Frequently Asked Questions - Full Service Family Practice Incentive Program


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INTRODUCTION

The following incentive payments are available to B.C.'s eligible family physicians. The purpose of the incentive payments is to improve patient care. Claims for payment are submitted through the Medical Services Plan (MSP) Claims System as you would other fee-for-service claims. Once billed, the payment(s) will be included as part of your future fee-for-service payment.

You are eligible to participate in the incentive program if you are:

  1. A general practitioner who has a valid B.C. MSP practitioner number (registered specialty 00). Practitioners who have billed any specialty consultation fee in the previous 12 months are not eligible.
  2. Currently in general practice in B.C. as a full service family physician, and
  3. Responsible for providing the patient's longitudinal general practice care.
Detailed eligibility requirements are identified in each section.

The General Practice Services Committee (GPSC) is committed to the support of Full Service Family Practice, a style of practice that includes most of the following:
  • Health and health risk assessments
  • Co-ordination of patient care across the spectrum of primary, secondary, and tertiary care, including making referrals and acting upon consultative advice
  • Longitudinal care of patients across the spectrum of their medical needs
  • Diagnosis and management of acute ailments
  • Chronic Disease Management, including implementation of B.C. guidelines
  • Primary reproductive care including the organization of appropriate screening
  • The provision of or the arrangement with another provider for the provision of prenatal, obstetrical, postnatal, and newborn care
  • Primary mental health care
  • Primary palliative care
  • Care and support of the frail elderly
  • Support for hospital, home, rehabilitation and long-term care facilities
  • Patient education and preventive care
  • The maintenance of a longitudinal patient record
  • An association with other practitioners that provides patients with a designated provider to contact for medical advice and/or care as appropriate both during and outside of office hours, an association that includes the use of call-group guidelines and protocols for patient follow-up
  • The future use of Information Technology systems as they become available to further enhance the co-ordination and provision of patient care.
The GPSC will be monitoring all of the incentive payments to ensure there is demonstrable improvement in the targeted areas of care and may make changes in the future to achieve the best results for full service family doctors and their patients.

List of Frequently Asked Questions

GENERAL PRACTITIONER OBSTETRICAL PREMIUM
Description and Eligibility

  1. When I submit a claim for the bonus payment on fee items 14104, 14108 or 14109, what is the exact amount of the payment?
  2. How is the bonus billed?
  3. How many bonuses may I bill in each calendar year?
  4. Is the delivery bonus for the first 25 deliveries of the year?
  5. Am I able to claim this new bonus for post-natal care following a C-Section in addition to the 25 delivery bonuses per year?
  6. If I am limited to a total of 25 bonuses per year, why would I choose to bill the smaller 14008?
  7. What happens if I have billed for 14008, and later go over my limit of 25 bonuses per calendar year so I ‘miss out’ on billing the higher 14004 or 14009?
  8. Are locums able to bill this bonus?
  9. In practice situations where a patient's care may be shared amongst partners is the bonus still applicable? If so, who bills it?
  10. If a GP refers a patient to me for only the maternity care, am I eligible to bill the bonus?
  11. Is the bonus billable if a delivery is performed during an on-call shift for a partner's patient?
  12. How is the bonus applied to multiple births?
  13. Can I bill for delivering mothers covered by other provinces?
  14. Can I still bill the payment if another doctor helps me with complications?
  15. Is this payment eligible for rural premiums?
  16. Are general practitioners who are paid by service contract, sessional or salary payments eligible to receive the obstetrical premium payments?
  17. Are Emergency Room physicians eligible for this payment?

MATERNITY NETWORK INITIATIVE
Description and Eligibility
  1. How do I register as a maternity network?
  2. How do I claim payments?
  3. What if I cannot find three other doctors to form a network?
  4. Does participating in this program mean the network members are on call for obstetrics for the community?
  5. Is the payment per doctor or per group?
  6. Do we have to advertise that we accept referrals?
  7. What if a doctor delivers 5 babies in one month, then none in the next seven months?
  8. Is this payment eligible for rural premiums?
  9. Are general practitioners who are paid by service contract, sessional or salary payments eligible to receive the maternity network payments?

EXPANDED FULL SERVICE FAMILY PRACTICE CONDITION BASED PAYMENTS
Description and Eligibility
  1. How do I claim the condition-based payments?
  2. Is it possible to claim for both the diabetes and heart failure flow sheets?
  3. When should the incentive bonus be billed?
  4. When can I start submitting the new 14050, 14051 and 14052 codes?
  5. I submitted some 13050 codes after April 1st. What should I do?
  6. Will payment item 14050, 14051 and 14052 replace the usual visit fees for those patients who have diabetes, congestive heart failure, or hypertension?
  7. Do I have to see the patient to bill the payment?
  8. Can I still bill if the patient is in a long-term care facility?
  9. Where can I find the clinical guidelines?
  10. Where can I obtain a copy of the patient flow sheets?
  11. Will other flow sheets be admissible for the bonus?
  12. Can I bill the payment even if the clinical or laboratory objectives have not been met?
  13. Can I bill for patients covered by other provinces?
  14. I have assumed the practice of another GP within the last months. May I still bill for patients' Chronic Disease Management Fees?
  15. Are the payments eligible for the rural premiums?
  16. Are general practitioners who are paid by service contract, sessional or salary payments eligible to receive the chronic care bonus payments?

FACILITY PATIENT CONFERENCING FEE
Description and Eligibility
  1. How do I claim the Patient Management Conference Fee payments?
  2. What is the maximum number of payments allowed per patient?
  3. Is this payment eligible for rural premiums?
  4. Are there circumstances where payment will be allowed even if the care conference did not occur in a face-to-face meeting in the facility?
  5. If more than one patient is discussed at the same case management conference is the fee billable for each patient discussed?
  6. Is the Facility Patient Conference Fee billable by physicians who are employed or under contract to a facility and would have attended the conference as a requirement of their employment or contract with the facility?
  7. Is the Facility Patient Conference Fee billable by physicians working in a or under salary, service contract or sessional arrangements?
  8. Can this fee be billed if I also submitted a Commmunit Patient Conference Fee on the same day?
  9. Are locums able to bill this bonus?
  10. Can I bill for patients covered by other provinces?
  11. Is this fee billable by hospitalists or on behalf of hospitalists?
  12. Can a community-based GP bill this fee for the discharge planning of a patient from an acute-care hospital?
  13. Are examples of templates for Care Plans available?

COMMUNITY PATIENT CONFERENCING FEE
Description and Eligibility
  1. How do I claim the Community Patient Conference Fee payments?
  2. What is the maximum number of payments allowed per patient?
  3. Is this fee billable if a claim the Facility Patient Conference Fee was also made for the patient on the same day?
  4. Is this payment eligible for rural premiums?
  5. Are locums able to bill this bonus?
  6. Can I bill for patients covered by other provinces?
  7. Is the Community Patient Conference Fee billable by physicians working under salary, service contract or sessional arrangements?
  8. Am I eligible to bill this fee when I refer an acutely-ill patient and discuss the case with an Emergency Room Physician/Specialist/Emergency Department nurse?
  9. Are examples of templates for Care Plans available?

COMPLEX CARE FEES
Summary
How to bill

  1. What is the purpose of the Complex Care Fees?
  2. What is a Complex Care Plan?
  3. Why was the Complex Care Fee changed?
  4. How do I bill the new Complex Care Fees?
  5. Must I spend at least 30 minutes with the patient to bill the Annual Complex Care Management Fee?
  6. May I bill the Complex Care fee on every patient I have with the two qualifying conditions?
  7. What is the difference between “assisted living” and “care facilities”?
  8. Why is this incentive limited to patients living in their homes or assisted living?
  9. Why are there restrictions excluding physicians “who are employed by or who are under contract to a facility and whose duties would otherwise include provision of this care” or to “physicians working under salary, service, or sessional arrangements?”
  10. Am I eligible to bill for the Community Conferencing Fee (G14016) in addition to receiving the Complex Care payment(s)?
  11. My software only captures one diagnostic code per billing. How do I indicate that the patient has two?
  12. What do I do if my patient has more than two of the eligible conditions?
  13. Am I eligible to bill for the Community Patient Conferencing Fee (G14016) in addition to receiving the Complex Care Management payment(s)?
  14. What is the difference between the Complex Care Telephone/Email Follow-Up Management Fee (G14039) and the Community Patient Conferencing Fee (G14016)?
  15. Am I eligible to bill for the Chronic Disease Management Fee(s) (G14050/G14051/G14052) in addition to receiving the Complex Care payment(s)?
  16. Why is the Complex Care Telephone/Email Follow-Up Management Fee (G14039) restricted to the GP that has been paid for the Annual Complex Care Fee (G14033)?
  17. If the Complex Care Telephone/Email Follow-Up Management Fee is restricted to the GP who has been paid for the Annual Complex Care Management Fee, what do group practices do when they share the care of the patient?
  18. Can I bill the Follow-up Management fees if I have billed for the Annual Complex Care Fee, but have not yet been paid?

PREVENTION FEE - CARDIOVASCULAR RISK ASSESSMENT
Description and Eligibility

  1. Why is the prevention fee limited to cardiovascular risk assessment, rather than allowing a broader range of choices?
  2. Why is the age range restricted to men ages 40-49 and women ages 50-59?
  3. Am I able to do the Cardiovascular Risk Assessment on any person in those age ranges?
  4. Am I eligible to bill for an office visit, procedure, or conference fee on the same day?
  5. Why is it payable for only 30 patients per year?
  6. Why is this fee payable only to the “General Practitioner or practice group that accepts the role of being Most Responsible for the longitudinal coordinated care of the patient for that calendar year”?
  7. Am I able to bill this on the same patient every year or is there a recommended frequency?
  8. If I find a patient at higher risk is willing to make changes, is there any information on where I can refer them for further support?
  9. Why does this initiative exclude “physicians who are employed by or who are under contract to a facility and whose duties would otherwise include provision of this care”?
  10. Is there any plan to expand this in the future to other conditions?

COMMUNITY BASED MENTAL HEALTH INITIATIVE
Description and Eligibility

  1. What is the purpose of the Mental Health Initiative Fees?
  2. What is a Mental Health Plan?
  3. How do I bill the Mental Health Fees?
  4. Must I spend a single block of at least 30 minutes with the patient to bill the Mental Health Planning Fee (G14043)?
  5. May I bill the Mental Health Planning Fee (G14043) on every patient I have with a qualifying diagnosis?
  6. When can I bill the Mental Health Management Fees (G14045-G14048)?
  7. When can I bill the Mental Health Telephone/Email Management fee?
  8. How would our group practice arrange to be able to ‘share’ these Mental Health Management Fees?
  9. What is the difference between “assisted living” and “care facilities”?
  10. Why is this incentive limited to patients living in their homes or in assisted living?
  11. Why are there restrictions excluding physicians “who are employed by or who are under contract to a facility and whose duties would otherwise include provision of this care” or to “physicians working under salary, service, or sessional arrangements?”
  12. Am I eligible to bill for the Community Patient Conferencing Fee (G14016) in addition to receiving the Mental Health Care payment(s)?
  13. Am I eligible to bill for the Chronic Disease Management Fee(s) (G14050/G14051/G14052) in addition to these Mental Health Initiative fees?
  14. Why is the Mental Health Telephone/Email Management Fee (G14049) restricted to the GP that has been paid for the Mental Health Planning Fee (G14043)?
  15. If the GP Mental Health Management fees (G14045-G14048) and the GP Mental Health Telephone/Email Management fees (G14049) are restricted to the GP who has been paid for the Mental Health Planning Fee (G14043), what do group practices do when they share the care of the patient?
  16. Can I access the Mental Health Management fees if I have billed for the Mental Health Planning fee but have not yet been paid for it?

GPSC PALLIATIVE CARE PLANNING AND MANAGEMENT FEES
Description and Eligibility

  1. G14063 Palliative Care planning fee
  2. G14069 Palliative Care Telephone/E-mail follow up management fee
  3. Eligibility for G14063 and G14069

ACUTE CARE DISCHARGE CONFERENCE FEE – CODE 14017
Description and Eligibility

  1. G14017  General Practice Acute Care Discharge Conference fee
  2. Eligible Patient Population (refer to Table 1 for details)
  3. Eligible Physician Population
  4. Notes

 

Frequently Asked Questions and Answers


GENERAL PRACTITIONER OBSTETRICAL PREMIUM

This program is a continuation of the Full Service Family Practice Obstetrical Care Incentive Program introduced in 2003. It provides a 50% bonus on the MSC Payment Schedule delivery fee codes 14104, 14108 and 14109. The purpose of the payment is to encourage full service family practitioners to continue to provide obstetrical care, giving women the benefit of choice and longitudinal care.

