Diabetes Annual Cycle of Care
Claiming the diabetes incentive payment
Activity
Comprehensive eye examination
Frequency per cycle
At least one every 2 years
Height initially, then weight; calculate BMI
Blood pressure
These are the minimum requirements of best-practice diabetes
care. All components of the Diabetes Annual Cycle of Care (DACC)
must have been completed over a period of 11 - 13 months.
Activities required twice in a cycle of care must be performed at
least five months apart.
Check if the patient has already claimed DACC: use HPOS Online
Checker, or phone Medicare on 132 150.
At least twice
To receive payment, GP must work at accredited practice, signed
on to the Practice Incentive Program (PIP) Diabetes Incentive.
Foot check
Use one of the below item numbers in place of the normal item number
when the cycle is complete. This will trigger a Service Incentive
Payment (SIP) of $40, paid on top of the consultation fee, to the GP
Provider.
Measure HbA1c
Total cholesterol, triglycerides & HDL
Microalbuminuria
Group A18 or A19 MBS item numbers:
At least once
2517 (level B in consulting rooms) or
2521 (level C in consulting rooms), or
estimated Glomerular Filtration Rate (eGFR)
2525 (level D in consulting rooms), or
Outside consulting rooms: 2518, 2522, 2525, 2526, 2620, 2622, 2624, 2631, 2633 or 2635.
Review medication
Diabetes SIP is payable once per patient per year.
Review and advise on diet
To claim the direct bill payment, use the usual MBS item numbers
10990 or 10991.
Review and advise on physical activity
All other consultations to meet the cycle of care requirements should
be billed using usual MBS attendance items.
Check smoking status; encourage smoking cessation
Provide self-care education
At least once and
reinforced as often as possible
A further outcomes payment is paid to practices that reach target
levels. See Department of Human Services PIP information or
phone 1800 222 032.
Contact [email protected] for checklists.
P (03) 9347 1188 | F (03) 9347 7433 | Level 1, 369 Royal Parade | PO Box 139 Parkville VIC 3052 | www.nwmphn.org.au
Resource updated March 2017
Diabetes Annual Cycle of Care
Medicare initiatives for patients with diabetes
Service
Description
MBS Item
Recommended
frequency
GP
Management
Plan (GPMP)
Team Care
Arrangement
(TCA)
Care Plan
Reviews
Practice Nurse
care plan
monitoring
Diabetes
Annual Cycle
of Care
Domiciliary
Medication
Management Review
(DMMR / HMR)
Case
Conference
Prepare plan for
patient and GP
outlining
problems, goals
and treatment
Prepare plan for
collaborating
multidisciplinary
team, outlining
problems, goals &
treatment
Review GPMP
and/or TCA
regularly
Practice Nurse
monitors care
plan and provides support
Annually complete
minimum requirements for diabetes
care†
Refer to accredited
pharmacist, review
report, advise patient
GP organises, or
participates in,
real-time conference
with at least 2 other
care providers
item 721
item 723
item 732
item 10997
item 2517-2525
on the visit that
completes the cycle
item 900
item 735-743 or
item 747-758
every 2 years
every 2 years
every 6 months
(after 12 months if
warranted*)
(after 12 months if
warranted*)
(after 3 months if
warranted*)
5 per year
Annual *
Once every
24 months*
Maximum of 5
conferences in
12 month period
$144.25
$114.30
$72.05 x 2
$12.00 x 5
$71.70 (item 2521)
+ SIP $40
+ SOP $20
$154.80
$120.95 (item 739)
x5
Annual Fees
As at July 2014
Plus cycle of care
consults between
planned visits
* More frequent only in exceptional circumstances (annotate the Medicare claim).
† For details of the Diabetes Cycle of Care, search by item number on www.mbsonline.gov.au
For Medicare chronic disease fact sheets, proforma, and patient brochures, go to
www.health.gov.au/mbsprimarycareitems
Before undertaking any Medicare service or claiming an item, read the rules for that item at:
www.mbsonline.gov.au
Planned care: prepare GPMP & TCA, then recall every 3-6 months. Alternate a “Diabetes Review”
(where GP claims normal consult and/or nurse claims item10997) with a “Care Plan Review”
(where GP claims item 732 for GPMP / TCA review).
