Asthma Care Plans for Australian GPs

Asthma care planning in Australian general practice has changed substantially in 2025. The National Asthma Council Australia released Version 3.0 of the Australian Asthma Handbook in September 2025, with new first-line recommendations for adults and adolescents. The Medicare Benefits Schedule framework for chronic disease management changed on 1 July 2025, replacing the long-standing GPMP and TCA items with a new GP Chronic Condition Management Plan (GPCCMP). Any care planning documentation in 2026 needs to reflect both changes. This article covers the current framework and how Lyrebird supports care plan drafting.

The Current Clinical Framework

The authoritative reference for asthma care in Australia is the Australian Asthma Handbook, published by the National Asthma Council Australia. Version 3.0 was published on 16 September 2025.

Two changes from V3.0 are particularly relevant for care plan documentation.

The first is a fundamental shift in first-line therapy for adults and adolescents aged 12 and over. The updated handbook recommends anti-inflammatory reliever (AIR)-only therapy or maintenance-and-reliever therapy (MART), rather than as-needed short-acting beta2 agonist (SABA) alone, which is no longer recommended as standalone therapy for this age group. All adults and adolescents with asthma now need inhaled corticosteroids (ICS) as part of their treatment. The typical starting point is low-dose budesonide-formoterol as needed.

The second is updated guidance on diagnosis and management of asthma in infants and children, consolidated into the handbook's age-specific management chapters.

A care plan prepared in 2026 that reflects the previous SABA-only approach for adults and adolescents is out of step with current national guidance.

The MBS Framework for Chronic Disease Management Changed on 1 July 2025

The previous GPMP (item 721) and TCA (item 723) items ceased on 1 July 2025. They have been replaced by a consolidated GP Chronic Condition Management Plan (GPCCMP) framework.

The new items are:

• Item 965 — Prepare a GPCCMP (face-to-face). Rebate $156.55.
• Item 967 — Review a GPCCMP (face-to-face). Rebate $156.55.
• Item 92029 — Prepare a GPCCMP (video telehealth).
• Item 92030 — Review a GPCCMP (video telehealth).
• Item 392 — Prepare a GPCCMP (prescribed medical practitioner, face-to-face).
• Item 393 — Review a GPCCMP (prescribed medical practitioner, face-to-face).

Key practical changes under the GPCCMP framework:

• A Team Care Arrangement is no longer billed separately. Multidisciplinary input is now built into the GPCCMP itself.
• Referrals to allied health are now via standard referral letters rather than prescribed forms.
• GPCCMP can be prepared once every 12 months and reviewed once every three months.
• Patients need to have their plan prepared or reviewed in the previous 18 months to retain access to allied health and related services.
• Patients with existing GPMPs and TCAs from before 1 July 2025 can continue accessing services under those arrangements until 30 June 2027 transition arrangements end.

Eligibility is unchanged in substance. The GPCCMP is available to patients with at least one medical condition present (or likely to be present) for at least six months or that is terminal. There is no prescribed list of eligible conditions, and clinical judgment determines eligibility. Asthma, as a chronic respiratory condition, clearly fits.

For the authoritative current details, see the MBS Online explanatory notes and the RACGP's Chronic Disease Management FAQs.

What an Asthma GPCCMP Contains

Six elements recur across current guidance for asthma-specific care planning, aligned with the Australian Asthma Handbook V3.0 management chapters.

Asthma diagnosis and severity classification. This should include the basis of diagnosis (symptoms, spirometry where performed) and the current severity stratification. Consistency between severity recorded in the care plan and subsequent consult notes matters, both for clinical continuity and for the defensibility of decisions later.

Baseline symptom control. The current level of control, assessed against standard criteria from the Asthma Handbook.

Current medications. Preventer, reliever, and any combination or additional therapy, with dose and frequency. Under V3.0, the documented regimen for adults and adolescents should typically include an ICS-containing therapy rather than SABA alone.

Trigger identification. Known or suspected triggers, and the avoidance or mitigation strategies in place.

Written Asthma Action Plan. The patient-facing plan covering what to do when well, when symptoms worsen, and when to seek urgent help. This is the patient-facing translation of the clinical plan. Written Asthma Action Plans are among the most evidence-supported interventions in asthma care and are emphasised in the V3.0 update.

Review schedule. When the next review is scheduled, what will be assessed, and any specific measures (such as repeat spirometry) planned. Under the GPCCMP framework, reviews can be conducted quarterly.

Record-keeping expectations follow the broader standards set by RACGP Standards Criterion C7.1, the AHPRA shared Code of conduct, and the Medical Board of Australia's Good medical practice.

Common Documentation Issues

Three patterns recur in asthma care plan audits.

Inconsistent severity classification. Severity recorded in the care plan sometimes differs from what subsequent consult notes suggest. This complicates both clinical continuity and billing defensibility. Avant's analysis of medical record issues in claims identifies inconsistency between records as a common failure mode.

Undocumented medication changes. Step-up or step-down changes between reviews are sometimes made in consult notes but not reflected in an updated care plan. This creates ambiguity about the current plan.

Outdated Written Asthma Action Plan. The patient-facing plan is sometimes created once and not updated as medication changes occur. Under the V3.0 changes, practices with patients still on SABA-only regimens from earlier guidance will need to review and update both the clinical plan and the Written Asthma Action Plan.

How Lyrebird Handles Asthma Care Plans

Lyrebird generates care plan drafts from the consult content using a care-plan-specific template. The workflow is to conduct the care plan consultation as usual, with the scribe running in the background, and Lyrebird organises the clinical content into the care plan structure.

For Bp Premier users, the care plan writes back to the patient record through the Best Practice integration.

The Written Asthma Action Plan component, which is patient-facing, is generated as a separate output formatted for printing or electronic sharing with the patient. The content is derived from the clinical care plan but phrased for patient use.

Avant's guidance on AI for medical documentation applies here as it does to all Lyrebird output: the AI-generated draft is reviewed and signed off by the clinician, who remains responsible for accuracy and for ensuring the plan reflects current guidelines and the individual patient's circumstances.

Template Customisation for Care Plans

Most GPs who produce frequent care plans develop a standard format that reflects their preferred phrasing, structure, and level of detail. Lyrebird's template customisation captures this, with the GCHHS lesson on optimising for reviewability identifying template adaptation as the single factor most closely tied to sustained output quality. Templates should reflect V3.0 guidance rather than earlier asthma management frameworks.

Integration With MBS Documentation

Care plans billed under MBS item 965 or 967 require specific documentation. The consultation must be face-to-face (or use the telehealth equivalents 92029 or 92030 for video consults), must involve the patient, and must produce a documented plan. A Lyrebird-generated plan captures this content in the draft, and the clinician's review before sign-off confirms it meets the item requirements. For the authoritative current position on item requirements, consult MBS Online directly.

Privacy and Regulatory Considerations

Asthma care plans generated through Lyrebird fall under the standard framework. The Australian Privacy Principles apply to the processing of patient data, with APP 8 specifically relevant for products that process data offshore. Lyrebird processes and stores all data on Australian servers. Patient consent is required before the scribe is used, consistent with the TGA's August 2025 guidance on digital scribes.

Next Steps

To trial Lyrebird directly, book a demo. Lyrebird Free is available for free to Best Practice clinics.