FEE ITEM DESCRIPTIONS-14004/14009/14008 - EFFECTIVE January 1, 2007

14004   Incentive for full service general practitioner - obstetric delivery bonus associated with vaginal delivery and postnatal care $258.33                         
  Notes:  
        i) Payable to the family physician who provides the maternity care and is responsible for or shares the responsibility for providing the patient's General Practice medical care.
        ii) Payable only when fee item 14104 billed in conjunction.
        iii) Maximum of one bonus per patient delivered.
        iv) Maximum of 25 bonuses per calendar year under fee item   14004, 14008, 14009 or a combination of these items.
    14009  

    Incentive for full service general practitioner - obstetric delivery bonus related to attendance at delivery and postnatal care associated with emergency caesarean section…$215.17

      Notes:    
        i) Payable to the family physician who provides the maternity care and is responsible for or shares the responsibility for        providing the patient's General Practice medical care
        ii) Payable only when fee item 14109 billed in conjunction
        iii) Maximum of one bonus per patient delivered
        iv) Maximum of 25 bonuses per calendar year under fee item 14004, 14008, 14009 or a combination of these items
    14008   Incentive for full service general practitioner-obstetric delivery bonus associated with post natal care after an elective c-section $48.32           
      Notes: i)
      Payable to the family physician who provides the maternity care and is responsible for or shares the responsibility for  providing the patient's General Practice medical care                 
        ii) Payable only when fee item 14108 billed in conjunction                 
        iii) Maximum of one bonus per patient delivered
        iv) Maximum of 25 bonuses per calendar year under fee item   14004, 14008, 14009 or a combination of these items.     

    Eligibility:

    The incentive payments are available to all general practitioners in B.C. who:

    • in addition to being paid the delivery fee items 14104, 14108 and 14109 for the patient,
    • provides the maternity care and is also responsible, or share responsibility, for providing the patient's general practice medical care.
    Practitioners who have billed any specialty consultation fee in the previous 12 months are not eligible. 


    1. When I submit a claim for the bonus payment on fee items 14104, 14108 or 14109, what is the exact amount of the payment?
    The obstetrical care bonus payment is to be claimed using specific fee codes:

    • Fee code 14004 (currently $258.33) with item 14104
    • Fee code 14008 (currently $48.32) with item 14108
    • Fee code 14009 (currently $215.17) with item 14109
    Each will be paid at 50% of the appropriate delivery fee code.

    A maximum of twenty five (25) services under fee item 14008, 14009 or 14004 may be claimed in a calendar year. Multiple incentives may now be billed on any given day, provided the annual maximum of 25 is not exceeded.

    2. How is the bonus billed?
    In addition to billing 14104 (Delivery and post-natal care) a 14004 would be billed. If billing a 14108 (GP elective C-section and post partum care (not the surgical assist fee) a 14008 would be billed. If billing 14109 (Delivery and postnatal care associated with emergency caesarean section) a 14009 would be billed, with the appropriate three-digit ICD-9 code, in order to receive the bonus. The maximum number of bonuses payable per calendar year is 25. They may be claimed under fee item 14004, 14008 or 14009 or a combination of these items but the combined total must not exceed 25.

    3. How many bonuses may I bill in each calendar year?
    You may bill for up to 25 deliveries in each calendar year.

    4. Is the delivery bonus for the first 25 deliveries of the year?
    No, it is for any combination of deliveries up to a maximum of 25 in a year.  It is up to the individual GP to decide which deliveries to bill the bonuses on, provided the combined total of all bonuses does not exceed 25 in a calendar year.

    5. Am I able to claim this new bonus for post-natal care following a C-Section in addition to the 25 delivery bonuses per year?
    No.  Any individual GP may bill up to 25 bonuses per year in total.  These can be any combination of 14004, 14008 and 14009, but the combined total of all bonuses cannot exceed the annual maximum of 25 per year.  It is up to the individual GP to decide which deliveries to bill the bonuses on, provided the combined total of all bonuses does not exceed 25 in a calendar year.

    6. If I am limited to a total of 25 bonuses per year, why would I choose to bill the smaller 14008?
    Most GPs providing obstetrics do not deliver more than 25 patients per year, so the 14008 allows them to bonus all their deliveries, regardless of type or number in any one day, to a maximum of 25 per calendar year.  A physician may choose whether to bill the 14008 or to wait for a future delivery to bill the higher 14004 or 14009. 

    7. What happens if I have billed for 14008, and later go over my limit of 25 bonuses per calendar year so I ‘miss out’ on billing the higher 14004 or 14009?
    You can submit an electronic debit request  to reverse the payment on a 14008, then subsequently bill the 14004 or 14009 if you qualify.

    8. Are locums able to bill this bonus?
    Yes. Locum coverage is considered part of the usual care provided by the host general practitioner.

    9. In practice situations where a patient's care may be shared amongst partners is the bonus still applicable? If so, who bills it?
    The physician performing the delivery (14104) or attendance at delivery and post natal care associated with a c-section (14109) may bill fee item 14004 or 14009. Practice groups providing on call patient coverage or access to patient records are considered to be sharing the responsibility of that patient's care and are eligible to bill one bonus for the patient. Fee item 14008 is payable to the physician who provides the maternity care and is responsible for or shares the responsibility for providing the patients general practice medical care and who provides post natal care after an elective c-section (fee item 14008).

    10. If a GP refers a patient to me for only the maternity care, am I eligible to bill the bonus?
    Yes. GPs specializing in general practice/obstetrics who receive referrals from other GPs for maternity care are considered to share in the general practice medical care of the patient, and so are eligible for this bonus even if the patient returns to the referring GP after the postpartum care.

    11. Is the bonus billable if a delivery is performed during an on-call shift for a partner's patient?
    Yes. This is considered shared care and eligible for one bonus per patient.

    12. How is the bonus applied to multiple births?
    Multiple births are considered one delivery, and thus eligible for one bonus.

    13. Can I bill for delivering mothers covered by other provinces?
    Yes. B.C. has a reciprocal billing agreement with other provinces except Quebec. Treat patients from other provinces (except Quebec) who have their babies in B.C. as though they were B.C. residents.

    14. Can I still bill the payment if another doctor helps me with complications?
    As long as you attend the delivery of the baby (or are prepared to until the need for an emergency c-section) and submit a claim for fee item 14104 or 14109 you may bill for the obstetrical bonus.. If another doctor helps by performing a forceps rotation, emergency c-section, or other additional procedure you are still eligible.

    15. Is this payment eligible for rural premiums?
    Yes.

    16. Are general practitioners who are paid by service contract, sessional or salary payments eligible to receive the obstetrical premium payments?
    Yes. When claiming for the obstetrical delivery bonus associated with vaginal delivery and post natal care, submit an encounter record for the vaginal delivery (14104) along with a fee for service claim for the obstetrical delivery incentive bonus (14004). When claiming for the obstetrical delivery bonus associated with attendance at delivery and post natal care for an emergency c-section (14109), submit an encounter record for 14109 along with a fee for service claim for the obstetrical delivery bonus (14009). When claiming for the GP elective c-section and postpartum care (14108), submit an encounter record for 14108 along with a fee for service claim for the obstetrical delivery bonus (14008). If a fee for service claim is submitted for 14104, 14108 or 14109, it will be refused or withdrawn as this service is funded through the alternative payment arrangement.

    17. Are Emergency Room physicians eligible for this payment?
    No. Emergency room physicians who happen to be on duty and deliver a baby have not shared the general practice maternity care.

    MATERNITY NETWORK INITIATIVE

    Effective December 31, 2007, eligible general practitioners can receive a $1,8500 quarterly payment (which includes additional CMPA subsidy with an approximate value of $650 per year) to cover the costs of group/network activities for their shared care of obstetric patients.

    Eligibility:
    To be eligible to be a member of the network, you must, for the complete three-month period up to the payment date:

    • Be a general practitioner in active practice in B.C.;
    • Have hospital privileges to provide obstetrical care;
    • Be associated and registered with a minimum of three other network members (special consideration will be given in those hospital communities with fewer than four doctors providing maternity care - see below). Refer to the Maternity Network Registration Form;
    • Cooperate with other members of the network so that one member is always available for deliveries;
    • Make patients aware of the members of the network and the support specialists available for complicated cases;
    • Accept a reasonable number of referrals of pregnant patients from doctors who do not have hospital privileges to deliver babies (preferred first visit to the doctor planning to deliver the baby is no later than 12 weeks of pregnancy; the referring doctor may, with the agreement of the delivering doctor, provide a portion of the prenatal care);
    • Share prenatal records (real or virtual) with other members of the network as practical, with the expectation to work toward utilizing an electronic prenatal record; and
    • Each doctor must schedule at least four deliveries in each six month period of time.

    1. How do I register as a maternity network?
    Please complete the Maternity Network Registration Form. Additional copies are available at: http://www.gpscbc.ca/family-practice-incentive/maternity-network-initiative/.

    Registering as a member of a maternity care network provides opportunities for enhanced communication and dialogue among B.C.'s GPs providing this important service. If desired, GPs registering as a network will receive pertinent updates from the GP Services Committee and other organizations on maternity care supports, resources, and CME opportunities available in the province.

    2. How do I claim payments?
    After a quarter in which you have met the eligibility criteria, submit a claim along with your usual claims. (Only payable to registered members of a maternity network.). Effective December 31, 2007 use the following values in the claim:

    • In the Fee item field: 14010 Claim amount: $1,850.00
    • In the patient's PHN field: 9824870522
    • In the Last name field: Maternity
    • In the First initial field G
    • If you require a date of birth, use: 2 November 1989
    • For Date of service use: last day in a quarter
    • Report the Diagnosis as: V26

    Notes:

    • Claims received for processing before the date of service, or with a date of service other than the last day in a quarter will be refused.
    • V26 is the ICD-9 code for "procreative management".

    3. What if I cannot find three other doctors to form a network?
    If fewer than four general practitioners deliver babies at your hospital or, if there are other extenuating circumstances, request an exemption by faxing to: Administrator, Maternity Care Network Initiative, 1-800-952-2895 (toll free). Exemptions may be granted for up to one year.

    4. Does participating in this program mean the network members are on call for obstetrics for the community?
    No. This is not an on call program. Although one eligibility criterion requires cooperation within the network to ensure that one member is always available for deliveries, participating in this program does not require you to be on call for patients outside your group.

    5. Is the payment per doctor or per group?
    As of June 30, 2006 the quarterly payment was initially set at $1,250. Effective December 31, 2006 the payment has been increased to  $1,500 per doctor.

    6. Do we have to advertise that we accept referrals?
    No, word of mouth is sufficient.

    7. What if a doctor delivers 5 babies in one month, then none in the next seven months?
    The condition of scheduling at least four deliveries in every six-month period seemed reasonable in ensuring a doctor was in active obstetrical practice. If this situation arises during the program, let the administrator know and the GPSC will review the situation.

    8. Is this payment eligible for rural premiums?
    No.

    9. Are general practitioners who are paid by service contract, sessional or salary payments eligible to receive the maternity network payments?
    Yes.

    EXPANDED FULL SERVICE FAMILY PRACTICE CONDITION BASED PAYMENTS

    Effective January 1, 2009, a minimum of 2 visits/encounters must have been billed and paid in the 12 months prior to billing the CDM fee.

    This program is a continuation of the Full Service Family Practice Condition Payment introduced in 2003. The program payments recognize that additional work, beyond the office visit payments, of providing guideline based care to patients over a year. The purpose of the condition based payments is to improve patient care.

    They are payable in recognition of the work that has been done and are not payable in advance of the work being done. The program has been enhanced through an increased annual bonus amount for provision of clinical guidelines based diabetes and congestive heart failure care (from $75 to $125 per person) and introduction of a $50 bonus payment for clinical guidelines based hypertension management.

    Eligibility:
    These payments are available to all general practitioners who have a valid B.C. Medical Service Plan practitioner number (registered specialty 00), except those who have billed any specialty consultation fee in the previous 12 months, and:

    • Whose majority professional activity is in full service family practice as described in the introduction, and
    • Who have provided the patient the majority of their longitudinal general practice care over the preceding year, and
    • Have provided the requisite level of guideline-based care.
    1. How do I claim the condition-based payments?
    Please note that effective April 1, 2006, the 14050 and 14051 codes have replaced the 13050 code bonus payments of diabetes and congestive heart failure care introduced under the Full Service Family Incentive Program in 2003, and that code 14052 has been added for hypertension.

    The incentive payments are payable if the patient has a confirmed diagnosis of diabetes mellitus, congestive heart failure, or hypertension. Only one payment per diagnosis is payable per patient per year.

    Condition-based bonus claims are submitted through the MSP Claims system the same way you would submit a MSP fee-for service claim. The submission must include the relevant ICD-9 code (428 congestive heart failure; 250 diabetes mellitus, 401 hypertension).

    The codes for claiming the condition-based bonuses are as follows:
    • 14050 diabetes mellitus (value $125.00)
    • 14051 congestive heart failure (value $125.00)
    • 14052 hypertension (value $50.00)
    Note: The bonus 14052 (hypertension) is not payable if a bonus payment 14050 (diabetes mellitus) or 14051 (congestive heart failure) has been paid for the patient in the preceding year. 14052 (hypertension) is only billable for patients with hypertension who do not also have a diagnosis of diabetes mellitus and/or congestive heart failure.

    2. Is it possible to claim for both the diabetes and heart failure flow sheets?
    If a patient has both diabetes mellitus and congestive heart failure, and criteria are met for each condition, two annual incentive bonuses may be billed separately.

