The Complex Care Management Fee is advance payment for the complexity of caring for patients with two of the eligible conditions and is payable upon the completion and documentation of a Complex Care Plan for the management of the complex care patient until the complex care plan is reviewed and revised in the next calendar year. A Complex Care Plan requires documentation of the following elements in the patient’s chart that: 1. There has been a detailed review of the case/chart and of current therapies; 2. There has been a face-to-face visit with the patient, or the patient’s medical representative if appropriate, on the same calendar day that the Complex Care Management Fee is billed; 3. Specifies a clinical plan for the care of that patient’s chronic diseases covered by the complex care fee; 4. Incorporates the patient’s values and personal health goals in the care plan with respect to the chronic diseases covered by the complex care fee; 5. Outlines expected outcomes as a result of this plan, including end-of-life Issues (advance care planning) when clinically appropriate; 6. Outlines linkages with other health care professionals that would be involved in the care, their expected roles; 7. Identifies an appropriate time frame for re-evaluation of the plan; 8. Confirms that the care plan has been communicated verbally or in writing to the patient and/or the patient’s medical representative, and to other involved health professionals as indicated. 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.
The Complex Care Management Fee was developed to compensate GPs for the management of complex patients who have chronic conditions from a least 2 of the 8 categories listed below. Providing the Complex Care planning visit and billing for the development of a care plan allows access to 5 telephone/e-mail fees (G14079) during the following 18 months.
These items are payable only to the General Practitioner who accepts the role of being Most Responsible for the longitudinal, coordinated care of that patient; by billing this fee the practitioner accepts that responsibility for the ensuing calendar year.
The Most Responsible General Practitioner may bill this fee when providing care only to community patients; i.e. residing in their homes or in assisted living with two or more of the following chronic conditions:
1) Diabetes mellitus (type 1 and 2)
2) Chronic Kidney Disease
3) Congestive heart failure
4) Chronic respiratory Condition (asthma, emphysema, chronic bronchitis, bronchiectasis, Pulmonary Fibrosis, Fibrosing Alveolitis, Cystic Fibrosis etc.)
5) Cerebrovascular disease
6) Ischemic heart disease, excluding the acute phase of myocardial infarct
7) Chronic Neurodegenerative Diseases (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.)
8) Chronic Liver Disease with evidence of hepatic dysfunction.
If a patient has more than 2 of the qualifying conditions, when billing the Complex Care Management Fee the submitted diagnostic code from Table 1 should represent the two conditions creating the most complexity.
Successful billing of the Complex Care Management Fee (G14033) allows access to 5 Telephone/E-mail follow- up fees (G14079) per calendar year over the following 18 months.
In order to encourage non-face-to-face communication with patients covered by some of the GPSC incentives, the initial four separate telephone/e-mail follow up fees have been simplified into a single code that will still apply to the planning incentives (Complex Care G14033, Mental Health G14043, Palliative Care G14063 & COPD G14053 which requires a COPD Action Plan). Patients covered by one or more of these incentives are eligible for five telephone/e-mail services over the 18 months following the billing of the qualifying incentive(s).
i) Payable once per calendar year.
ii) Payable in addition to office visits or home visits same day.
iii) Visit or CPx fee to indicate face-to-face interaction with patient same day must accompany billing.
iv) G14016, Community Patient Conferencing Fee, payable on same day for same patient if all criteria met.
v) G14015, Facility Patient Conferencing Fee, not payable on the same day for the same patient, as facility patients not eligible.
vi) G14017, Acute Care Discharge Planning Conferencing Fee, not payable on the same day for the same patient, as facility patients not eligible.
vii) CDM fees G14050/G14051/G14052/G14053 payable on same day for same patient, if all other criteria met.
viii) Minimum required time 30 minutes in addition to visit time same day.
ix) Maximum of 5 complex care fees (G14033 and/or G14075) and/or GP unattached complex/high needs patient attachment fees (G14074) per day per physician.
x) G14075, GP Attachment Complex Care Management Fee, is not payable in the same calendar year for same patient as G14033, GP Annual Complex Care Management Fee.
xi) G14079 – Telephone/e-mail follow up fee is not payable on the same day.
xii) Not payable for patients seen in locations other than the office, home or assisted living residence where no professional staff on site.
xiii) Not payable to physicians who are employed by or who are under contract to a facility and whose duties would otherwise include provision of this care;
xiv) Not payable to physicians working under salary, service contract or sessional arrangements whose duties would otherwise include provision of this care.