Transcript Society of General Practitioners

GPSC and Related MSP Fees
UPDATE 2011
Educational materials
• GPSC Website www.gpscbc.ca
• Society of General Practitioners of BC
www.sgp.bc.ca
• BC Medical Association www.bcma.org
– MSP Fee Guide and Updates
– Uninsured service guidelines
• MSP schedule of fees and Resource Manual for
Physicians: www.healthservices.gov.bc.ca/msp
• Billing questions: [email protected] or
[email protected]
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Know Your Fee Schedule
• BC Medical Services Commission “Schedule of Benefits”
dictate the fees you receive
• Fees change - Read all Bulletins & Fact Sheets from
MOH, BCMA, SGP and GPSC
• Don’t assume “what you have seen or heard” from
others is best practice billing
• MSP offers billing seminars for MOAs
• Stay up-to-date
– review the Fee Schedule and the explanatory preamble
• IGNORANCE leads to LOST INCOME
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OVERVIEW
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Chronic Disease Management
Complex Care
Conferencing and Telephone Consulting
Palliative Care
Community GP Mental Health Initiative
Prevention Fees
Maternity Billings (GPSC & MSP)
Maternity Networks
House Calls
Facility Fees
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CHRONIC DISEASE
MANAGEMENT
14050 – Diabetes Mellitus (ICD-9 code 250) $125.00
14051 – Congestive Heart Failure (ICD-9 code
428) - $125.00
It is not mandatory to provide diabetic or CHF patients with their flow sheet.
14052 – Hypertension (ICD-9 code 401) $50.00 Patients must be given a copy of their flow sheet for the year.
14053 – COPD (ICD-9 codes 491, 492, 494 or 496) $125.00 –Requires use of COPD Action Plan for patients rather than a
flow sheet.
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Chronic Disease
Management (cont)
• Diabetes, CHF and COPD Condition Based
payments may be billed on the same patient
• Hypertension CDM fee code is not billable if also
billing for Diabetes and/or CHF (but is billable
with COPD)
• Use of flow sheets as a tool for tracking care.
Not mandatory to use “official” GPAC flow sheet,
provided all required information is included
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Chronic Disease
Management (cont)
• Billing for office visits should continue as usual; The CDM fee
is a management bonus billable yearly on the anniversary of
the initial billing date
• Effective Jan. 1, 2009 – must have at least 2 visits with pt
in 12 months previous to billing CDM. The CDM fees are
for the GP who has accepted responsibility for the
ongoing, longitudinal care of the patient
• Use of flow sheets as a tool for tracking care. Not mandatory
to use “official” GPAC flow sheet, provided all required
information is included
• GPs in APP programs eligible for CDM incentives
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COMPLEX CARE
• Eligible patients must have two of the following eligible
chronic conditions:
– Diabetes mellitus (type 1 and 2) (DM)
– Chronic Kidney Disease – effective January 1, 2011 includes
chronic (> 6 mo) Glomerulonephritis/Polycystic Kidney
disease/Nephrotic Syndrome in addition to renal failure with
eGFR values less than 60 (CKD)
– Congestive heart failure (CHF)
– Cerebrovascular disease (CVD)
– Ischemic heart disease (IHD), excluding the acute phase of
myocardial infarct
– Chronic Respiratory Condition (asthma, emphysema, chronic
bronchitis, bronchiectasis, Pulmonary Fibrosis, Fibrosing
Alveolitis, Cystic Fibrosis etc.)
– Chronic Neurodegenerative Diseases (CND) (Multiple Sclerosis,
Amyotrophic Lateral Sclerosis, Parkinson’s disease, Alzheimer’s disease, stroke or other
brain injury with a permanent neurological deficit, paraplegia or quadriplegia etc.)
– Chronic Liver Disease (CLD) with evidence of hepatic dysfunction.
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COMPLEX CARE
• Payment to compensate for the extra time required to
provide planned care to more complex patients that are
living in their home or in assisted living over the year
following the Complex Care Planning visit.
• Payable only to the General Practitioner who accepts
the role of being Most Responsible for the
longitudinal, coordinated care of that patient.
• Not billable by or on behalf of GPs on contract
(salary/service/sessional) where the care provided under
this incentive is already compensated.