    3. When should the incentive bonus be billed?
    Care provided must be consistent with the BC clinical guideline recommendations for Diabetes Mellitus and may only be billed after one year of care has been provided and the patient has been seen at least twice in the preceding 12 months.
    i) Diabetes Patient Care Flow Sheet
    Fee item 14050 may be billed after 2 columns of the flow sheet have been completed. Although it is not required that the patient be given a copy of their flow sheet, this is highly recommended by the GP Services Committee.

    ii) Congestive Heart Failure Care Flow Sheet
    Fee item 14051 may be billed once the Goals Column, Initial Review (Baseline) Column, and subsequent column (visit intervals to be determined by the physician) have been completed. Although it is not required that the patient be given a copy of their flow sheet, this is highly recommended by the GP Services Committee.

    iii) Hypertension
    Fee item 14052 may be billed after the patient has been provided guideline based care for one year. The patient must be given a copy of their flow sheet for the year. Flow sheets may be completed retroactively if guideline criteria have been met.
    Note: Items 14050 (DM) and 14051 (CHF) are not payable if corresponding 13050 payments have been made within the last 12 months. The new fee codes may be billed when 12 months has lapsed since the last corresponding 13050 payment.

    4. When can I start submitting the new 14050, 14051 and 14052 codes?
    May 20, 2006.

    5. I submitted some 13050 codes after April 1st. What should I do?
    Regretfully, the computer system is unable to adjust these claims. You will be required to debit claims for 13050 with dates of service commencing April 1, 2006, and submitted between April 1 and May 4, 2006, and resubmit the appropriate fee code and payment rate. You may submit your adjustments starting May 20, 2006. Please note claims submitted between May 5 and June 6, 2006, under fee code 13050 have been held and will be adjusted by MSP.

    6. Will payment item 14050, 14051 and 14052 replace the usual visit fees for those patients who have diabetes, congestive heart failure, or hypertension?
    No. Billing for office visits should continue as usual. This bonus is billed in addition to any other fees incurred by usual patient care. It is a management bonus, intended to compensate for the time taken to maintain patient care plans in accordance with the B.C. clinical guidelines.

    7. Do I have to see the patient to bill the payment?
    You will have to see the patient to provide care according to the guidelines, but you do not have to see the patient to fill in the flow sheet.

    8. Can I still bill if the patient is in a long-term care facility?
    Patients in long-term care facilities are eligible, however clinical judgment may be needed about the appropriateness of following these guidelines in patients with dementia or very limited life expectancy.

    9. Where can I find the clinical guidelines?
    The Diabetes Care, Heart Failure Care, and the Treatment of Essential Hypertension guidelines are found on the Guidelines and Protocols page of the Medical Services Plan web site, http://www.bcguidelines.ca/.
    A link is also provided on the BCMA web site, http://www.gpscbc.ca/family-practice-incentive/maternity-network-initiative/.

    10. Where can I obtain a copy of the patient flow sheets?
    The patient flow sheets can be found on the B.C. Medical Association web site, http://www.gpscbc.ca/family-practice-incentive/maternity-network-initiative/, or the Guidelines and Protocols Advisory Committee web site, http://www.bcguidelines.ca/flow_sheets.html.

    Should you wish to receive a pad of pre-printed flow sheets, please fax your request to:
    1 800-952-2895 (toll-free).

    11. Will other flow sheets be admissible for the bonus?
    Other flow sheets can be used if they are consistent with the B.C. clinical guidelines for diabetes, heart failure, and/or essential hypertension management, and contain the same information included in the patient flow sheets that are part of the B.C. clinical guideline.

    Physicians are not required to submit the completed flow sheets to the Ministry of Health in order to receive the incentive payment. Instead, this program will be subject to the usual process of random audit through the Ministry of Health's Billing Integrity Program. Therefore, it is important that you keep all of your completed patient flow sheets on file.

    12. Can I bill the payment even if the clinical or laboratory objectives have not been met?
    The payment is provided for the provision of guideline-based care, and is NOT a payment simply because the patient has a diagnosis of diabetes, congestive heart failure, or hypertension. However, you may still claim for the payment if you have attempted to provide the appropriate level of care but for some reason care objectives have not been met. If this is the case, however, for audit purposes you must have clear chart entries that show that you attempted to provide the recommended level of care. You may also still claim for the payment if you have provided the recommended care but the patient does not meet care objectives (e.g. BP = 130/80 or A1C < 7%).

    13. Can I bill for patients covered by other provinces?
    Patients covered by other provinces who are temporarily in B.C. are not eligible as their regular physician is in the other province. If they stay in B.C. and obtain coverage under the Medical Services Plan then they become eligible for the program. In a few border communities a B.C. physician may provide the majority of care for an Alberta or Yukon patient, and these patients will be eligible.

    14. I have assumed the practice of another GP within the last 12 months. May I still bill for patients' Chronic Disease Management (CDM) fees?
    If the practice you assumed has provided the requisite care to the patient (see question 3 in this section) you may bill the CDM payment on its anniversary date, without having to wait a full 12 months from the time you assumed responsibility for the practice. You may not bill the CDM fees if a patient did not receive the requisite level of care, or a CDM fee code has been billed for the patient in the past 12 months.

    15. Are the payments eligible for the rural premiums?
    No.

    16. Are general practitioners who are paid by service contract, sessional or salary payments eligible to receive the chronic care bonus payments?
    Yes.

    FACILITY PATIENT CONFERENCING FEE

    Fee item and description:

    14015 General Practice Facility Patient Conferencing: when requested by facility to review ongoing management of the patient in that facility or to determine whether a patient in a facility with complex supportive care needs can safely return to the community or transition to a supportive care or long-term care facility
    - per 15 minutes or greater portion thereof........................................................$40.00
    Notes:
    1. Refer to Table 1 below for eligible patient populations.Must be performed in the facility and results of the conference must be recorded in the patient chart.Payable only for patients in a facility. Facilities limited to: hospital, palliative care facility LTC facility, rehab facility, sub-acute facility, psychiatric facility, detox/drug and alcohol facility, community placement agency, disease clinic (DEC, arthritis, CHF, asthma, cancer or other palliative diagnoses, etc).Requesting care providers limited to: long term care nurses, home care nurses, care coordinators, liaison nurses, rehab consultants, psychiatrists, social workers, CDM nurses, any health care provider charged with coordinating discharge and follow-up planning.Requires interdisciplinary team meeting of at least 2 health professionals in total, and will include family members when available. Maximum payable per patient is 90 minutes per calendar year. Maximum payable on any one day is 60 minutes. Claim must state start and end times of the service.If multiple patients are discussed, the billings shall be for consecutive, non-overlapping time periods.Not payable to physicians who are employed by or who are under contract to a facility who would otherwise have attended the conference as a requirement of their employment or contract with the facility; or physicians working under salary, service contract or sessional arrangements.Not payable on the same day for the same patient as the Community Patient Conferencing Fee (14016)
    2. Visit payable in addition if medically required and does not take place concurrently with the patient conference. Medically required visits performed consecutive to the Facility Patient Conferencing are payable.
    This fee is for patient care conferences taking place in a facility.

    Eligibility:
    This incentive payment is available to improve patient care to:
    • All general practitioners who have a valid B.C. Medical Service Plan practitioner number (registered specialty 00) (practitioners who have billed any speciality fee in the previous 12 months are not eligible); and
    • Whose majority professional activity is in full service family practice as described in the introduction; and
    • Is considered the most responsible GP for that patient at the time of service.
    • This payment is billable for the groups of patients identified in Table 1.
    1. How do I claim the Patient Management Conferencing Fee payments?
    Submit the new fee item 14015 (value $40 for each 15 minute unit or major portion thereof) through the MSP Claims System under the patient's PHN. The claim must include ICD-9 codes V15, V58, or the code for one of the major disorders (See Table 1).

    2. What is the maximum number of payments allowed per patient?
    A maximum of four units (60 minutes) per day, to a maximum of six units (90 minutes) per calendar year.

    3. Is this payment eligible for rural premiums?
    Yes.

    4. Are there circumstances where payment will be allowed even if the care conference did not occur in a face-to-face meeting in the facility?
    Face to face meetings are expected. Only under exceptional circumstances will care conferences by teleconference will be payable. For audit purposes, when this occurs, a chart entry is required to indicate that you were not physically present and the circumstances that prevented it.

    5. If more than one patient is discussed at the same case management conference is the fee billable for each patient discussed?
    Yes. The fee is billable under the PHN of each of the patients discussed, for the length of time that each patient's care was discussed. Concurrent billing for more than one patient is not permitted. That is, if you attend a care conference and two patients are discussed over the course of an hour the total time billed must not exceed one hour.

    6. Is the Facility Patient Conferencing Fee billable by physicians who are employed or under contract to a facility and would have attended the conference as a requirement of their employment or contract with the facility?
    No.

    7. Is the Facility Patient Conferencing Fee billable by physicians working in a or under salary, service contract or sessional arrangements?
    No. Physicians working under these funding arrangements are paid a set amount for their time, and therefore would not qualify for this payment.

    8. Can this fee be billed if I also submitted a Community Patient Conferencing Fee on the same day?
    No. It is not payable on the same day of service for the same patient as the Community Patient Conferencing Fee. The Community Patient Conferencing Fee is intended for patients living in the community while the Facility Patient Conferencing Fee is intended for patients in a facility.

    If a Community Patient Conferencing Fee was billed and the patient is subsequently admitted to a facility and a patient management conference is requested by that facility, fee item 14015 may be billed. Conversely, if a Facility Patient Conferencing Fee is billed and the patient is subsequently discharged from the facility and additional clinical action planning is required, fee item 14016 may be billed. They may not, however, be billed on the same calendar day.

    9. Are locums able to bill this bonus?
    Yes. Locum coverage is considered part of the usual care provided by the host general practitioner.

    10. Can I bill for patients covered by other provinces?
    No.

    11. Is this fee billable by hospitalists or on behalf of hospitalists?
    No. Refer to bullet ix under the fee description above. Hospitalists are under contract to a facility and would have attended the conference as part of their duties.

    12. Can a community-based GP bill this fee for the discharge planning of a patient from an acute-care hospital?
    This fee does not cover routine discharge planning from an acute-care facility, nor is this fee payable for conferencing with acute-care nurses on the patient’s ward. The fee description above stipulates:
    iv) “Requesting care providers limited to: long term care nurses, home care nurses, care coordinators, liaison nurses, rehab consultants, psychiatrists, social workers, CDM nurses, any health care provider charged with coordinating discharge and follow-up planning.”
    If a patient’s diagnosis is covered under the restrictions of this fee and the condition is sufficiently complex to warrant a discharge conference with the above care providers, the GP’s attendance at this conference is payable under this fee item - provided the GP is not employed by or under contract to the facility and would otherwise have attended the conference as a requirement of their employment or contract with the facility; or working under salary, service contract or sessional arrangements.

    13. Are examples of templates for Care Plans available?
    Yes. You may wish to use or modify this template.

    COMMUNITY PATIENT CONFERENCING FEE

    Fee item and description:

    14016 General Practice Community Patient Conferencing Fee: Creation of a coordinated clinical action plan for the care of community-based patients with more complex needs. Payable only when coordination of care and collaborative planning with other health care providers (e.g. specialists, psychologists or counsellors, long-term care case managers, home care or specialty care nurses, physiotherapists, occupational therapists, social workers, specialists in medicine or psychiatry) as well as with the patient and possibly family members (as required due to the severity of the patients condition).
    - per 15 minutes or greater portion thereof........................................................$40.00
    Notes:
    1. Refer to Table 1 for eligible patient populations.
    2. Fee includes:
      1. The interviewing of patient and family members as indicated and the conferencing with other health care providers as described above -- this does not require face-to-face interaction in all case; and;
      2. As appropriate, interviewing of, and conferencing with patients, family members, and other community health care providers; organizing and reviewing appropriate laboratory and imaging investigations, administration of other types of testing as clinically indicated (e.g., Beck Depression Inventory, MMSE, etc); provision of degrees of intervention or No CPR documentation; and
      3. The communication of that plan to patient, other health care providers, and family members or others involved in the provision of care, as appropriate; and
      4. The care plan must be recorded in the chart and include the following information:
        1. Patient’s Name
        2. Date of Service
        3. Diagnosis:
          1. V15 (Frail Elderly)
          2. V28 (Palliative/End of Life Care)
          3. Mental Illness (enter ICD-9 code of qualifying illness)
          4. Patients of any age with multiple medical needs or complex co-morbidity (enter ICD-9 for one of the major disorders)
        4. Reason for need of Clinical Action Plan
        5. Health Care Providers with whom you conferred & their role in provision of care
        6. Clinical Plan Determined, including tests ordered and/or administered
        7. Patient risks based on assessment of appropriate domains (list of co-morbidities and safety risks)
        8. List of priority interventions that reflect patient goals for treatment
        9. What referrals will be made, what follow-up has been arranged (including timelines and contact information), as well as advanced planning information
        10. Start and stop times of service
    3. Maximum payable per patient is 90 minutes per calendar year. Maximum payable on any one day is 60 minutes.
    4. Claim must state start and end times of service.
    5. Not payable to the same patient on the same date of service as the Facility Patient Conference fee (fee item 14015).
    6. Not payable to physicians who are employed by, or who are under contract to a facility, who would otherwise have attended the conference as a requirement of their employment or contract with the facility; or physicians working under salary, service contract or sessional arrangements.
    7. Visit payable in addition if medically required and does not take place concurrently with clinical action plan.
    Eligibility:
    This incentive payment is available to improve patient care to:
    • All general practitioners who have a valid B.C. Medical Service Plan practitioner number (registered specialty 00), except those with access to any specialty consultation fee, and
    • Whose majority professional activity is in full service family practice as described in the introduction; is considered the most responsible general practitioners for that patient at the time of service; and
    • Where the severity of the patient's condition justifies the development of a clinical action plan.
    This fee compensates family physicians for the creation of a coordinated clinical action plan for the care of community-based patients identified in Table 1. The clinical action plan fee depends not on the diagnosis alone, but rather the severity of the problems. As such, the fee is billable only when case conferencing and collaborative planning with other health care providers is required (e.g., specialists, psychologists or counsellors, home care or specialty care nurses, physiotherapists, occupational therapists, social workers, specialists in medicine or psychiatry), as well as with the patient and possibly family members, in order to develop the clinical action plan.

