few ongoing conditions. We haven’t reviewed everything together for a while — should we do that today or book a longer appointment?”
This approach:
- improves patient awareness
- strengthens continuity of care
- builds trust
- opens the door for structured review
Structuring a Chronic Disease Review
A comprehensive chronic care consultation may include:
- medication review
- adherence assessment
- monitoring of key parameters
- cardiovascular risk reassessment
- lifestyle review
- allied health referrals
- documentation of goals and follow-up
If you want to improve how care goals are written:
👉 How to Write SMART Goals in Chronic Disease Management
Why Patients Value Structured Reviews
Patients often say things like:
- “No one has reviewed everything together before.”
- “We usually only talk about one problem at a time.”
- “I didn’t realise my asthma wasn’t controlled.”
Structured reviews provide:
- clarity
- a treatment roadmap
- improved patient engagement
This aligns with long-term care principles described here:
👉 Managing Chronic Disease as a Lifetime Project
Turning Everyday Consults Into Preventive Medicine
The mindset shift is simple.
From:
“What is today’s problem?”
To:
“What long-term risks can I stabilise today?”
One simple question can change a patient’s trajectory:
“Before you go — how have your chronic conditions been lately?”
Documentation and Compliance
When billing Medicare items, ensure:
- clinical criteria are satisfied
- documentation supports the claim
- consultation complexity aligns with the item
- services are not duplicated
- the patient understands the plan
Ethical use of MBS items protects both clinician and patient.
The Bigger Picture: Chronic Care as a System
Chronic disease management works best when:
- care plans are structured
- follow-up reviews are scheduled
- monitoring is consistent
- multidisciplinary care is coordinated
Rather than isolated consultations, chronic care should function as a continuous clinical system.
Related article:
👉 If the Goal Is Not Achieved, Fix the System
Final Thoughts
The goal is not to convert consultations.
The goal is to improve outcomes.
A simple “by the way” question can:
- detect deterioration earlier
- improve medication adherence
- strengthen the doctor–patient relationship
- enable structured chronic care planning
Used ethically and appropriately, structured chronic care reviews benefit both patients and clinicians.
Explore AI Tools for Structured Chronic Care
- Explore the GPCCMP Generator
- Try the AI Agent for GPs
- Access mental health planning tools via the MHCP Generator
- View the full workflow suite on the Caredevo Offer Page
- Read more insights on the Caredevo Blog
Next step
See how AI can help you structure chronic care reviews seamlessly in everyday consults.