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COMPLEX CARE
• The Complex Care Planning Visit can be provided and billed once at
anytime in the calendar year. The development of the care plan is
done jointly with the patient &/or the patient representative as
appropriate. The patient & or their representative/family should
leave the planning process knowing there is a plan for their
care and what that plan is.
• While CDM fees which are billed annually for overall guideline
informed management over the previous year, it is not required that
the Complex Care Fee be billed on the anniversary date of the first
billing for the complex care planning visit.
• There are also fees for up to 4 non-face-to-face encounters during
the 18 months following the billing of the complex care management
fee.
• CDM Fees and Conferencing Fees payable in addition when
indicated.
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Revised Complex Care Fee
Specific Dual Diagnoses Codes
Dx Code Dual Diagnoses
N519
N414
N428
N250
N430
N585
N573
R414
R428
R250
R430
R585
R573
I428
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CND + Respiratory
CND + IHD
CND + CHF
CND + DM
CND + CVD
CND + CKD
CND + CLD
Respiratory + IHD
Respiratory + CHF
Respiratory + DM
Respiratory + IHD
Respiratory + CKD
Respiratory + CLD
IHD + CHF
Dx Code Dual Diagnoses
I250
I430
I585
I573
H250
H430
H585
H491
D430
D585
D573
C585
C573
K573
IHD + DM
IHD + CVD
IHD + CKD
IHD + CLD
CHF + DM
CHF + CVD
CHF + CKD
CHF + COPD
DM + CVD
DM + CKD
DM + CLD
CVD + CKD
CVD + CLD
CKD + CLD
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COMPLEX CARE (cont’d)
• 14033 Annual Complex Care Management Fee $315
– Minimum 30 min complex care planning process that:
• Reviews the Complex Conditions and current treatment
(not necessarily all face-to-face)
• The development of the care plan is done jointly with the
patient &/or the patient representative as appropriate. The
patient & or their representative/family should leave the
planning process knowing there is a plan for their care
and what that plan is.
– Bill 14033 plus office visit (or CPX) for that initial
process on the day of the planning visit
– Care provided face to face over rest of calendar year
billed under MSP visit fees
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COMPLEX CARE (cont’d)
• 14039 Complex Care Telephone/E-mail Follow-up
Management fee $15
– Once 14033 has been successfully billed – over the
next 18 months GP or practice group may access up
to 4 phone/e-mail follow up fees (requires 2 way
communication with patient or patient’s medical
representative) .
– When the Complex Care plan is reviewed, revised and
rebilled in the subsequent calendar year, the allowable
G14039 resets to 4 over the following 18 months.
– Telephone/E-mail (2 way) service may be provided by GP
or staff. Not for simple appointment reminders or
prescription renewals.
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CONFERENCING FEES
14015, 14016, 14017 & 14018
• 14016 – Community Patient Conferencing
Fee
• 14015 – Facility Patient Conferencing Fee
• 14017 – Acute Care Discharge Planning
Conferencing Fee
• 14018 – Urgent Telephone Conferencing /
Consultation with a Specialist or GP with
Specialty Training
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CONFERENCING FEES
14015, 14016, 14017 & 14018
• Developed to compensate the GP when
conferencing with other health care
professionals (including specialists and GPs with
specialty training) for the creation of a
coordinated clinical action plan for the care of
patients with more complex needs.
• Not billable by or on behalf of GPs on contract
(salary/service/sessional) where the care
provided under this incentive is already
compensated.
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CONFERENCING FEES
14015, 14016 & 14017
• All three for same eligible patient population, only
location different:
•
•
•
•
•
Frail elderly (ICD-9 code V15)
Palliative care (ICD-9 code V58)
End of life (ICD-9 code V58)
Mental illness
Patients of any age with multiple medical needs or complex
co-morbidity – pregnancy is considered a co-morbidity in
complex maternity patients.
• Payable in units of $40.00 per 15 minutes or greater
portion.
• Billable in addition to any visit as long as not done
simultaneously
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Facility Patient Conference Fee 14015
• Billable when requested by the facility to attend
care conferences with at least 2 other health
care providers for patients in a care facility.