    1. How do I claim the Commmunity Patient Conferencing Fee payments?
    Submit the new fee item 14016 (value $40 for each 15 minute unit or major portion thereof) through the MSP Claims System under the patient's PHN. The claim must include ICD-9 codes V15, V58, or the code for one of the major disorders (See Table 1), and the chart entry must contain the elements specified in section ii(d) of the fee description above.

    2. What is the maximum number of payments allowed per patient?
    A maximum of four units (60 minutes) per day, to a maximum of six units (90 minutes) per calendar year.

    3. Is this fee billable if a claim the Facility Patient Conferencing Fee was also made for the patient on the same day?
    No.

    4. Is this payment eligible for rural premiums?
    Yes.

    5. Are locums able to bill this bonus?
    Yes. Locum coverage is considered part of the usual care provided by the host general practitioner.

    6. Can I bill for patients covered by other provinces?
    No.

    7. Is the Community Patient Conferencing Fee billable by physicians working under salary, service contract or sessional arrangements?
    No. Physicians working under these funding arrangements are paid a set amount for their time, and therefore would not qualify for this payment.

    8. Am I eligible to bill this fee when I refer an acutely-ill patient and discuss the case with an Emergency Room Physician/Specialist/Emergency Department nurse?
    No. This fee covers the two-way collaborative conferencing with other providers in the development of a clinical action plan. The transmission of information in a referral process does not qualify.

    Example #1: Mr. B, 73 years old, arrives for his office visit accompanied by his two children. They are concerned that, since his wife’s death a year ago, he has deteriorated significantly. The house is dirty and his personal hygiene has slipped. He is not eating and has lost weight, and is drinking more than he used to. He is no longer as interested in his family’s activities and, on occasion, he has forgotten the names of his grandchildren. You initially meet with all three, then you excuse the daughters and meet alone with Mr. B. He is unkempt, his clothes hang on his body, and he doesn’t engage in conversation with you as he did in the past. He admits to drinking at least a bottle of wine per day, and frequently comments that he wished he had died before his wife. You perform a full physical examination, without significant findings. You order laboratory investigations. At this point you also personally administer a Beck Depression Inventory and a Mini-Mental Status Examination, which reveals severe depression and mild cognitive impairment. You then meet with the patient and, with his permission, his children and discuss your findings and plan; Mr. B tells you to follow up with his children as his memory “hasn’t been so good.” Following this, through the course of the day you conference with (depending on your community) the Quick Response Team/ Geriatric Outreach/ Home Care Nurse to arrange for a home visit assessment, and also conference with a psychiatrist to discuss initiation of treatment and arrange for him to be seen. You phone his pharmacist to prescribe the antidepressant agreed upon during the telephone conference with the psychiatrist and to arrange for all his medications to be blister-packed as he has been forgetting to take them. You then phone his daughter to advise her of the steps taken and the appointments you have made for him, and arrange a follow-up office visit in two weeks.
    Billing: You are eligible in this case to bill 17101 for the full physical examination. You are also eligible to bill the appropriate units of 14016 for the time following the examination spent administering the Beck and MMSE, and organizing the care plan with other health care providers and with the patient and family.

    Example #2: Mr. Y, whose wife has an aggressive recurrence of ovarian cancer, phones to say that she has had a horrible night with pain, and with vomiting induced by the analgesic prescribed on her recent office visit. You talk to your patient Mrs. Y, who is now reluctantly willing to agree to a DNR. You conference with the doctor on call for Palliative Care, or your local colleague who has special skills in this field, then arrange for the Palliative Care Nurse/Home Care Nurse to visit and initiate the treatment plan established and to arrange for the completed DNR form to be picked up and added to Mrs. Y’s home chart. Another phone call to the pharmacist is required to prescribe the necessary medications and arrange for them to pick up the triplicate on their delivery run.
    Billing: No visit occurred, but you are still eligible to bill the appropriate number of units of 14016 for the time spent conferencing with other providers and organizing your patient’s care plan.

    Example #3: Kay, a 28-year old woman, is brought to your office with her mother after a long disappearance. She has been living on the streets again and has been using a wide variety of street drugs. She wants to get off them, and is already entering withdrawal. You discuss options with her. You conference with one of the local Drug and Alcohol Centre’s counselors and develop a plan for how to handle her care until a detox bed becomes available in 3 to 5 days. You arrange for the appropriate laboratory testing/screening. You arrange with Kay’s pharmacist for daily pickups of her medications.
    Billing: You are entitled to bill for a visit fee for Kay, and eligible to bill the appropriate number of 14016 units for the time spent in conferencing with the other providers and for developing her clinical action plan.

    9. Are examples of templates for Care Plans available?
    Yes. You may wish to use or modify this template.

    Table 1:  Eligible patients populations for the Facility Patient Conferencing Fee and the Community Patient Conferencing Fee




    i. Frail elderly (ICD-9 code V15)
    Patients over the age of 69 years with at least 3 out of the following factors:
    • Unintentional weight loss (10 lbs in the past year)
    • General feeling of exhaustion
    • Weakness (as measured by grip strength)
    • Slow gait speed (decreased balance and motility)
    • Low levels of physical activity (slowed performance and relative inactivity)
    • Incontinence
    • Cognitive impairment
    ii. Palliative care (ICD-9 code V58)
    Patients of any age who:
    • Are living at home ("home" is defined as wherever the person is living, whether in their own home or living with family or friends, or living in a supportive living residence or hospice); and
    • Have been diagnosed with a life-threatening illness or condition; and
    • Have a life expectancy of up to six months; and
    • Consent to the focus of care being palliative rather than treatment aimed at cure.
    iii. End of life (ICD-9 code V58)
    Patients of any age:
    • Who have been told by their physician that they have less than six months to live; and
    • With terminal disease who wish to discuss end of life, hospice or palliative care.
    iv. Mental illness
    Patients of any age with any of the following disorders are considered to have mental illness:
    • Mood Disorders
    • Anxiety and Somatoform Disorders
    • Schizophrenia and other Psychotic Disorders
    • Eating Disorders
    • Substance Use Disorders
    • Infant, Child and Adolescent Disorders
    • Delirium, Dementia and Other Cognitive Disorders
    • Sleep Disorders
    • Personality Disorders
    • Developmentally Delayed, Fetal Alcohol Spectrum Disorders and Autism Spectrum Disorders
    • Sexual Dysfunction
    • Dissociative Disorders
    • Mental Disorders due to a General Medical Condition
    • Factitious Disorder
    Definitions and the management of these mental disorders are defined in the Manual: Management of Mental Disorders, Canadian Edition, Volume One and Two, edited by Dr. Elliot Goldner, Mental Health Evaluation and Community Consultation Unit, University of British Columbia. Definitions for Delerium, Dementia and Other Cognitive Disorders; Developmental Disabilities; Dissociative Disorders; Mental Disorders due to a General Medical Condition and Factitious Disorder are found in the Diagnostic and Statistical Manual of Mental Disorders - DSM-IVR.

    v. Patients of any age with multiple medical needs or complex co-morbidity
    Patients of any age with multiple medical conditions or co-morbidities (three or more distinct but potentially interacting problems) where care needs to be coordinated over a period of time between several health disciplines. On your claim form use the code for one of the major disorders (on April 1, 2007, it is expected that codes for all three main disorders will be required).

    COMPLEX CARE FEE - Summary

    The intent of the Complex Care Fee is to compensate GPs for the extra time required to provide planned care for complex patients who live at home or in an assisted living facility (excluding long-term care facilities).

    This means that in addition to the fees you already receive for looking after patients with complex care issues, you can now bills these new Complex Care Fees.

    Under the revised Complex Care Management Fees, there is only one billing option for the planning and provision of care for eligible patients over the course of the calendar year:

    • Fee Item G14033 provides compensation for the creation of a Complex Care Plan for eligible patients; those with two qualifying co-morbidities. This fee of $315 is payable once per calendar year for the provision and monitoring of the Complex Care Plan during that calendar year;
    • Provision of care for eligible patients will be billed on a standard fee-for-service basis. Face-to-face visits between the GP and patient are required using the appropriate MSP fee code.
    • Additionally, once a GP/FP or practice has determined a patient is eligible for a Complex Care Plan and has created and has successfully billed for this plan, they may access a new Complex Care Follow-Up Management Fee under Fee Item G14039. These fees compensate the GP/FP or practice for 2-way telephone or email communication with the patient or the patient's medical representative. These fees are paid at $15 for up to a maximum of 4 services per calendar year.

    Due to the time, intensity and complexity of creating the complex care plan, GPSC has determined that a maximum of five (5) Complex Care Management Fees can be billed by a GP per calendar day. Upon application, an exemption may be granted by GPSC under some circumstances; e.g. GP/FPs electing to dedicate a half-day for practice meetings with Complex Care patients. These applications must be in writing and must include the specifics of the reasons for requesting an exemption.

    The General Practitioner or practice group may bill these fees when providing care to patients residing in their homes or in assisted living with any two of the following chronic conditions:

    Diabetes mellitus (type 1 and 2)
    Chronic renal failure with eGFR values less than 60
    Congestive heart failure
    Asthma
    Chronic obstructive pulmonary disease (emphysema and chronic bronchitis)
    Cerebrovascular disease
    Ischemic heart disease, excluding the acute phase of myocardial infarct
    Chronic neurodegenerative disease
    Chronic liver disease of at least 6 months, with the exception of:
         1. self limiting conditions,
         2. hepatitis carrier states normal liver function tests,
         3. benign conditions with elevation of liver function tests.

    *Diagnostic codes have been developed to cover all combinations of any two of the following conditions - refer to Table 1.

    These items are 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. By billing this fee the practitioner or practice accepts this responsibility for the ensuing calendar year.

    These complex care fee items are:

    • Not payable to physicians who have been paid for any specialty consultation fee in the previous 12 months;
    • Not payable to physicians who are employed by or who are under contract whose duties would otherwise include provision of this care;
    • Not payable to physicians working under salary, service contract or sessional arrangements and whose duties would otherwise include provision of this care.

    G14033 - Annual Complex Care Management Fee $315.00

    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 the Complex Care Plan for the management of the complex care patient during that 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 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.

    Notes:

    1. Payable once per calendar year;
    2. Payable in addition to office visits, CPx, or home visits with patient on the same day, which must accompany billing;
    3. Visit or CPx fee to indicate face-to-face interaction with patient same day must accompany billing;
    4. G14016, Community Patient Conferencing Fee, payable on same day for same patient if all criteria met;
    5. G14015, facility patient conferencing fee, not payable on the same day for the same patient, as facility patients not eligible;
    6. CDM fees G14050/G14051/G14052 payable on same day for same patient, if all other criteria met;
    7. Minimum required time 30 minutes in addition to visit time same day;
    8. Maximum of 5 complex care fees per day per physician.
    9. Not payable for patients seen in locations other than the office, home or assisted living residence where no professional staff on site;

    G14039 - Complex Care Telephone/Email Follow-Up Management Fee $15.00

    This fee is payable for follow-up management, via 2-way telephone or email communication, of patients for whom a Complex Care Management Fee (G14033) has been paid. Access to this fee is restricted to the GP that has been paid for the Complex Care Management Fee (G14033) and is therefore Most Responsible GP (MRGP) for the care of that patient for the submitted chronic conditions for that calendar year. The only exception would be if the billing GP has the approval of the Most Responsible GP, and this must be documented as a note entry accompanying the billing. As with all clinical services, dates of services under this item should be documented in the patient record together with the name of the person who communicated with the patient or patient's medical representative as well as a brief notation on the content of the communication.