Also consider:



GP Mental Health Treatment Plan for patients with depression or anxiety:
MBS item 2700, 2701, 2715 or 2717
Health assessments as relevant (eg. Older persons, etc.)
Asthma Cycle of Care, etc. as relevant
P (03) 9347 1188 | F (03) 9347 7433 | Level 1, 369 Royal Parade | PO Box 139 Parkville VIC 3052 | www.nwmphn.org.au
Resource updated March 2017
Diabetes Annual Cycle of Care
Services for people with diabetes
NWMPHN
North Western Melbourne Primary Health Network (NWMPHN): see www.nwmphn.org.au
Medicines Line
National Prescribing Service, Tel 1300 888 763, www.nps.org.au/healthprofessionals
Clinical Guidelines
For assessment, management and referral information go to Melbourne.healthpathways.org.au Go to ‘Melbourne Localised Pathways > Diabetes
General practice management of type 2 diabetes 2016-18: http://www.racgp.org.au/your-practice/guidelines/diabetes/
Lifestyle guidelines
RACGP ‘SNAP’, Red Book, Green Book:
National Diabetes Services
Scheme (NDSS)
Provides blood and urine testing strips, syringes and needles for special injection systems at subsidised prices to people who register for its benefits. Go to
http://www.diabetesvic.org.au/ and follow the NDSS links. See NDSS Online Services Directory for access points, doctors, endocrinologists, credentialed diabetes educators, dietitians and other health professionals in your area. Go to http://osd.ndss.com.au/
Community Health Service
Diabetes-related services, eg: diabetes education, dietetics, physiotherapy, podiatry, counselling, health coaching and lifestyle modification
programs.
HARP Hospital Admission Risk Program
Diabetes education / insulin initiation / for people
with complex factors, or hospital admission in past
12 months, or imminent risk of hospitalisation.
Allied health providers
Medicare registered allied health providers
accept ‘EPC’ referrals for patients with
GPMP + TCA.
Go to Services > Diabetes
www.racgp.org.au/your-practice/guidelines/
 Merri CHS: www.merrichs.org.au 11 Glenlyon Road, Brunswick. Tel. 9387 6711 Fax: 9495 2599 Other sites: Brunswick West, Coburg, Fawkner & Glenroy
 cohealth various sites. See www.cohealth.org.au
 Inner East CHS: www.iechs.com.au 283 Church Street, Richmond, Tel. 9429 1811 Fax. 9429 8536 Other sites: Hawthorn & Ashburton
 North Richmond CHS, www.nrch.com.au 23 Lennox Street, Richmond. Tel. 9418 9800 Fax. 9428 2269
 Dianella, various sites. See www.dianella.org.au
 Partnerships in Health, Melbourne Health HARP
Tel: 9319 9492 Fax. 8387 2217
 Restoring Health, St. Vincent’s Health HARP
Tel: 1300 131 470
 Diabetes Co-Management Program, MPCN Tel. 9347 1188 Fax. 9347 1188
 Diabetes Foot Unit , Melbourne Health HARP
Tel: 9342 7134 F: 9342 3118
 National Human Services Directory (NHSD) www.nhsd.com.au
Commonwealth Carelink Centres Tel: 1800 052 222, www.commCarelink.health.gov.au
 Australian Diabetes Educators Association (ADEA): Tel: 02 6287 4822, www.adea.com.au
Dieticians Association of Australia: Tel:
02 6163 5200, www.daa.asn.au
 Exercise Physiologists: Tel: 07 3856 5622, www.essa.org.au
Australian Physiotherapy Association (APA): Tel: 03 9092 0888 www.physiotherapy.asn.au
 Australian Podiatry Council: Tel: 03 9416 3111, www.apodc.com.au
 Department of Health, GP Portal: www.health.vic.gov.au/generalpractice/
 Australian College of Optometry: free service with Pension/Health/DVA Gold card, or under 18 yrs, or student http://www.aco.org.au/eye-care-services/referrals
 For Credentialed Diabetes Educators (CDE) contact HARP or community health services or DA–Vic (as below), or search ADEA or NHSD www.nhsd.com.au.
