GPSC and Related MSP Fees
UPDATE 2010
Dr. Cathy Clelland
Dr. Bill Cavers
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: info@sgp.bc.ca cclelland@bcma.bc.ca
or gpsc.billing@bcma.bc.ca
2
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.
3
Overview
•
•
•
•
•
•
•
•
•
•
4
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
GPSC and Related MSP Fees
UPDATE 2010
CHRONIC DISEASE
MANAGEMENT
5
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.
6
Chronic Disease Management
• Diabetes, CHF and COPD Condition Based
payments may be billed for 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.
7
Chronic Disease Management
• 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.
8
GPSC and Related MSP Fees
UPDATE 2010
COMPLEX CARE
9
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
10
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 or practice
group that 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.
11
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 and/or the patient
representative as appropriate. The patient and/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.
12
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
13
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
Complex Care
• 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.
14
Complex Care
• 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.
15
GPSC and Related MSP Fees
UPDATE 2010
CONFERENCING FEES
16
Conferencing Fees
14015, 14016, 14017 & 14018
• 14016 – Community Patient Conferencing Fee
• 14015 – Facility Patient Conferencing Fee
• 14017 – Acute Care Discharge Planning
Conferencing Fee
• 14018 – Telephone Conferencing/Consultation
with a Specialist or GP with Specialty Training
17
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.
18
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.
19
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):
–
–
–
–
–
–
20
Palliative care facility
LTC facility
Rehab facility
Sub-acute facility
Psychiatric facility
Detox/drug and alcohol facility (in-patient).
Community Patient Conference Fee
14016
• Eligible patient population living in their home or in
assisted living/group home.
• Patients seen in out patient setting:
–
–
–
–
Physician Office
Home/Assisted Living/Group Home
Community placement agency (moved from facility conference fee)
Disease clinic e.g.. DEC, arthritis, CHF, asthma, cancer or other
palliative diagnoses, etc. (moved from facility conference fee).
• 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.
21
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.
22
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.
23
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
24
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.
25
GPSC and Related MSP Fees
UPDATE 2010
PALLIATIVE CARE
26
Palliative Care
• 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.
27
Palliative Care
• 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.
28
Palliative Care
• 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.
29
Palliative Care
• 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” (i.e..
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.
30
GPSC and Related MSP Fees
UPDATE 2010
MENTAL HEALTH
31
Community GP Mental Health
• 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.
32
Community GP Mental Health
• 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.
33
Community GP Mental Health
• GP Mental Health Planning Fee G14043
$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 who reside
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).
34
Community GP Mental Health
• GP Mental Health Telephone/Email
Management Fee G14049
$15
– This fee is payable for up to 5 telephone/email services (2-way
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.
35
Community GP Mental Health
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.
36
GPSC and Related MSP Fees
UPDATE 2010
PREVENTION
37
Prevention Fee
• Effective January 1, 2010 the 14034 Cardiovascular Risk
Assessment Fee will be replaced
• The new “Personal Health Risk Assessment” fee, G140XX, 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.
• 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.
38
GPSC and Related MSP Fees
UPDATE 2010
MATERNITY CARE
39
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 – e.g.. 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.
40
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 > $523.00).
• 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.
41
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.
42
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).
43
GP Obstetrics
• 14199 – Prolonged Second Stage of Labour – regardless
of time of day, for every 30 minutes (or greater portion) >
2 hours. Note - 2nd stage starts at full dilation, not when
pushing begins.
• Prolonged 2nd and 3rd Stage of Labour out of office hours
– for every 30 min (or greater portion) after first 30 min –
billable even if only part of time out of hours.
– 01205 Evening 1800 hr – 2300 hr (effective April 1/11 weekday
evenings only)
– 01206 Nights 2300 hr – 0800 hr
– 01207 Weekends/Stat Holidays 0800 - 1800 (effective April 1/11
0800 – 2300 hr).
• 00119 – Well Newborn Care in hospital.
• If complicated newborn care (e.g.. Jaundice, NICU, etc),
bill appropriate hospital visits (13008/13028 +/- 13338 – see
acute care section for more details) +/- 12201 out of office
CPX instead.
44
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.
• Must still submit a bill through Teleplan with
date of service March 31, June 30, September
30 and December 31 each time.
45
GPSC and Related MSP Fees
UPDATE 2010
HOUSE CALLS
&
FACILITY CARE
46
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 (e.g.. 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).
47
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.
• If providing procedure service (e.g.. 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).
48
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 (subsequent MRP patients seen)/13028 (subsequent supportive
care patients seen)
– 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.
• 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.
49
Facility Billings – Acute Care
• Community GPs with courtesy or associate privileges i.e. 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
– 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.
50
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 per day regardless of number of
facilities) – up to twice per week without note.
• Specially called (00112 weekday daytime,
outside this time bill call out fee plus out of office
visit otherwise).
• Facility Care Conference Fees (14015).
51
GPSC and Related MSP Fees
UPDATE 2010
BILLING EXAMPLES
52
Billing Examples
1a) 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
1b) 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:
–
–
–
–
53
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
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 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 visit (1st GPSC Mental Health
Management visit – eligible for up to 3 more in this
calendar year if needed):
–
–
–
–
–
54
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
Billing Examples
3) 88 year old patient with COPD and hypertension living at
home, brought in by 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
55
Dx Code: 496
Dx Code: V15
Dx Code: 496
Billing Examples
4) 55 year old male with diabetes and ALS, seen
for complete physical, complex care planning.
The diabetes CDM is also due:
–
–
–
–
56
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.
Billing Examples
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
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
• Patient #2
• Patient #3
• Patient #4
• Patient #5
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13008 plus 13338 + 14017 X 2 units
13008
13028
13028
00109
Billing Examples
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’s family is present
as he is recently deemed palliative for end stage CHF and
this care conference takes 50 minutes. You see patient C
for first time 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 and Related MSP Fees
UPDATE 2010
Questions?
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