    Notes:

    1. Payable a maximum of 4 times per calendar year per patient;
    2. Not payable unless the GP/FP is eligible for and has been paid for the Annual Complex Care Management Fee (G14033) during the same calendar year;
    3. Telephone or e-mail management requires two-way communication between the patient and physician or medical office staff on a clinical level; it is not billable for simple notification of office appointments;
    4. Payable only to the physician that has successfully billed for the Annual Complex Care Management Fee (G14033) unless the billing physician has the approval of the GP responsible for the Annual Complex Care Management Fee (G14033) and a note entry is submitted indicating this;
    5. G14016, Community Conferencing Fee, payable on same day for same patient if all criteria met. Time spent on telephone under this fee with patient does not count toward the time requirement for the G14016;
    6. Not payable on the same calendar day as a visit fee by the same physician for the same patient.
    7. Chart entry requires the capture of the name of the person who communicated with the patient or patient's representative as well as capture of the elements of care discussed

    HOW TO BILL

    • Have a face-to-face visit with the eligible patient, and the patient's medical representative if appropriate;
    • Review the patient's history/chart and create a Complex Care Plan including the elements itemized above, which is billable only on the day of a face-to-face visit;
    • Over the rest of the calendar year, conduct a review of the Complex Care Plan and provide other follow ups as clinically indicated. Follow-up may be face-to-face or by telephone/e-mail as appropriate, with the appropriate fee being payable.

    Step 1.  Create a Complex Care Plan - G14033 - $315.00

    The Complex Care Management Fee acknowledges that eligible patients require medical management that is more time intense and complex. This fee compensates the GP/FP for the creation of a clinical action plan for the patient as described above, and for the additional complexity of managing these patients for the calendar year in which the Complex Care Plan is billed.
    The initial service allowing access shall be the development of a Complex Care Plan for a patient residing in their home or assisted living (excluding care facilities) with two or more of the above chronic conditions. This requires fulfillment of the itemized elements of service and documentation of these as specified in the fee item above.

    Step 2.  Provide Office Visit Follow-Up

    GPSC received feedback that, under the previous Option Two, GPs were uncertain when to bill for a visit under a different diagnostic code and when to include the service in the care pre-paid with this option. Concern was also expressed that care being provided under Option Two was not being tracked by MSP and therefore the patient may not appear to be receiving their majority source of care from their doctor. Under this revised Complex Care Management Fee, the complexity is pre-paid when the planning visit is undertaken, but each and every visit for the rest of the year will be billable under the appropriate MSP fee and with the presenting complaint diagnostic code.

    Step 3.  Provide Follow-Up Telephone/Email Management - G14039 - $15.00

    This new addition to the complex care fees allows for the provision of medical management through 2-way telephone or e-mail communication with the patient and/or the patient's medical representatives. These non-face-to-face services are payable to a maximum of 4 times per calendar year. These services will also be applied toward the majority source of care calculation for these patients.

    Step 4.  Use the ICD9 codes listed in Table 1

    Diagnostic codes have been developed to cover all combinations of any two of the chronic conditions covered under the complex care fees.

    Table 1: Complex Care Diagnostic codes

    Diagnostic Code

    Condition One

    Condition Two

    N519

    Chronic Neurodegenerative Disorder

    Chronic Respiratory Condition

    N414

    Chronic Neurodegenerative Disorder

    Ischemic Heart Disease

    N428

    Chronic Neurodegenerative Disorder

    Congestive Heart Failure

    N250

    Chronic Neurodegenerative Disorder

    Diabetes

    N430

    Chronic Neurodegenerative Disorder

    Cerebrovascular Disease

    N585

    Chronic Neurodegenerative Disorder

    Chronic Kidney Disease (Renal Failure)

    N573

    Chronic Neurodegenerative Disorder

    Chronic Liver Disease (Hepatic Failure)

    R414

    Chronic Respiratory Condition

    Ischemic Heart Disease

    R428

    Chronic Respiratory Condition

    Congestive Heart Failure

    R250

    Chronic Respiratory Condition

    Diabetes

    R430

    Chronic Respiratory Condition

    Cerebrovascular Disease

    R585

    Chronic Respiratory Condition

    Chronic Kidney Disease (Renal Failure)

    R573

    Chronic Respiratory Condition

    Chronic Liver Disease (Hepatic Failure)

    I428

    Ischemic Heart Disease

    Congestive Heart Failure

    I250

    Ischemic Heart Disease

    Diabetes

    I430

    Ischemic Heart Disease

    Cerebrovascular Disease

    I585

    Ischemic Heart Disease

    Chronic Kidney Disease (Renal Failure)

    I573

    Ischemic Heart Disease

    Chronic Liver Disease (Hepatic Failure)

    H250

    Congestive Heart Failure

    Diabetes

    H430

    Congestive Heart Failure

    Cerebrovascular Disease

    H585

    Congestive Heart Failure

    Chronic Kidney Disease (Renal Failure)

    H573

    Congestive Heart Failure

    Chronic Liver Disease (Hepatic Failure)

    D430

    Diabetes

    Cerebrovascular Disease

    D585

    Diabetes

    Chronic Kidney Disease (Renal Failure)

    D573

    Diabetes

    Chronic Liver Disease (Hepatic Failure)

    C585

    Cerebrovascular Disease

    Chronic Kidney Disease (Renal Failure)

    C573

    Cerebrovascular Disease

    Chronic Liver Disease (Hepatic Failure)

    K573

    Chronic Kidney Disease (Renal Failure)

    Chronic Liver Disease (Hepatic Failure)

    Complex Care Frequently Asked Questions

    1. What is the purpose of the Complex Care Management Fees?

      The Complex Care Management Fees have been created to provide recognition that patients with co-morbid conditions require more time and effort to provide quality care, and to remove the financial barrier to providing this care as opposed to seeing more patients of a simpler clinical condition.

    2. What is a Complex Care Plan?

      The initial service allowing “portal” access to the complex care fees shall be the development of a Complex Care Plan for a patient residing in their home or assisted living (excluding care facilities) with two or more of the above chronic conditions.  This plan should be reviewed and revised as clinically indicated.  It is essentially an expansion of the SOAP formula for chart documentation.

      A complex care plan requires documentation in the patient’s chart that:

      • there has been a detailed review of the case/chart and of current therapies;
      • 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; 
      • specifies a clinical plan for the care of that patient’s chronic diseases covered by the complex care fee;
      • incorporates the patient’s values and personal health goals in the care plan with respect to the chronic diseases covered by the Complex Care Management Fee;
      • outlines expected outcomes as a result of this plan, including end-of-life issues when clinically appropriate;
      • outlines linkages with other health care professionals that would be involved in the care, their expected roles;
      • identifies an appropriate time frame for re-evaluation of the plan;
      • 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.
    3. Why was the Complex Care Fee changed?

      The GP Services Committee received significant feedback that the original 2 options for billing the Complex Care fee were too complicated.  Several concerns have been addressed by combining the 2 original fees:

      Option One Complaints

      1. This fee option has been difficult to track;
      2. Physicians were uncertain when to bill the minor care plan review (G14031) vs. the follow up fees (G14032).
      3. While phone or e-mail management was an option included in the Option 2 block care payment, any phone or e-mail management under Option 1 was not billable.

      With this revision, the complexity aspect of care is payable under a single fee, once per year, at the time of the major care planning visit.  In addition, the new follow-up fee provides access to non-face-to-face compensation for all complex care patients.

      Option Two Complaints

      1. It has been confusing as to whether visits were or were not included in the pre-paid annual block visit fee if other matters were discussed ;
      2. Physicians expressed concern that care they provided to these patients that did not generate any billing would not be recognized in the calculation of “Majority Source of Care” patients, as there was no electronic indication that the care was actually provided.
      3. There has been discomfort about accepting a pre-paid amount equivalent to six office visits as full annual payment for the two qualifying conditions;

      With this revision, all services provided will be included in the Majority Source of Care calculations, including the new non-face-to-face follow-up fees, care provided by 2-way phone or e-mail communication with eligible patients or their medical representatives. 

      With this revision, visit fees revert to standard Fee-for-Service, so each visit is compensable and, in addition, compensation is provided for non face-to-face 2-way interaction with patients or their medical representatives.

    4. How do I bill the new Complex Care Fees?

      The first service must be the creation of a Complex Care Plan (see Question 2 above for details) in consultation with your eligible patient.  You may then bill fee code 14033 (Annual Complex Care Management Fee) as well as the appropriate visit fee.  The visit fee can be a standard in-office or out-of-office visit, a CPx, home visit, or prolonged counselling visit as appropriate

      Note:

      1. A visit fee code MUST accompany the billing for the Annual Complex Care Management Fee (G14033)
      2. Fee item G14033 MUST be dated the same date of service as the date of the patient visit in which the Complex Care Plan was discussed.
      3. It is strongly recommended that your chart entry include the time spent in preparing the Complex Care Plan and, if a Prolonged Counselling visit is billed, the time spent on the face-to-face visit;
      4. Time spent on preparation of the Complex Care plan does not count towards the time requirement for a prolonged counselling visit
    5. Must I spend at least 30 minutes with the patient to bill the Annual Complex Care Management Fee?

      The complex care fee compensates for the time taken to review the chart, prepare a preliminary plan, discuss and finalize the plan with a face-to-face visit with the patient and/or the patient’s medical representative, and to document the plan.  It does not have to be done as a single 30-minute block, but as an aggregate amount of time spent.  In most cases, GPs are reviewing the charts in advance, then meeting with the patient and/or representative, then subsequent to the meeting preparing the documentation of the final plan.  It is strongly recommended, however, that your chart record include the time that has been spent in this process. 

      Note: As in Question 4 above, the date of service for the Annual Complex Care Management Fee MUST be the same as the date of service for the office visit in which the plan was discussed and finalized with the patient.
    6. May I bill the Complex Care fee on every patient I have with the two qualifying conditions?

      Yes – but, some patients with two qualifying conditions may not be acute or complex enough to require a care plan or any significant additional time in providing care.   
      Whether the patient needs an annual plan or not is left to your professional judgement, and to trust.  

      The Annual Complex Care Management Fee is a means of removing the disincentive to providing the time to those qualifying patients who truly need it.  If the Annual Complex Care fee is billed for all potentially qualifying patients, GP Services Committee will have fewer funds to allocate for other areas requiring support.

    7. What is the difference between “assisted living” and “care facilities”?

      There are a wide range of living facilities currently available.  Some, referred to under the terms of this initiative as ‘assisted living’ facilities, provide only basic supports such as meals and housecleaning, and do not provide their residents with nursing and other health support. 

      A “care facility” on the other hand, is defined under the terms of this initiative as being a facility that does provide supervision and support from other health professionals such as nurses.
    8. Why is this incentive limited to patients living in their homes or assisted living?

      While there may be exceptions, patients residing in a Long Term Care Facility or hospital usually have a resident team of health care providers available to share in the organization and provision of care.  Patients residing in their homes or in assisted living usually do not have such a team, so the organization and supervision of care is usually more complex and time consuming for the General Practitioner (GP).

    9. Why are there restrictions excluding physicians “who are employed by or who are under contract to a facility and whose duties would otherwise include provision of this care” or to “physicians working under salary, service, or sessional arrangements?”

      The current Fee-for-Service payment schedule tends to encourage the provision of a higher volume of easier services as opposed to fewer, more complex and time-intensive services.  This incentive has been designed to offset this disincentive. 

      If a physician is already compensated for providing these services through terms of employment, or through time-neutral payments such as salary, service, or sessional arrangements, their time is considered to be already compensated.

    10. There are many co-morbidities that result in complexity of care. Why is this incentive limited to a list of seven conditions?

      According to Ministry of Health data, patients living with two or more of the eligible conditions are among the most chronically ill in the province and high users of the acute care system.  As a trial, the GP Services Committee has elected to introduce incentives on a smaller scale.  As this revision shows, they can and will be modified depending upon the outcomes the incentive creates. 

      Compiling the list of eligible conditions has been a difficult task, and it has required a careful balance.  It is apparent that many additional conditions create complexities in providing care, but at the same time the 2006 Letter of Agreement stipulated a budget for all the activities of the GP Services Committee, and requires that GPSC remain within that budget.

    11. My software only captures one diagnostic code per billing. How do I indicate that the patient has two?

      This has been a problem.  While Teleplan requires that eligible software has the ability to enter more than one diagnostic code, many versions of software currently used do not support this.  Also, vendors are currently so occupied with the PITO qualification process that we cannot realistically expect them to modify current versions.

      To get around this barrier without requiring that many GPs modify their current software, GPSC created a number of different diagnostic codes to indicate different combinations of two eligible criteria.
    12. What do I do if my patient has more than two of the eligible conditions?

      Choose which two of the patient’s eligible conditions to submit.  Review the list of diagnostic codes provided and choose the one that reflects the two eligible conditions you wish to submit.  Since the revised Complex Care payment involves the advance payment for the planning and “complexity” of the complex care conditions, but the care provided is billable on a fee-for-services basis, all patient care services are compensated as they occur regardless of the diagnoses.

    13. Am I eligible to bill for the Community Patient Conferencing Fee (G14016) in addition to receiving the Complex Care Management payment(s)?

      Yes.  If the physician needs to conference with allied health professions about the care plan and any changes, then the services provided in conferencing with other health care professionals is payable over and above the Complex Care Management Payments, provided that the all criteria for the Conferencing fee are met.  The time spent on the phone or e-mail with the patient for the non-face-to-face complex care management does not count toward the total time billed under the community patient conferencing fee.