Lifestyle programs
Life! Taking Action on Diabetes, Diabetes Australia-Victoria lifestyle courses and phone health coaching: tel. DA-Vic 13 7475 or www.diabeteslife.org.au, Heart Foundation
Walking group, Tel. 1300 362 787, http://www.heartfoundation.org.au/active-living/walking/Pages/welcome.aspx Living longer, living stronger (Victoria), Tel. 1300 182 324,
www.cotavic.org.au/healthy and active ageing/living longer Lift for Life, Tel. 1 300 733 143, www.liftforlife.com.au Heartmoves, Tel. 1300 362 787,
www.heartfoundation.org.au/Professional_Information/Lifestyle_Risk/Physical_Activity/heartmovers.html Beat It, Lift for Life and Heartmoves at Moreland Council leisure centres: [email protected] Tel. 9240 1111; see ‘Active Moreland’ www.moreland.vic.gov.au Moonee Valley City Council, Tel. 9243 8806, go to
www.mvcc.vic.gov.au search ‘healthy ageing’ Living with Diabetes info sessions, North Yarra Community Health, Tel: 9411 4333 HEAL:
https://www.essa.org.au/for-gps/heal-program/where-to-find-heal/#VIC
 Alternatives at www.healthylivingnetwork.com.au & www.healthinsite.gov.au
Diabetes Australia-Vic
DA-Vic:
Peer Support Groups
Diabetes Australia-Victoria provides details of local community based groups:
Multilingual Help Line
To access a dietician or diabetes educator through an interpreter service contact: www.diabetesaustralia.com.au/multilingualdiabetes Arabic  9321 5428;
 9321 5429; Greek  9321 5430; Italian  9321 5431; Turkish  9321 5432; Vietnamese  9321 5433; other  9321 5438.
Diabetes Foot Care
Audio-visual resources from Australian Diabetes Society, to assist healthcare professionals diagnose and manage diabetes-related foot complications:
https://diabetessociety.com.au/diabetesfoot/.
Diabetes Education, Programs, Support Groups, Prevention Kits & NDSS: Tel. 1300 136 588, www.diabetesvic.org.au
Tel 1300 136 588, www.diabetesvic.org.au
P (03) 9347 1188 | F (03) 9347 7433 | Level 1, 369 Royal Parade | PO Box 139 Parkville VIC 3052 | www.nwmphn.org.au
Chinese /Cantonese
Resource updated March 2017
Diabetes Annual Cycle of Care
Planned care schedule
Patient’s name .......................................................................................................................................
Diabetes Cycle of Care SIP last claimed: ........../.........../.........
Action
Frequency
per Cycle
Care Plan
(GPMP+TCA)
Provide
consumer
information
Annual*
Height
initially
Weight
twice yearly
BMI (and waist)
twice yearly
Blood Pressure
twice yearly
Foot check
twice yearly
HbA1c
yearly
Total Chol & HDL
yearly
Triglycerides
yearly
Microalbuminuria
yearly
Urine ACR
yearly
eGFR (blood test)
yearly
Medication Rev
yearly
Self-care, diet,
smoking, physical
activity
yearly
Ophthalmology
every 2 yrs
at diagnosis
GPMP-TCA last claimed:
I.D. ...............................................
Schedule commenced: ........./............/...........
........./............/...........
1st Visit
Week 1-2
Week 2-4
Month 3
Month 6
Month 9
Month 12
Discuss diagnosis, treatment, risks, patient
questions.
Schedule care plan.
Start Cycle of Care.
Prep GPMP & TCA; arrange services; provide
education.
Claim 721 + 723
Check Cycle of Care &
monitor care plan.
Check Cycle of Care &
monitor care plan.
Claim item 10997 (+
Claim item 10997 (+
usual consult item if
usual consult item if
PN & GP Review GPMP &
TCA (recommended every
3-6 months). Claim
10997+732 x 2
Check Cycle of Care &
monitor care plan.
Nurse = item 10997 GP =
usual consult
Complete cycle of care;
claim SIP item.
Prepare new GPMP+TCA
if due and if required*.
patients sees GP).
patients sees GP).
e.g. DA-Vic, Cycle of Care
e.g. Patient hand held
record
e.g. Better Health Channel
P (03) 9347 1188 | F (03) 9347 7433 | Level 1, 369 Royal Parade | PO Box 139 Parkville VIC 3052 | www.nwmphn.org.au
Resource updated March 2017