This article describes how to use Lyrebird Scribe to generate GP Chronic Condition Management Plans (GPCCMP).
Generating Chronic Condition Management Plans with Lyrebird Scribe
The new framework for Chronic Disease Management introduces the GP Chronic Condition Management Plan (GPCCMP), which will replace the existing GP Management Plan (GPMP), Team Care Arrangement (TCA), and related review items. The existing items for GPMP (721) and TCA (723) have been replaced with new item numbers:
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965 for the initial development of a GPCCMP; and
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967 for the quarterly review of a GPCCMP.
To assist with billing sustainability, eligibility has been expanded. This means that while the current approximate eligible patients in a clinic is around 16%, expanded eligibility should put that figure closer to almost 60%.
How does Lyrebird Scribe help?
To support the transition, Lyrebird Health and Best Practice have worked together to deliver a greater experience for users while documenting and managing patient consultations related to chronic diseases. Lyrebird will evaluate whether the patient is eligible for CCM billing automatically, based on their clinical history and the updated Medicare rules.
Watch the demonstration from Lyrebird below:
How does this change the Lyrebird workflow?
- For users with an active Lyrebird Health subscription, Lyrebird will automatically activate in the background when a GP opens a patient record.
- Lyrebird Scribe will evaluate whether the patient is eligible for CCM billing automatically, based on the patient's clinical history and the updated Medicare rules.
- If the patient is eligible, Lyrebird Scribe will launch a prepopulated care plan workflow, ready for review once the consult has been completed.
- Lyrebird Scribe will update the clinical record after the care plan has been created and reviewed, ensuring that the correct billing item has been used (965 or 967). The required clinical notes for Medicare compliance will be captured.
For users with an active Lyrebird and Cubiko subscription, Cubiko's care prompts will be shared directly from within Lyrebird.
Additional resources
- Lyrebird Health have prepared resources, user guides and video tutorials to assist with these changes.
- Practices can join Lyrebird's free education session, Mastering the CDM to CCM Transition with Lyrebird on the 9th of July, 7:00pm AEST. Click to register your attendance.
Information correct at time of publishing (02 July 2025).
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