    14. What is the difference between the Complex Care Telephone/Email Follow-Up Management Fee (G14039) and the Community Patient Conferencing Fee (G14016)?

      The Complex Care Follow-Up Telephone/Email Management payment relates to services provided to the patient or the patient’s medical representative as indicated.  The Community Patient Conferencing Fee relates to services spent conferencing with other health care providers in a 2-way discussion on the provision of care to benefit the patient.

    15. Am I eligible to bill for the Chronic Disease Management Fee(s) (G14050/G14051/G14052) in addition to receiving the Complex Care payment(s)?

      Yes, The Chronic Disease Management Fees (G14050, G14051, G14052) are independent of the Complex Care fees, and are payable on the same patient as long as the criteria for those fees are met.

    16. Why is the Complex Care Telephone/Email Follow-Up Management Fee (G14039) restricted to the GP that has been paid for the Annual Complex Care Fee (G14033)?

      This fee is designed to allow greater flexibility in providing follow-up to a plan that has been created.  The GP that has been paid for the Annual Complex Care Management Fee has also accepted the responsibility of being the Most Responsible GP (MRGP) for that patient’s care for the two submitted chronic illnesses for that calendar year.  The Annual Complex Care Management Plan requires work, the shouldering of responsibility, and the co-ordination of care.  It has considerable value.  This fee is therefore restricted to the GP that has created the clinical action plan.

    17. If the Complex Care Telephone/Email Follow-Up Management Fee is restricted to the GP who has been paid for the Annual Complex Care Management Fee, what do group practices do when they share the care of the patient?

      An exception has been made, allowing another GP to bill for this fee with the approval of the Most Responsible GP (MRGP). This allows flexibility in situations when patient care is shared between GPs. In this circumstance, the alternate GP must submit the claim with a note record indicating he/she is in the group of the MRGP and is sharing the care of the patient.

      If a disagreement arises about the billing of this service, GP Services will adjudicate based upon whether the Most Responsible GP, i.e. the GP paid for the Annual Complex Care Fee, approved or did not approve the service provided. GP Services feels that this provides the maximum flexibility while still maintaining responsibility.

    18. Can I bill the Follow-up Management fees if I have billed for the Annual Complex Care Fee, but have not yet been paid?

      Adjudication of this will depend upon whether the GP is eventually paid for the Annual Complex Care Fee.  In other words, if a GP bills the Annual Complex Care Management Fee (G14033) then provides—and bills for—a follow-up service under G14039 prior to receiving payment for G14033, payment for G14039 will made only if G14033 is subsequently paid to that GP.  Until that time it will show as “BH’ on the remittance.

    Complex Care Billing Comparison Options One/Two with new Single Option

    Mrs. J. is a 68 year old lady with diabetes and asthma. She has made an appointment to see you in January 2008 for her major annual review of her care plan that was set up the previous year. You review her medications and most recent lab tests as well as her peak flow chart. After also checking her diabetes flow sheet, you discuss with her the complex care plan for the remainder of the year and set up an appointment for her to have her complete check up in March when it is due.

    In February, Mrs. J calls when you are on call to advise that her peak flow has suddenly dropped into her low yellow zone after visiting her daughter who has a cat. She tells you that her maintenance dose of Flovent has been 125 mcg twice daily, so you ask her to increase to 250 mcg twice daily and to come in to the office to see you the following day. When you see her, you determine she has had a flare of her asthma but that there is no sign of acute infection, and so advise to continue with the increased Flovent. You see her again 3 days later and her peak flows have improved. You advise her to stay on this higher dose for the next 2 weeks, and that you will have your office nurse call to check on her.

    When contacted in early March, her peak flows have stayed stable and she is advised to go back to her maintenance dose. You see her again in March for her CPX and over the rest of the year for follow up of her complex conditions she is seen in July, October and December twice due to a flare of her asthma. In addition, in September, she is seen by you for a bladder infection and treated appropriately. Mrs. J's Diagnostic Code for her Complex Care Management under all options is A250.

    The billing comparisons of the original Options One and Two and the new Single Option are:

    Month

    Service

    Option One

    Option Two

    Revised Single Option

    Jan.

    Major Complex Care
    Planning Visit

    14030
    16100

    $100.00
    $32.08

    14033
    13136

    $315.00
    $192.48

    14033
    16100

    $315.00
    $32.08

    Feb.

    Phone call
    Complex Care Office Visit

    Complex Care Office visit

    N/C
    14032
    16100
    14032
    16100


    $35.00
    $32.08
    $35.00
    $32.08

    N/C
    N/C

    N/C

     

    14039
    16100

    16100

    $15.00
    $32.08

    $32.08

    March

    Phone call
    CPX

    N/C
    16101


    $71.34

    N/C
    16101


    $71.34

    14039
    16101

    $15.00
    $71.34

    July

    Complex Care Office Visit

    14032
    16100

    $35.00
    $32.08

    N/C

     

    16100

    $32.08

    Sept.

    UTI Office Visit

    16100
    15130

    $32.08
    $1.96

    16100
    15130

    $32.08
    $1.96

    16100
    15130

    $32.08
    $1.96

    Oct.

    Complex Care Office Visit –
    Minor Care Plan review

    14031
    16100

    $75.00
    $32.08

    N/C

     

    16100

    $32.08

    Dec.

    Complex Care Office Visit

    Office visit for asthma flare

    14032
    16100
    16100

    $35.00
    $32.08
    $32.08

    N/C

    N/C

     

    16100

    16100

    $32.08

    $32.08

    Total

     

    $644.94

    $612.86

    $674.94

     

    PREVENTING THE ONSET OF CHRONIC DISEASES

    G 14034 Cardiovascular Risk Assessment Fee: $100
    This fee is payable on the completion of cardiovascular risk assessment of an individual using the parameters of age, gender, smoking status, fasting blood sugar, blood pressure, and lipid profile as a minimum.  More detailed assessment parameters could include family history, waist circumference, diet, alcohol use, exercise levels, and stress levels. 
    Notes:

    • the eligible population will be men and women between 18 and 69 years;
    • a chart record is required that includes the minimum parameters above and evidence of an appropriate response to major high risk findings, including interventions, prescriptions, referrals to appropriate health care professional and/or linkages with community supports;
    • interventions should be aligned with the current guidelines published by the Guideline and Protocol Advisory Committee (GPAC); eg. Diabetes, hypertension, lipids;
    • payable for a maximum of 30 patients per physician per calendar year;
    • Payable in addition to office visit fee(s) billed same day
    • Payable once per calendar year per patient.

    This assessment is intended to assure that major guideline-recommended measurements are made for appropriate age groups; a specific % 10 yr. M.I. risk assessment is optional.  The essence of the activity is that the family physician discusses with the patient the major risk factors and their presence or absence.

    Eligibility

    • Payable only to the General Practitioner or practice group that accepts the role of being Most Responsible for the longitudinal, coordinated care of the patient for that  calendar year;
    • Not payable to physicians who have been paid for any specialty consultation fee in the previous 12 months;
    • 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;
    • Not payable to physicians working under salary, service contract or sessional arrangements and whose duties would otherwise include provision of this care.

    RATIONALE
    Person/Population Focus
    Over one million people in British Columbia currently live with one to three chronic diseases.  Almost half of the population is at risk for and/or has been tested for a chronic disease.  A key response to the demographic and disease trends towards an increasingly older population with more chronic diseases is to invest in strategies that will prevent or delay the onset of chronic diseases.  There is growing evidence that this is possible.  According to the World Health Organization, 80% of the cases of some chronic diseases such as Type 2 diabetes can be prevented.  Research has found that moderate exercise and diet control among overweight people with pre-diabetes (impaired glucose tolerance) reduces the likelihood of developing diabetes by more than 50%.  Many chronic diseases such as diabetes and cardiovascular disease have similar risk factors.  Addressing these common risk factors, reducing tobacco and alcohol use, eating healthily and being active underlies the logic for the cross-government ActNow initiative.  However, despite the evidence, for many people understanding and making healthy choices remain elusive.  People are faced with life-time habits, lack of resources or family/social supports, or life’s pressures that make "adding something else" impossible.   Personal change needs the same support as professional change i.e.:

    • to receive and understand personal data to show the outcome of remaining with the status quo;
    • to learn evidence-based approaches that have worked for many other people
    • to put those approaches into action with others (buddy, group, family)
    • to measure results and be accountable for these results to others

    Physician Focus
    Family physicians want to provide their patients with preventative care.   The role of the family physician in prevention is twofold: (a) very influential health professional and (b) facilitator.  Most physicians can already identify these patients in their practices.  The family physician can use a variety of tools to assess risk of chronic diseases – and share these data with the patient.  The focus of this initiative is to more formally introduce the process of cardiovascular risk assessment and follow up to family practice. 

    Health System Focus
    The current health system is not linked to community resources in a way that supports health improvement for the majority of the population.  Most communities have infrastructure, services and resources that can provide support to people who want to quit smoking, reduce alcohol intake, improve their diet and increase their activity levels.  However, these resources are not often linked together and are very rarely formally linked to primary health care.  Family physicians and their patients are not going to succeed at very difficult life changes for health if supports and expertise are not readily available.  To this end GPSC has linked with Health Authorities and the BC Healthy Living Alliance – responsible for creating an effective infrastructure in communities to supply people, identified as being at risk of developing chronic disease, with tools, supports, and opportunities for healthy change.

    Community infrastructure for overall health must be clearly identifiable to family physicians and their patients.  Therefore, regional change teams put into place through GPSC non-compensation funding will be required to provide physicians with direct facilitation support and/or referral information for each community.  In addition, family physicians wishing to take on the direct facilitation role with their patients will also be supported and trained in group patient visits. 

    Principles For the Prevention Payment

          • Focus on the patients at greater risk for the onset of chronic disease 
          • Achieve equity of access to improved health status for patients. Horizontal equity refers to similar public funding for patients with similar needs.  Vertical equity refers to more support given for patients with greater need;
          • Reward the intervention and knowledge of the family physician with direct facilitation and/or referral to information and community-based services
          • Retain and encourage family physicians already providing preventative care and encourage general practitioners currently targeting patients who have relatively straight forward clinical needs to take on their greater share of at risk patients. 
          • The 2007 GPSC approach to prevention is experimental.  It is understood that not all higher risk patients will be identified through this initiative.  GPSC will work closely with Family Physicians to determine the effectiveness of this incentive from the perspectives of patient, provider, and system, and retains the right and authority to modify this incentive based on results.  It is anticipated that future initiatives in preventative care will evolve through ongoing input from Family Physicians

    PREVENTION FEE - CARDIOVASCULAR RISK ASSESSMENT

    Cardiovascular Risk Assessment Fee: $100

    This fee is effective April 1, 2007 and will be billable after May 4, 2007. It is payable on the completion of cardiovascular risk assessment of an individual using the parameters of age, gender, smoking status, fasting blood sugar, blood pressure, and lipid profile as a minimum. More detailed assessment parameters could include family history, waist circumference, diet, alcohol use, exercise levels, and stress levels.

    Notes:

    1. the eligible population will be males ages 40-49, women between 50-59;
    2. a chart record is required that includes the minimum parameters above and evidence of an appropriate response to major high risk findings, including interventions, prescriptions, referrals to appropriate health care professional and/or linkages with community supports;
    3. interventions should be aligned with the current guidelines published by the Guideline and Protocol Advisory Committee (GPAC); eg. Diabetes, hypertension, lipids;
    4. payable for a maximum of 30 patients per physician per calendar year;
    5. Payable in addition to office visit fee(s) billed same day
    6. Payable once per calendar year per patient.

    This assessment is intended to assure that major guideline-recommended measurements are made for appropriate age groups; a specific % 10 yr. M.I. risk assessment is optional. Coronary Heart Disease Risk Scoring sheets for men and women are included below for physician use if they wish. The essence of the activity is that the family physician discusses with the patient the major risk factors and their presence or absence.

    Eligibility

    • Payable only to the General Practitioner or practice group that accepts the role of being Most Responsible for the longitudinal, coordinated care of the patient for that calendar year;
    • Not payable to physicians who have been paid for any specialty consultation fee in the previous 12 months;
    • 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;
    • Not payable to physicians working under salary, service contract or sessional arrangements and whose duties would otherwise include provision of this care.

    Rationale
    Person/Population Focus

    Over one million people in British Columbia currently live with one to three chronic diseases. Almost half of the population is at risk for and/or has been tested for a chronic disease. A key response to the demographic and disease trends towards an increasingly older population with more chronic diseases is to invest in strategies that will prevent or delay the onset of chronic diseases. There is growing evidence that this is possible.

    According to the World Health Organization, 80% of the cases of some chronic diseases such as Type 2 diabetes can be prevented. Research has found that moderate exercise and diet control among overweight people with pre-diabetes (impaired glucose tolerance) reduces the likelihood of developing diabetes by more than 50%. Many chronic diseases such as diabetes and cardiovascular disease have similar risk factors. Addressing these common risk factors, reducing tobacco and alcohol use, eating healthily and being active underlies the logic for the cross-government ActNow imitative.