• Eligible Facilities (Patient Admitted):
–
–
–
–
–
–
–
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Acute Care (complicated or ALC patients)
Palliative care facility
LTC facility
Rehab facility
Sub-acute facility
Psychiatric facility
Detox/drug and alcohol facility (in-patient)
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Community Patient Conference Fee
14016
• Eligible patient population living in their home or in
assisted living/group home
• Patients seen in outpatient setting:
–
–
–
–
Physician Office
Home/Assisted Living/Group Home
Community placement agency (moved from facility conference fee)
Disease clinic eg. DEC, arthritis, CHF, asthma, cancer or other palliative
diagnoses, etc.
• Requires conferencing with at least 1 other health care
provider (Includes telephone consultation with Specialists and
resulting plan implementation for eligible patient population)
• Not billable for simple advice about community patients
when initiated by the community care worker (does not
include Specialists) – Bill 13005
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Acute Care Discharge Planning
Conferencing Fee – 14017
• Billable when discharge planning
conference with at least 2 other health
care providers is requested by the facility
or by Community GP
• For patients with complex supportive
needs, in order to plan for safe return to
the community or transition to a different
acute care or supportive care or long-term
care facility.
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GP Urgent Telephone Conference
with a Specialist Fee 14018
• Intent is to improve management of the patient with acute needs,
and reduce unnecessary ER or hospital admissions/transfers.
• Billable when the patient’s condition requires urgent conferencing
with a specialist or GP with specialty training, and the development
and implementation of a care plan within the next 24 hours to keep
the patient stable in their current environment.
• This fee is not restricted by diagnosis or location of the patient, but
by the urgency of the need for care.
• $40 flat rate fee value
• Billable in addition to visit fee provided not done simultaneously
• Effective September 1, 2010
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General Practitioners with Specialty
Training Telephone Advice Fees
• G14021 GP with Specialty Training Telephone
Advice - Initiated by a Specialist or General
Practitioner, Urgent
$60.00
• G14022 GP with Specialty Training Telephone
Patient Management - Initiated by a Specialist or
General Practitioner, One Week
$40.00
• G14023 GP with Specialty Training Telephone
Patient Management / Follow-Up
$20.00
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General Practitioners with Specialty
Training Telephone Advice Fees
• “Mirror fees” to the SSC Specialist Telephone Advice fees for
FRCP certified Specialists (10001, 10002, 10003)
• Must not have billed another GPSC fee item on the specific
patient in the previous 18 months.
• Service may be provided when physician is located in office or
hospital.
• For the purpose of these telephone advice fee items a “General
Practitioner (GP) with Specialty Training” is defined as a GP
with specialty training who is acknowledged by the health
authority to act in a specialist capacity and who provides
specialist services in a health authority setting.
• Telephone advice must be related to the field in which the GP
has received specialty training.
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Palliative Care Incentive
• Preparation and advance care planning are a critical first
step once it has been determined that a patient’s condition
is terminal.
• The “Palliative Care Planning fee” will compensate the
family physician for undertaking and documenting a care
plan.
• Once the planning process has been completed and the
planning fee successfully billed, the Family Physician or
practice group will be able to access up to 5 phone/e-mail
follow- up management fees
• The Palliative Care Incentive is a payment initiative that is
intended to complement the existing conferencing
component of end-of-life care when sharing care with other
health care professionals.
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Palliative Care Incentive
• Palliative Care planning fee (G14063) …. $100
– This fee is payable upon the development and
documentation of a Palliative Care Plan for patients who
have been determined to have reached the palliative stage
of a life-limiting disease or illness.
– requires a face-to-face visit and assessment of the patient
or the patient’s alternate substitute decision maker or legal
health representative.
– Medical Diagnoses include end-stage cardiac, respiratory,
renal and liver disease, end stage dementia, degenerative
neuromuscular disease, HIV/AIDS or malignancy.
– Eligible patients must be resident in the community; in a
home or in assisted living or supportive housing.
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Palliative Care Incentive
• Palliative Care Telephone/E-mail follow up
management fee (G14069) …….. $15.00
– This fee is payable for 2-way communication with
eligible patients or their representative via telephone
or e-mail for the provision of clinical follow-up
management by the GP who has created and billed for
the Palliative Care Planning fee (G14063).
– Billable up to 5 times after successful billing of
G14063
– This fee is not to be billed for simple appointment
reminders or referral notification.
