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Dr. Cathy Clelland Dr. Bill Cavers

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  1. Dr. Cathy Clelland Dr. Bill Cavers GPSC and Related MSP Fees UPDATE 2010

  2. 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.cacclelland@bcma.bc.ca or gpsc.billing@bcma.bc.ca 2

  3. 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 othersisbest practicebilling. MSP offers billing seminars for MOAs. Stay up-to-date review the Fee Schedule and the explanatory preamble. IGNORANCE leads to LOST INCOME. 3

  4. Overview • 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 4

  5. CHRONIC DISEASE MANAGEMENT GPSC and Related MSP FeesUPDATE 2010 5

  6. 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

  7. 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

  8. 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. Chronic Disease Management 8

  9. COMPLEX CARE GPSC and Related MSP FeesUPDATE 2010 9

  10. 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

  11. 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. Complex Care 11

  12. 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. Complex Care 12

  13. Revised Complex Care Fee Specific Dual Diagnoses Codes Dx Code Dual Diagnoses Dx Code Dual Diagnoses N519 CND + Respiratory I250 IHD + DM N414 CND + IHD I430 IHD + CVD N428 CND + CHF I585 IHD + CKD N250 CND + DM I573 IHD + CLD N430 CND + CVD H250 CHF + DM N585 CND + CKD H430 CHF + CVD N573 CND + CLD H585 CHF + CKD R414Respiratory + IHD H491 CHF + COPD R428 Respiratory + CHF D430 DM + CVD R250Respiratory + DM D585 DM + CKD R430 Respiratory + IHD D573 DM + CLD R585 Respiratory + CKD C585 CVD + CKD R573 Respiratory + CLD C573 CVD + CLD I428 IHD + CHF K573 CKD + CLD 13

  14. 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. Complex Care 14

  15. 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. Complex Care 15

  16. CONFERENCING FEES GPSC and Related MSP FeesUPDATE 2010 16

  17. Conferencing Fees14015, 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

  18. Conferencing Fees14015, 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

  19. Conferencing Fees14015, 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

  20. Facility Patient Conference Fee14015 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): Palliative care facility LTC facility Rehab facility Sub-acute facility Psychiatric facility Detox/drug and alcohol facility (in-patient). 20

  21. Community Patient Conference Fee14016 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

  22. 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

  23. GP Urgent Telephone Conference with a Specialist Fee14018 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

  24. 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

  25. 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

  26. PALLIATIVE CARE GPSC and Related MSP FeesUPDATE 2010 26

  27. 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

  28. 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

  29. 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. Palliative Care 29

  30. 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. Palliative Care 30

  31. MENTAL HEALTH GPSC and Related MSP FeesUPDATE 2010 31

  32. 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

  33. 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 33

  34. 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). Community GP Mental Health 34

  35. 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. Community GP Mental Health 35

  36. 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. Community GP Mental Health 36

  37. PREVENTION GPSC and Related MSP FeesUPDATE 2010 37

  38. 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

  39. MATERNITY CARE GPSC and Related MSP FeesUPDATE 2010 39

  40. 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

  41. 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

  42. 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

  43. 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

  44. 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. GP Obstetrics 44

  45. 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

  46. HOUSE CALLS & FACILITY CARE GPSC and Related MSP FeesUPDATE 2010 46

  47. 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

  48. 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

  49. 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

  50. 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