    However, despite the evidence, for many people understanding and making healthy choices remain elusive. People are faced with life-time habits, lack of resources or family/social supports, or life’s pressures that make "adding something else" impossible. Personal change needs the same support as professional change i.e.:

    • to receive and understand personal data to show the outcome of remaining with the status quo;
    • to learn evidence-based approaches that have worked for many other people
    • to put those approaches into action with others (buddy, group, family)
    • to measure results and be accountable for these results to others

    Physician Focus

    Family physicians want to provide their patients with preventative care. The role of the family physician in prevention is twofold: (a) very influential health professional and (b) facilitator. Most physicians can already identify these patients in their practices. The family physician can use a variety of tools to assess risk of chronic diseases – and share these data with the patient. The focus of this initiative is to more formally introduce the process of cardiovascular risk assessment and follow up to family practice.

    Principles For the Prevention Payment

    • Focus on the patients at greater risk for the onset of chronic disease
    • Achieve equity of access to improved health status for patients. Horizontal equity refers to similar public funding for patients with similar needs. Vertical equity refers to more support given for patients with greater need;
    • Reward the intervention and knowledge of the family physician with direct facilitation and/or referral to information and community-based services
    • Retain and encourage family physicians already providing preventative care and encourage general practitioners currently targeting patients who have relatively straight forward clinical needs to take on their greater share of at risk patients.
    • The 2007 GPSC approach to prevention is experimental. It is understood that not all higher risk patients will be identified through this initiative. GPSC will work closely with Family Physicians to determine the effectiveness of this incentive from the perspectives of patient, provider, and system, and retains the right and authority to modify this incentive based on results. It is anticipated that future initiatives in preventative care will evolve through ongoing input from Family Physicians
    CORONARY HEART DISEASE RISK SCORING SHEET FOR MEN
    Step Factor Result Points
    1 Age    
    2 Total Cholesterol    
    3 HDL Cholesterol    
    4 Blood Pressure    
    5 Diabetes (Y or N)    
    6 Cigarette Smoker (Y or N)    
    7 1 - 6 Point Total    
    8 Estimated 10 Year CHD Risk    
    9 Low 10 Year CHD Risk    
    10 Relative Risk (Step 8 divided by step 9)    

    Step 3 - HDL Cholesterol

    Mmol/l Points
    < 0.90 2
    0.91 - 1.16 1
    1.17 - 1.29 0
    1.30 - 1.55 0
    > 1.56 -2

    Step 5 - Diabetes

    No 0 Points
    Yes 2 Points

    Step 6 - Smoker

    No 0 Points
    Yes 2 Points

    Step 8 CHD Risk from Total Points Table

    Total Points 10 Yr CHD Risk
    < -1 2%
    0 3%
    1 3%
    2 4%
    3 5%
    4 7%
    5 8%
    6 10%
    7 13%
    8 16%
    9 20%
    10 25%
    11 31%
    12 37%
    13 45%
    > 14 > 53%
     

    Color Key

    Color Risk
    Green Very Low
    White Low
    Yellow Moderate
    Rose High
    Red Very High

    Step 1 - Age

    Years Points
    30 - 34 -1
    35 - 39 0
    40 - 44 1
    45 - 40 2
    50 - 54 3
    55 - 59 4
    60 - 64 5
    65 - 69 6
    70 - 74 7

    Step 2 - Total Cholesterol

    Mmol/l Points
    < 4.14 -3
    4.15 - 5.17 0
    5.18 - 6.21 1
    6.22 - 7.24 2
    > 7.25 3

    Step 4 - Blood Pressure

    Systolic Diastolic
    mmHg < 80 80-84 85-89 90-99 > 99
    < 120 - 0 pts
    120-129 0 pts
    130-139 0 pts
    140-159 2 pts
    > 160 3 pts

    Step 9 Comparisons to Men of Same Age

    Years Ave. 10 yr Risk Low 10 yr Risk
    30 - 34 3% 2%
    35 - 39 5% 3%
    40 - 44 7% 4%
    45 - 49 11% 4%
    50 - 54 14% 6%
    55 - 59 16% 7%
    60 - 64 21% 9%
    65 - 69 25% 11%
    70 - 74 30% 14%

    Step 10 Relative 10 Year Risk

    Divide value of Step 8 by value of Step 9 to determine relative risk (eg. 4.0 calculation = 4 times average risk)

    CORONARY HEART DISEASE RISK SCORING SHEET FOR WOMEN
    Step Factor Result Points
    1 Age    
    2 Total Cholesterol    
    3 HDL Cholesterol    
    4 Blood Pressure    
    5 Diabetes (Y or N)    
    6 Cigarette Smoker (Y or N)    
    7 1 - 6 Point Total    
    8 Estimated 10 Year CHD Risk    
    9 Low 10 Year CHD Risk    
    10 Relative Risk (Step 8 divided by step 9)    

    Step 3 - HDL Cholesterol

    Mmol/l Points
    < 0.90 5
    0.91 - 1.16 2
    1.17 - 1.29 1
    1.30 - 1.55 0
    > 1.56 -3

    Step 5 - Diabetes

    No 0 Points
    Yes 4 Points

    Step 6 - Smoker

    No 0 Points
    Yes 2 Points

    Step 8 CHD Risk from Total Points Table

    Total Points 10 Yr CHD Risk
    < -2 1%
    -1 2%
    0 2%
    1 2%
    2 3%
    3 3%
    4 4%
    5 4%
    6 5%
    7 6%
    8 7%
    9 8%
    10 10%
    11 11%
    12 13%
    13 15%
    14 18%
    15 20%
    16 24%
    > 17 > 27%
     

    Color Key

    Color Risk
    Green Very Low
    White Low
    Yellow Moderate
    Rose High
    Red Very High

    Step 1 - Age

    Years Points
    30 - 34 -9
    35 - 39 -4
    40 - 44 0
    45 - 49 3
    50 - 54 6
    55 - 59 7
    60 - 64 8
    65 - 69 8
    70 - 74 8

    Step 2 - Total Cholesterol

    Mmol/l Points
    < 4.14 -2
    4.15 - 5.17 0
    5.18 - 6.21 1
    6.22 - 7.24 1
    > 7.25 3

    Step 4 - Blood Pressure

    Systolic Diastolic
    mmHg < 80 80-84 85-89 90-99 > 99
    < 120 - 3 pts
    120-129 0 pts
    130-139 0 pts
    140-159 2 pts
    > 160 3 pts

    Step 9 Comparisons to Women of Same Age

    Years Ave. 10 yr Risk Low 10 yr Risk
    30 - 34 < 1% < 1%
    35 - 39 1% < 1%
    40 - 44 2% 2%
    45 - 49 5% 3%
    50 - 54 8% 5%
    55 - 59 12% 7%
    60 - 64 12% 8%
    65 - 69 13% 8%
    70 - 74 14% 8%

    Step 10 Relative 10 Year Risk

    Divide value of Step 8 by value of Step 9 to determine relative risk (eg. 4.0 calculation = 4 times average risk

    Frequently Asked Questions

    1. Why is the prevention fee limited to cardiovascular risk assessment, rather than allowing a broader range of choices?

      The funding for prevention is only 5% of the new funds allocated to GP Services in the 2006 Letter of Agreement. The GP Services Committee is also charged under the 2006 agreement with evaluating and reporting on the outcomes of any initiatives it introduces. The committee therefore felt that it would be more likely to see a measurable difference with a more focused initiative at this time.

    2. Why is the age range restricted to men ages 40-49 and women ages 50-59?

      This initiative is focused on evidence-based interventions. Performing a cardiovascular risk assessment in patients at either end of the age scales has not been shown to be as effective at preventing cardiovascular illness as the age ranges specified.

    3. Am I able to do the Cardiovascular Risk Assessment on any person in those age ranges?

      Yes. At the same time it is also hoped that GPs will use discretion in using this initiative just as they use discretion in using other fees, and will focus on their patients who are at higher risk.

    4. Am I eligible to bill for an office visit, procedure, or conference fee on the same day?

      Yes.

    5. Why is it payable for only 30 patients per year?

      This decision was made for financial reasons. First, the prevention budget as noted above is limited. Second, as this is a trial entry into the field of prevention initiatives, the GP Services Committee decided to take a more limited 'first step' in order to see what the outcomes of this initiative would be.

      A GP is always permitted to do a cardiovascular risk assessment on more than 30 patients per year, but our budget limits the payment to only 30. It is conceivable, too, that the time and effort needed to perform this risk assessment and subsequent patient counselling will become easier and less time-consuming as it is done more often.

    6. Why is this fee payable only to the "General Practitioner or practice group that accepts the role of being Most Responsible for the longitudinal coordinated care of the patient for that calendar year"?

      The mandate of the GP Services Committee is to support and enhance Full Service Family Practice, and this style of practice routinely accepts responsibility for longitudinal, coordinated care of a patient. Also, just as important as the risk assessment is what is done with that evaluation over the course of time, and that full value is derived from having an ongoing relationship with the patient over time.

    7. Am I able to bill this on the same patient every year or is there a recommended frequency?

      In high risk patients a review every year are appropriate and so this may be billed on the same patient every year. If in your clinical judgement, risk assessments every two years would be appropriate, this would free up additional Cardiovascular Risk Assessment fees in alternate years.

    8. If I find a patient at higher risk is willing to make changes, is there any information on where I can refer them for further support?

      Patients may be referred to a number of support groups and programs that are available. Programs such as Healthy Hearts, Canadian Lung Association, Canadian Heart and Stroke Foundation, etc. have patient support materials available.

    9. Why does this initiative exclude "physicians who are employed by or who are under contract to a facility and whose duties would otherwise include provision of this care"?

      This incentive has been designed to remove the disincentive that exists, under current fee for service payments, to provide more time-consuming complex care to a patient in lieu of seeing more patients of a simpler clinical condition. The physician’s time is considered to be already compensated if he/she is under a contract "whose duties would otherwise include provision of this care", or is being compensated by a salary, service, or sessional arrangement.

    10. Is there any plan to expand this in the future to other conditions?

      While this area of prevention care is a first step, expansion into other areas has been discussed at GPSC and will be revisited in the future depending on the feedback and assessment of this initiative.

    COMMUNITY BASED MENTAL HEALTH INITIATIVE

    Family physicians will identify their high-risk patients living in the community (i.e. home or assisted living) who meet the following criteria:

    1. Axis I diagnosis confirmed by DSM IV criteria;
    2. Severity and Acuity level causing sufficient interference in activities of daily living that developing a management plan would be appropriate

    Additional factors that increase risk include drug or alcohol addiction, cognitive impairment, poor nutritional status, and socioeconomic factors such as homelessness. Given these factors, the approach to be encouraged is to manage the whole patient, not the disease.

    The physician – or practice – will need to accept the role of being Most Responsible for the longitudinal, co-ordinated care of that patient for that calendar year

    The Mental Health Planning Fee and resulting access to an increased number of billable GP management/counselling fees is intended to recognize the significant investment in time and skill such clients/patients require in General Practice. These Fee items are intended to acknowledge the vital role of the GP in supporting patients with mental illness and addictions to remain safely in their home community. Once the Mental Health Plan is developed, GPs are encouraged to collaborate with community mental health resources, in providing longitudinal mental health support for these patients across the spectrum of care needs. This networking is complementary to and eligible for the Community Patient Conferencing Fee (G14016) if all other requirements are met.

    The initial GP/FP service providing 'Portal' access to the mental health care management fees shall be the development of a Mental Health Care Plan for a patient with significant mental health conditions residing in their home or assisted living (excluding care facilities).

    This fee requires the GP to conduct a comprehensive review of the patient's chart/history, assessment of the patient's current psychosocial symptoms/issues by means of psychiatric history, mental status examination, and use of appropriate validated assessment tools, with confirmation of diagnosis through DSM IV diagnostic criteria. It requires a face-to-face visit with the patient, with or without the patient's medical representative.

    From these activities (review, assessment, planning and documentation) a Mental Health Care Plan for that patient will be developed that documents in the patient's chart:

    • that there has been a detailed review of the patient's chart/history and current therapies;
    • the patient's mental health status and provisional diagnosis by means of psychiatric history and mental state examination;
    • the use of and results of validated assessment tools. GPSC strongly recommends that these evaluative tools, as clinically indicated, be kept in the patient's chart for immediate accessibility for subsequent review. Assessment tools such as the following are recommended, but other assessment tools that allow risk monitoring and progress of treatment are acceptable:
      1. PHQ9, Beck Inventory, Ham-D for depression;
      2. MMSE for cognitive impairment;
      3. MDQ for bipolar illness;
      4. GAD-7 for anxiety;
      5. Suicide Risk Assessment;
      6. Audit (Alcohol Use Disorders Identification Test) for Alcohol Misuse;
    • DSM-IV Axis I confirmatory diagnostic criteria;
    • a summary of the condition and a specific plan for that patient's care;
    • an outline of expected outcomes;
    • outlined linkages with other health care professionals (Including Community Mental Health Resources and Psychiatrists, as indicated and/or available) who will be involved in the patient's care, and their expected roles;
    • an appropriate time frame for re-evaluation of the Mental Health Plan;
    • that the developed plan has been communicated verbally or in writing to the patient and/or the patient's medical representative, and to other health professionals as indicated.