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PALLIATIVE CARE
MSP Fees
 July 1/08 – Expansion of qualifying patients for 00127/13127
to include “terminally ill patients suffering from malignant
disease or AIDS or end-stage respiratory, cardiac, liver and
renal disease and end-stage dementia with life expectancy up
to 6 months and the focus of care is palliative rather than
treatment aimed at cure.”
 April 1, 2009 – 00127/13127 billable on ongoing basis for up
to 180 days once patient deemed “palliative” (ie. eligible for
palliative benefits program, but not necessary to have
applied). Additional 90 days if submitted with e-note.
 Community Based Patients also eligible for GPSC
conferencing fees.
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COMMUNITY GP MENTAL
HEALTH INITIATIVE
GPSC Mental Health Initiative to compensate
the Family Physician or practice accepting the
role of ‘Most Responsible FP’ for the care of
patients who:
 Have an Axis I diagnosis confirmed by DSM IV
criteria;
 With severity and acuity level causing sufficient
interference in activities of daily living that developing
a management plan for the rest of the year would be
appropriate
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COMMUNITY GP MENTAL
HEALTH INITIATIVE
• Has 3 Components
– Mental Health Planning Fee
– Mental Health Telephone/E-mail Follow Up Fee
– Mental Health Management Fee
• Not billable by or on behalf of GPs on contract
(salary/service/sessional) where the care
provided under this incentive is already
compensated.
COMMUNITY GP MENTAL
HEALTH INITIATIVE (cont’d)
G14043 – GP Mental Health Planning Fee
$100.00
– This fee is payable upon the development and
documentation of a patient’s Mental Health Plan for
care over the rest of the calendar year for patients
resident in the community (home or assisted living,
excluding care facilities)
– Requires 30 minute face-to-face visit. If longer, bill
office visit (up to 50 min) or counseling visit if meets
preamble criteria (over 50 min) in addition
– Billable once per calendar year (not necessary to be on
anniversary of previous year – do when clinically indicated)
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COMMUNITY GP MENTAL
HEALTH INITIATIVE
(cont’d)
G14049 – GP Mental Health Telephone/Email
Management Fee …….. $15
– This fee is payable for up to 5 telephone/email services (2way communication) with eligible patients or their
representative via telephone or email for the provision of
clinical follow-up management by the GP who has created
and billed for the GP Mental Health Planning Fee
(G14043).
– Available for up to 18 months after billing G14043. Reset
to 5 with rebilling of G14043 in next calendar year.
– This fee is not to be billed for simple appointment
reminders or referral notification.
COMMUNITY GP MENTAL
HEALTH INITIATIVE (cont’d)
Counselling Equivalent Fees Accessible after Initial
Planning Visit:
14044-GP Mental Health Management Fee age 2–49 = 00120
14045-GP Mental Health Management Fee age 50–59 = 15320
14046-GP Mental Health Management Fee age 60–69 = 16120
14047-GP Mental Health Management Fee age 70–79 = 17120
14048-GP Mental Health Management Fee age 80 + = 18120
– These fees are payable for GP Mental Health Management
(counselling) required beyond the four (4) MSP counselling fees
(age-appropriate 00120 fees billable under the MSP guide to fees)
for patients with a chronic mental health condition on whom a
Mental Health Plan has been created and billed.
– Payable only if the Mental Health Planning Fee (G14043) has
been previously billed by the same physician in the same calendar
year.
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PREVENTION FEE G14066
•
Effective January 1, 2010 the 14034 Cardiovascular Risk Assessment
Fee will be replaced
•
The new “Personal Health Risk Assessment” fee, G14066, will be billable in
addition to an office visit, to undertake a personal health risk assessment
visit with their “at risk” patients as part of proactive care, or in response to a
patient request for preventive care.
•
Targeted patients include those with:
– Smoking
– Unhealthy eating
– Physical inactivity
– Medical Obesity
•
Risk assessment visit to review all prevention/screening services (eg. pap,
mammogram, stool OB, immunizations, etc) appropriate for the individual,
not just the issue that puts them in high risk group.
