A Heart Health Check brings cardiovascular prevention into a focused GP consult. The challenge is turning the assessment into a plan the patient understands, with a record that captures your findings and decisions. For Australian GPs, that also means separating Medicare eligibility from clinical risk-assessment guidance. A consistent consult structure helps you keep patient care, documentation and billing requirements aligned.

What is a Heart Health Check?

A Heart Health Check combines cardiovascular disease (CVD) risk assessment with a management plan to reduce future risk. It involves a clinical history, examination, risk discussion and agreed next steps. A blood pressure reading or cholesterol result alone does not cover the full assessment. The Heart Foundation’s Heart Health Check Toolkit supports this broader prevention workflow.

Our Clinical Notes workflow can help you capture and structure a draft record of that conversation. You remain responsible for the assessment, clinical decisions and final note.

Who is eligible for MBS item 699?

For GPs, Medicare Benefits Schedule (MBS) item 699 covers a heart health assessment for a patient aged 30 years or over, at consulting rooms, lasting at least 20 minutes. Its required components are:

• Relevant information and patient history.
• A basic physical examination, including recorded blood pressure and cholesterol.
• Interventions and referrals initiated where indicated.
• An implemented management plan.
• Preventive healthcare advice and information for the patient.

The age threshold applies to Medicare-eligible patients who would benefit from the assessment. It is distinct from the clinical age ranges for formal CVD risk calculation.

Claiming limits and attendance

Services Australia’s billing guidance allows a heart health assessment once every 12 months and excludes hospital inpatients and residential aged-care recipients.

The item’s explanatory note also prevents claiming after another health assessment in the previous 12 months, except items 715, 228, 92004 and 92011. It requires personal attendance by the GP. Suitably qualified practice nurses or Aboriginal and Torres Strait Islander health practitioners may assist under supervision; the GP attendance must meet the 20-minute minimum.

The assessment should generally be provided by the patient’s usual doctor and should not take the form of a screening service. A separate consultation alongside it should occur only when clinically necessary. Commonwealth or state-funded services have additional restrictions, with specified subsection 19(2) exemptions.

Who should have a formal CVD risk calculation?

The Aus CVD Risk Calculator recommends risk assessment for these groups without known atherosclerotic CVD:

For First Nations people aged 18–29 years, guidance recommends assessing individual risk factors. That earlier clinical assessment does not change item 699’s minimum age.

Moderate-to-severe chronic kidney disease and familial hypercholesterolaemia confer clinically determined high risk and follow the high-risk management pathway rather than a calculator-derived score. For known atherosclerotic CVD, use disease-specific management rather than a primary-prevention risk calculation.

The primary-prevention calculator’s scope does not, by itself, determine eligibility for an individual item 699 claim.

For clinical care, the 2023 Australian guideline supersedes the 2012 guidance still mentioned in the MBS explanatory note.

A practical Heart Health Check structure

Build the consult around the decisions you need to make with the patient. The appointment length is a minimum billing condition, rather than a reason to compress a complex assessment into 20 minutes.

1. Prepare the record and explain the assessment

Before the consult, establish the patient’s assessment history, relevant diagnoses, medicines and available pathology. Arrange information collection so the GP has the results needed for the assessment and discussion. The practice implementation toolkit includes team roles and patient invitation resources.

Explain the assessment and its likely benefits, obtain consent and record it before proceeding. The assessment consent requirements also cover consent from an appropriate parent, carer or representative when the patient cannot consent.

Ask what matters to the patient. Their concerns, readiness for change and practical barriers belong alongside the clinical risk factors.

2. Take the history and record findings

Cover relevant medical and family history, smoking, diabetes, medicines and the patient’s circumstances. Discuss nutrition, physical activity and alcohol in a way that identifies useful support rather than assigning blame.

Record the examination findings, including blood pressure, and the cholesterol results used. Keep the dates and units with measurements so that an earlier pathology result cannot be mistaken for a measurement taken today. Document additional investigations according to clinical need, rather than turning the template into a universal test panel.

3. Calculate risk where appropriate and explain its meaning

Use the current Aus CVD Risk Calculator for a patient within its clinical scope. Capture the inputs actually used: age, sex at birth, smoking status, systolic blood pressure, total cholesterol to high-density lipoprotein (HDL) cholesterol ratio, diabetes status and CVD medicine use within the last six months: blood pressure-lowering, lipid-modifying or antithrombotic medicines, or none. Postcode and atrial fibrillation history are additional calculator fields.

For people with diabetes, the Australian CVD risk guideline also includes diabetes-specific variables: haemoglobin A1c (HbA1c), time since diagnosis, urine albumin-to-creatinine ratio, estimated glomerular filtration rate, body mass index and insulin use. Record missing information explicitly rather than filling gaps with assumed normal values.

Document the five-year risk estimate, its category and any clinically relevant reclassification factors. The current categories are low risk below 5%, intermediate risk from 5% to below 10%, and high risk at 10% or above. Family history, kidney measures, ethnicity and severe mental illness can affect clinical interpretation; a percentage alone does not capture the whole decision.

Use consistent language when discussing the result. Explain the time horizon, what the estimate means and how management may reduce risk. Avoid translating a low five-year estimate into reassurance that the person has no cardiovascular risk.

4. Agree on management and follow-up

Make the plan specific to the patient’s risk, preferences and circumstances. Record advice, agreed goals, indicated referrals, and decisions about blood pressure-lowering or lipid-modifying treatment. Include the reason for a decision to start, continue, defer or decline treatment where relevant.

The Heart Foundation’s assessment and management templates include a CVD risk assessment form and a My Healthy Heart plan for the patient to take away. They are available as fillable PDFs and Rich Text Format (RTF) files.

For each action, record who will do it and when it will be reviewed. Separate follow-up of an abnormal result or new treatment from the timing of the next formal risk assessment. The once-per-12-month claiming limit does not set every patient’s clinical review interval.

Build a Heart Health Check template workflow in Lyrebird

A useful template keeps the reasoning visible: the information available, the assessment made and the plan agreed with the patient. In Lyrebird, you can use ambient capture, dictation or typed notes to create a structured draft, with a custom template matching your practice’s preferred headings.

The following is a practical documentation structure, not an approved Medicare claim form or a prebuilt Heart Health Check template.

Keep capture, calculation and sign-off separate

1. Set the structure. Create a custom note template using the headings above, adapted to your practice. Keep prompts separate from completed findings so a heading cannot be mistaken for evidence that care occurred.
2. Prepare for capture. Apply your practice’s patient notice and consent process. Obtain and record any consent required for the specific capture workflow before it starts. Consent to the Heart Health Check and consent for AI capture are separate decisions.
3. Capture the clinical discussion. Include the findings and decisions you actually make. Enter or dictate relevant results and the calculated risk rather than expecting the draft to infer missing information.
4. Draft supporting documents. Our Documents & Letters workflow can use the clinical note to draft documents with custom templates, such as a referral or patient management summary.
5. Review, edit and sign off. Reconcile the draft with the consult and patient record. Correct omissions, unsupported findings, medicine details, measurements and risk values before saving the final documentation.

Template completion does not establish Medicare eligibility or replace the required attendance. The clinician determines calculator suitability, risk interpretation, management and the claim.

The assessment retention requirement is two years after the service. This requirement does not authorise deletion of the wider medical record after two years.

A well-structured record should leave the next clinician, and the patient, clear about what was found and what happens next. To discuss how a custom assessment template fits your practice’s documentation workflow:

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