What Exactly is a 'Chronic Medical Condition'?
Tanya Gradolf, CDM November 08
Many GPs aim to utilise EPC services to the fullest without falling foul of a Medicare audit. Sometimes they are faced with patients who cannot be clearly identified by the guidelines.
This month I've received a number of queries regarding the definition of 'chronic medical condition'. When faced with this dilemma, consider how your GP peer group would classify the patient.
MBS's definition
According to MBS, a chronic medical condition is…
…one that has been or is likely to be present for at least six months, including but not limited to asthma, cancer, cardiovascular illness, diabetes mellitus, mental health conditions, arthritis and musculoskeletal conditions.
MBS's own Q&A document elaborates further (from pages 12-13, my own emphasis added);
Questions have asked whether the following are chronic medical conditions for the purposes of the items:
- alcohol or other substance abuse
- smoking
- obesity
- unspecified chronic pain
- hypertension
- hypercholesterolemia, or syndrome X
- impaired fasting glucose tolerance or impaired glucose tolerance
- pregnancy
The general position on these 'conditions' is that they have not been regarded as chronic medical conditions for the purpose of the EPC items to date, and this remains the case with the CDM items. (Note that in many cases a patient may have complications or co-morbidities, that may be a result of or exacerbated by such conditions or risk factors, that would make them eligible for CDM services.)
In some cases these 'conditions' would not be commonly regarded as chronic medical conditions of themselves, others may more accurately be regarded as risk factors for development of chronic conditions, some possibly relate more to personal choice/behavioral issues and some (pregnancy without complications) could be regarded as a normal part of life.
It is recognised, however, that conditions such as the above can occur across a wide spectrum of severity and in a broad range of circumstances, with, for example, some patients with one (or more) of the above conditions being unable to self-manage or comply with care and treatment, being functionally disabled by their condition etc.
A GP must assess whether a patient is eligible for a CDM service, having reference firstly to the MBS eligibility criteria and the guidance above setting out the general position.
Where a patient's 'condition' would not obviously come within the MBS definition, a GP may still consider that, notwithstanding the above, the patient's condition and circumstances are such that they require the preparation of a GP Management Plan, for example, because of non-compliance, inability to self-manage, functional disability etc.
In these cases, the GP should be satisfied that their peers would regard the provision of a CDM service as appropriate for that patient, given the patient's needs and circumstances.
When in doubt ring the Medicare Provider line 132 150. GPs can discuss their concerns with a Medicare doctor.
This article is available online at http://bddgp.org.au/article/2008/11/cdm
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