•
The value will be set at $50 (plus office visit) and would be billable for up to
100 patients per calendar year per physician – you must track as MSP
cannot and if go over 100, you will be debited later;
•
Use Diagnostic Code
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OFFICE BILLING –
MATERNITY CARE
• All visits prior to 1st Prenatal and unrelated presenting complaints
use office Visit/Counseling fee
• 14090 – First Prenatal CPX – also billable when patient transfers
care to new physician (with electronic note)
• 14091 – Office Prenatal Visits – up to 14 per pregnancy, if
complications cause more, bill with Dx Code and note
• 14094 – Post Partum Visit – Effective Nov 1, 2010– billable as many
times as clinically indicated in 6 weeks post partum with all forms of
delivery, by the delivering physician
• May still bill counseling visit (00120) if all preamble requirements
fulfilled – eg. Counseling about abnormal results from Maternal
Serum Screening
• May bill HIV fee 13015 ($80.00) per half hour if primarily dealing with
HIV management in pregnancy.
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GP OBSTETRICS
• Delivery Fees
•
– 14104 – Vaginal Delivery and in-hospital post partum care
– 14105 – Management of Labour and Transfer for Delivery to
Higher Level of Care Facility
– 14108 – Elective C/Section and in-hospital post partum care
– 14109 – Emergency C/Section and in-hospital post partum care
C/Section Assist – 00196 (00197 if additional procedures
done and total surgical fee > $527.00)
• First Surgical Assist of the Day fee - 13194
• Surgical Assist fee and first surgical assist of day
billed in addition to 14108/14109
• Vaginal and Emergency C/S deliveries are subject
to additional call in and out of office hours
surcharges.
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GPSC Obstetric Delivery
Bonuses
•
•
•
•
•
14004 – Payable in conjunction with 14104
14005 – Payable in conjunction with 14105
14008 – Payable in conjunction with 14108
14009 – Payable in conjunction with 14109
Available to all GPs in BC who in addition to being paid
the delivery fee codes for the patient are also
responsible or share responsibility for providing the
patient’s general practice medical care.
• Maximum total of 25 bonuses claimed per calendar year
– 14004, 14005, 14008 or 14009 (any combination). GP
must keep track as MSP unable to, if over 25, will be
debited later.
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GP OBSTETRICS
• Call Out fees:
– 00112 Weekday 0800 hr – 1800 hr (only if call out
time and actual delivery time are different)
– 01200 Evening 1800 hr – 2300 hr
– 01201 Nights 2300 hr – 0800 hr
– 01202 Weekends/Stat Holidays 0800 – 1800
• Out of Office Hours Surgical Surcharges:
– 01210 Evening 1800 hr – 2300 hr (effective April 1/11
weekday evenings only)
– 01211 Nights 2300 hr – 0800 hr
– 01212 Weekends/Stat Holidays 0800 – 1800 hr
(effective April 1/11 0800 – 2300 hr)
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GP OBSTETRICS
• 14199 – Prolonged Second Stage of Labour – regardless of
time of day, for every 30 minutes (or greater portion) > 2
hours – remember 2nd stage starts at full dilation, not when
starts pushing
• Prolonged 2nd and 3rd Stage of Labour out of office hours –
Use non-surgical surcharge fees for every 30 min (or greater
portion) after first 30 min – billable even if only part of time out
of hours.
– 01205 *Weekday Evening 1800 hr – 2300 hr
– 01206 Nights 2300 hr – 0800 hr
– 01207 *Saturday/Sunday/Stat Holidays 0800 - 2300
(*Note: changes in times effective April 1/11)
• 00119 – Well Newborn Care in hospital
• If complicated newborn care (eg. Jaundice, NICU, etc), bill
appropriate hospital visits (13008/13028 +/- 13338 – see acute
care section for more details) +/- 12201 out of office CPX instead
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MATERNITY NETWORK
PAYMENT
• 14010 - Quarterly payment to cover the costs of
group/network activities for their shared care of
obstetric patients.
– Payment increased to $2100 per quarter for dates of service
December 31, 2010 and onward.
• To Bill, Eligible GPs must complete a network
registration form for the group (minimum 4 GPs –
exemptions in small rural communities) and
schedule 4 deliveries in each 6 month period.
• Must still submit a bill through Teleplan with date of
service March 31, June 30, September 30 and
December 31 each time.
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HOUSE CALLS
 April 1, 2009 – removal of “call to” requirement for 00103 to
support planned proactive care. Billable 7 days per week 0800 –
2300 hrs. (Nights 01201 + Out of office visit fee)
 If providing procedure service in home (eg. Suspicious lesion
removal) and must bring in tray from office, can bill tray fee in
addition to procedure fee
 If clinically appropriate, home bound patients eligible for CDM
fees 14050, 14051, 14052, 41053 as well as Complex Care,
Mental Health or Palliative Planning fees (See GPSC section for
details)
 Community Patient conferencing fees billable when conferencing
with at least 1 other Allied Health Professional about patient care
plan in the home – Includes telephone consultation with
specialist (see GPSC section)
 Palliative Care Planning fee is billable at a house call (see GPSC
section)
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Facility Billings - LTC
 Effective April 1, 2009 – 00115 billable 7 days per week 0800
– 2300 hours.
 LTC visits 00114 billable up to every 2 weeks for planned
proactive care. Effective Nov 1, 2010 bill 13334 1st LTC
patient seen bonus fee in addition to visit fee 00114.
 If providing procedure service (eg. Suspicious lesion removal)
and must bring in tray from office, can bill tray fee with
electronic note in addition to procedure fee
 If clinically appropriate, LTC patients eligible for CDM fees
14050, 14051, 14052, 14053 (See GPSC section for details)
 Facility Patient conferencing fees (14015) billable when
requested by LTC Facility to attend care conference with at
least 2 other Allied Health Professionals (see GPSC section)
 Visits for Terminal Care whether in formal palliative care bed
or not (00127 +/- 13338 if not already billed in acute care)
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Facility Billings – Acute Care
Community GP = the patients FP/call group providing
longitudinal care in the community (not eligible if APP FP
where hospital care covered under contract)
• Community GP with active privileges – can write orders
and actively manage patients in hospital
– 13008 (MRP patients seen up to daily X 30 days the twice per
week)/13028 (supportive care patients seen up to daily X 10 days then
once per week)
– Effective Nov 1, 2010 new 13338 first patient of the day bonus billed in
addition to 13008 or 13028 visit fee but only 1 per day regardless of how
many facilities visited.
• Basic 00108/00128 should only be billed/proxy billed by APP GPs
where hospital care covered under contract)
• 00109 (first patient visit of stay when MRP for admission CPX) – any
GP with active privileges
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Facility Billings – Acute Care
• Community GPs with courtesy or associate privileges ie. Not
allowed to write orders or manage patient care in hospital
– 13228 visit fee billable once per week – payable even if 00108
proxy billed for Hospitalist care.
– Effective Nov 1, 2010 new 13339 first patient of day bonus billed
in addition to 13228
• Acute Care Discharge Planning Conferencing fee (14017)
billable by Community GP with either active or
Courtesy/Associate privileges
• Visits for Terminal Care – not dependent on patient being in
“palliative care” designated bed – when managing care
– 00127 visit fee for terminal care = value to 13008
– 13338 billable in addition for first patient seen but only 1 per day
regardless of how many facilities visited.
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Facility Billings –
Sub-Acute Care
Effective Nov 1, 2010 for medically necessary,
Non- urgent/emergent visits in sub-acute care bill
13008 +/- 13338 (max 1 bonus per day regardless of
number of facilities) – up to twice per week without
note – if more frequently – use e-note to explain as
will be manually adjudicated.
 Specially called (00112 weekday daytime, outside
this time bill call out fee plus out of office visit
otherwise)
• Facility Care Conference Fees (14015)

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Billing Examples
1(a). Office visit for Rx Renewal and CHF follow-up in
72 yr old with Ischemic Heart Disease, CHF and
severe OA. He is also due for CHF CDM. Advised at
visit to make appointment for CPX and complex care
plan review 2 weeks later:
– Fee code: 17100
– Fee code: 14051
Dx Code: 428
Dx Code: 428
1(b). Same 72 year old returns 2 weeks later for 45 min.
CPX and CC plan review. Urine dip done at time.
You also have a 10 minute conference with the
Cardiac Rehab unit about his complex care plan:
–
–
–
–
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Fee code: 17101
Fee code: 14033
Fee code: 15130
Fee code: 14016 X 1 unit
Dx Code: 428
Dx Code: I428
Dx Code: 01L
Dx Code: 428
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Billing Examples
2. You have been providing 20+ min. counseling to a 32 yr
old patient with Bipolar Disorder 3 times already this
year. You decide he would benefit from a 30 minute
Mental Health planning visit with followed by 25 minute
counseling (4th MSP counseling of year) 1 week later,
then telephone follow up of medication use 3 days
following this. Third Visit is 20 minute counseling vist
(1st GPSC Mental Health Management visit – eligible for
up to 3 more in this calendar year if needed):
– First 3 MSP counseling visits in year each with Fee Codes:
00120
– Mental Health Planning visit Fee Code: 14043 Dx Code: 296
– Subsequent counseling visit Fee Code: 00120 Dx Code: 296
– Phone call Fee Code: 14049 Dx Code: 296
– First GPSC Mental Health Management Fee Code: 14044
Dx Code: 296
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Billing Examples (cont.)
3. 88 year old patient with COPD and hypertension
living at home, brought in my family due to concerns
of her self care. Assessment found acute
pneumonia with hypoxia. Telephone consult with
respirologist on call and a plan is developed. Also
discussed with home care nursing to go in to see
patient every other day over the following week to
monitor home O2 use and effects. Consultation and
conferencing time 25 minutes total. Brief phone call
from home care nurse for advice 2 days later:
– Fee code: 18100
– Fee code: 14016 X 2 units
– 2 days later Fee code: 13005
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Dx Code: 496
Dx Code: V15
Dx Code: 496
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Billing Examples (cont.)
4. 55 year old male with diabetes and ALS, seen for
complete physical, complex care planning. The
diabetes CDM is also due:
–
–
–
–
Fee Code: 15301
Dx Code: 250
Fee Code: 14033
Dx Code: N250
Fee Code: 14050
Dx Code: 250
Phone call review and advice after billing 14033 can be billed
using the new 14039 for complex care patient telephone/email
follow up to a maximum of 4 times over the rest of the calendar
year
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Billing Examples (cont.)
5. Mrs. C is an 84 widowed patient with COPD who has been diagnosed
with terminal lung cancer. She continues to live at home supported
by her family, but as she has deteriorated, her care needs are
increasing. She was seen in the office for a 45 min. visit with her
daughter in attendance. You review her diagnosis, prognosis,
complete palliative benefits papers, and jointly decided on a
management plan. You then contact the Home Hospice program
and initiate their involvement followed by a call to the daughter to
confirm the home care plan. Total conferencing time 20 min. You go
out to see her in 7 days to reassess as she is not able to come to the
office.
– Billings all with Dx Code 162:
• Day 1
– 18100 office visit
– 14063
– 14016 X 1 unit
• Day 7 – 00103 planned proactive house call
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Billing Examples (cont.)
6. You make rounds in the local hospital where you have active
privileges. You have 5 patients to see. The first 2 patients
you see have been under your daily MRP care for a few
days, the first patient also has a 25 minute discharge
planning care conference that you attend after the visit, and
the next 2 you see are post-operative supportive care
patients and the final patient you see is a new admission
that you must do a review, CPX and admission orders on.
– Billings:
• Patient #1
13008 plus 13338 + 14017 X 2 units
• Patient #2
13008
• Patient #3
13028
• Patient #4
13028
• Patient #5
00109
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Billing Examples (cont.)
7. You attend a care conference at a local nursing home
where you review three patients who are under your care.
At the care conference is the ward nurse, social worker,
pharmacist, dietician and PT/OT. Patient A and B each
take 20 minutes to review, but patient C family is present
as he is recently deemed palliative for end stage CHF and
this care conference takes 50 minutes. You see patient C
first that day and then 4 times in the next 10 days (5
terminal care visits in total) until he passes away. You
see patient A and B following the care conference for
planned LTC visits starting with pt A.
– Billings:
• Patient A
1 unit X 14015 Dx V15 plus 00114 plus 13334
• Patient B
1 unit X 14015 Dx V15 plus 00114
• Patient C
3 units X 14015 Dx V58 day 1, plus 5 X 00127 (plus
5 X 13338 if not already billed for same days in acute care) Dx 428
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GPSC & Related MSP
UPDATE 2010
Questions?
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