    Once the Mental Health Plan has been created, the General Practitioner or practice group can access two additional supports:

    1. GP Mental Health Management Fees, an additional four (4) visit fees equivalent to the current age differential 00120 series. These fees are billable after the current 4 Counselling Visit per year (00120 fees per MSP Payment Schedule) have been billed.
    2. GP Mental Health Telephone/Email Management Fees; access to telephone/email follow-up fees to allow flexibility in providing non-face-to-face management/follow-up for these patients. These telephone/email follow-up services may be provided by the physician or other medical professionals that are directly under the family physician or practice group's supervision (e.g. MOA or Office nurse). The telephone follow up care fee is to be used for providing clinical management such as medication, symptom, and clinical status monitoring. It is not for simple appointment reminder or referral notification. The telephone management fee may be billed up to a maximum of 5 times per calendar year, for either physician-initiated or patient-initiated follow up.

    The Mental Health Telephone/Email Management Fee may be billed on the same day as the community patient conferencing fee (14016) provided all other criteria are met, but the time spent with the patient on the telephone does not count toward the time requirement of the conferencing fee.

    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 patients resident in the community (home or assisted living, excluding care facilities) with a confirmed Axis I diagnosis of sufficient severity and acuity to cause interference in activities of daily living and warrant the development of a management plan.

    This fee requires the GP to conduct a comprehensive review of the patient's chart/history, assessment of the patient's current psychosocial symptoms/issues by means of psychiatric history, mental status examination, and use of appropriate validated assessment tools, with confirmation of diagnosis through DSM IV diagnostic criteria. It requires a face-to-face visit with the patient, with or without the patient's medical representative.

    From these activities (review, assessment, planning and documentation) a Mental Health Plan for that patient will be developed that documents in the patient's chart:

    • that there has been a detailed review of the patient's chart/history and current therapies;
    • the patient's mental health status and provisional diagnosis by means of psychiatric history and mental state examination;
    • the use of and results of validated assessment tools. GPSC strongly recommends that these evaluative tools, as clinically indicated, be kept in the patient's chart for immediate accessibility for subsequent review. Assessment tools such as the following are recommended, but other assessment tools that allow risk monitoring and progress of treatment are acceptable:
      1. PHQ9, Beck Inventory, Ham-D for depression;
      2. MMSE for cognitive impairment;
      3. MDQ for bipolar illness;
      4. GAD-7 for anxiety;
      5. Suicide Risk Assessment;
      6. Audit (Alcohol Use Disorders Identification Test) for Alcohol Misuse;
    • DSM-IV Axis I confirmatory diagnostic criteria;
    • a summary of the condition and a specific plan for that patient's care;
    • an outline of expected outcomes;
    • outlined linkages with other health care professionals (Including Community Mental Health Resources and Psychiatrists, as indicated and/or available) who will be involved in the patient's care, and their expected roles;
    • an appropriate time frame for re-evaluation of the Mental Health Plan;
    • that the developed plan has been communicated verbally or in writing to the patient and/or the patient's Medical Representative, and to other health professionals as indicated.

    Notes:

    1. Requires documentation of the patient's mental health status and diagnosis by means of psychiatric history, mental state examination, and confirmatory DSM IV diagnostic criteria. Confirmation of Axis 1 Diagnosis is required for patients eligible for the GP Mental Health Planning Fee. Not intended for patients with self limiting or transient mental health symptoms (e.g. Brief situational adjustment reaction, normal grief, life transitions) for whom a plan for longer term mental health care is not necessary.
    2. Payable once per calendar year per patient;
    3. Payable in addition to a visit fee billed same day;
    4. Minimum required time 30 minutes in addition to visit time same day;
    5. G14016, community conferencing fee payable on same day for same patient, if all criteria met;
    6. Not payable on the same day as G14045, G14046, G14047, G14048 (GP Mental Health Management Fees);
    7. Not payable on the same day as G14049 (GP Mental Health Telephone/Email Management Fee)
    8. Not intended as a routine annual fee if the patient does not require ongoing Mental Health Plan review and revision;
    9. G14015, Facility Patient Conferencing Fee, not payable on same day for same patient as facility patients are not eligible.

    G14045-GP Mental Health Management Fee age 2–59 = $50.31

    G14046-GP Mental Health Management Fee age 60–69 = $57.86

    G14047-GP Mental Health Management Fee age 70–79 = $62.89

    G14048-GP Mental Health Management Fee age 80+ = $65.41

    These fees are payable for GP Mental Health Management required beyond the four (4) MSP counselling fees (age-appropriate 00120 fees billable under the MSP Payment Schedule) for patients with a chronic mental health condition on whom a Mental Health Plan has been created and billed.

    Notes:

    1. Payable a maximum of 4 times per calendar year per patient;
    2. Payable only if the Mental Health Planning Fee (G14043) has been previously billed and paid in the same calendar year by the same physician;
    3. Payable only to the physician paid for the GP Mental Health Planning Fee (G14043), unless that physician has agreed to share care with another delegated physician;
    4. Not payable unless the age-appropriate 00120 series has been fully utilized;
    5. Minimum time required is 20 minutes;
    6. Not payable on same day as G14043 (GP Mental Health Planning Fee), or G14049 (GP Mental Health Telephone/Email Management Fee);
    7. G14016 (Community Patient Conferencing Fee) payable on same day for same patient if all criteria met;
    8. G14015 (Facility Patient Conferencing Fee) not payable on same day as facility patients not eligible;
    9. CDM fees (G14050, G14051, G14052) payable if all criteria met.

    Eligibility

    • Eligible patients must be community based, (living in their home or assisted living). Facility based patients are not eligible.
    • Payable only to the General Practitioner or practice group that accepts the role of being Most Responsible for the longitudinal, coordinated care of the patient for that calendar year;
    • Not payable to physicians who have been paid for any specialty consultation fee in the previous 12 months;
    • Not payable to physicians who are employed by or who are under contract whose duties would otherwise include provision of this care;
    • Not payable to physicians working under salary, service contract or sessional arrangements and whose duties would otherwise include provision of this care.

    G14049 – GP Mental Health Telephone/Email Management Fee = $15.00

    This fee is payable for 2-way communication with eligible patients 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). This fee is not to be billed for simple appointment reminders or referral notification.

    Notes:

    1. Payable to a maximum of 5 times per calendar year per patient;
    2. Not payable unless the GP/FP is eligible for and has paid for the GP Mental Health Planning Fee (G14043) during the same calendar year;
    3. Telephone/Email Management requires 2-way communication between the patient and physician or medical office staff on a clinical level; it is not payable for simple notification of office appointments;
    4. Payable only to the physician paid for the GP Mental Health Planning Fee (G14043) unless that physician has agreed to share care with another delegated physician;
    5. G14016, Community Patient Conferencing Fee, payable on same day for same patient if all criteria met. Time spent on telephone under this fee with patient does not count toward the time requirement for the G14016;
    6. Not payable on the same calendar day as a visit or service fee by same physician for same patient with the exception of G14016;
    7. Chart entry must record the name of the person who communicated with the patient or patient's medical representative, as well as capture the elements of care discussed;

    Eligibility

    • Eligible patients are community based, living in their home or assisted living. Facility based patients are not eligible.
    • Payable only to the General Practitioner or practice group that accepts the role of being Most Responsible for the longitudinal, coordinated care of the patient for that calendar year;
    • Not payable to physicians who have been paid for any specialty consultation fee in the previous 12 months;
    • Not payable to physicians who are employed by or who are under contract whose duties would otherwise include provision of this care;
    • Not payable to physicians working under salary, service contract or sessional arrangements and whose duties would otherwise include provision of this care.

    Mental Health Frequently Asked Questions

    1. What is the purpose of the Mental Health Initiative Fees?

      Family Physicians provide the majority of mental care in BC.  This is time consuming and is often not adequately compensated, so the Mental Health fees have been created to provide compensation for the provision of this care.  Additionally, there is known benefit from having a longer planning visit with patients suffering from chronic mental health conditions and this initiative was developed to remove the financial barrier to providing this care, as opposed to seeing a greater number of patients with simpler clinical conditions.

      This initiative is designed to focus on those patients with greater need and those that require more time of the community General Practitioner (GP), so the eligible patient population is restricted to patients living in the community (their own homes or assisted living) 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 would be appropriate.
    2. What is a Mental Health Plan?

      The initial service allowing access to the mental health care fees shall be the development of a Mental Health Plan for a patient residing in his/her home or assisted living (excludes care facilities) with a diagnosed DSM IV Axis I mental health condition.  This plan should be reviewed and revised as clinically indicated. 

      Creation of a Mental Health Plan requires the GP to conduct a comprehensive review of the patient’s chart/history, assessment of the patient’s current psychosocial symptoms/issues by means of psychiatric history, mental status examination, and use of appropriate validated assessment tools, with confirmation of diagnosis through DSM IV diagnostic criteria.  It requires a face-to-face visit with the patient, with or without the patient’s medical representative.   

      From these activities (review, assessment, planning and documentation) a Mental Health Plan for that patient will be developed that documents in the patient’s chart:

      • that there has been a detailed review of the patient’s chart/history and current therapies;
      • the patient’s mental health status and provisional diagnosis by means of psychiatric history and mental state examination;
      • the use of and results of validated assessment tools. GP Services Committee strongly recommends that these evaluative tools, as clinically indicated, be kept in the patient’s chart for immediate accessibility for subsequent review.  Assessment tools such as the following are recommended, but other assessment tools that allow risk monitoring and progress of treatment are acceptable:

        i) PHQ9, Beck Inventory, Ham-D for depression;
        ii)  MMSE for cognitive impairment;
        iii)  MDQ for bipolar illness;
        iv)  GAD-7 for anxiety;
        v)  Suicide Risk Assessment;
        v)  Audit (Alcohol Use Disorders Identification Test) for Alcohol Misuse;

      • DSM-IV Axis I confirmatory diagnostic criteria;
      • a summary of the condition and a specific plan for that patient’s care;
      • an outline of expected outcomes;
      • outlined linkages with other health care professionals (Including Community Mental Health Resources and Psychiatrists, as indicated and/or available) who will be involved in the patient’s care, and their expected roles;
      • an appropriate time frame for re-evaluation of the Mental Health Plan;
      • that the developed plan has been communicated verbally or in writing to the patient and/or the patient’s Medical Representative, and to other health professionals as indicated.
    3. How do I bill the Mental Health Fees?

      The first service must be the creation of a Mental Health Plan as described in Question 2 above.  This acts as a “portal” to access the other Mental Health Management Fees.  The GP Mental Health Planning Fee (G14043) may be billed once per calendar year per patient upon:

      i)  confirming that the patient is living in his/her own home or in assisted living;
      ii) confirming through DSM IV criteria that the patient has an Axis I disorder;
      iii) determining that the severity and acuity level of this Axis I disorder is causing sufficient interference in activities of daily living that developing a management plan to maintain the patient safely in the community would be appropriate, and
      iv) creating a Mental Health Plan for that patient that includes all of the elements outlined in fee G14043 (See Question 2 above).

      Note:

      • A visit fee code MAY accompany the billing for the GP Mental Health Planning Fee (G14043), but this is not a requirement. The first 30 minutes of time is the requirement of the GP Mental Health Planning Fee (G14043); additional time past the first 30 minutes counts towards the visit fee that may be billed in addition to G14043;
      • this visit may be a standard office or out-of-office visit, a CPx, home visit, or a Prolonged Counselling visit as appropriate;
      • Fee item G14043 MUST be dated the same date as the patient visit in which the Mental Health Plan was discussed/confirmed;
      • It is strongly recommended that your chart entry include the time spent in preparing the Mental Health Plan and, if a visit is also billed, the amount of time spent with the patient in addition to the minimum 30 minutes required to bill G14043;
      • Time spent on preparation of the Mental Health plan does not count towards the time requirement for a Prolonged Counselling visit.
    4. Must I spend a single block of at least 30 minutes with the patient to bill the Mental Health Planning Fee (G14043)?

      Unlike the Complex Care Fee, the Mental Health Planning Fee does require a minimum block of 30 consecutive minutes in face-to-face interaction with the patient.  Provision of quality mental health care through assessment, development of a plan, and discussion with the patient and/or patient’s medical representative does require more face-to-face time than a regular office visit.  

      A block of 30 minutes in face-to-face contact with the patient is therefore required to bill the GP Mental Health Planning Fee G14043.  Time spent in addition to 30 minutes counts towards the visit fee that may be billed on the same day.  It is strongly recommended that your chart entry include the time spent in preparing the Mental Health Plan and, if a visit is also billed, the amount of time spent with the patient in addition to the minimum 30 minutes required to bill G14043;

    5. May I bill the Mental Health Planning Fee (G14043) on every patient I have with a qualifying diagnosis?

      The fee requires both:

      1. a qualifying Axis I diagnosis, and
      2. that this diagnosis has “a Severity and Acuity level causing sufficient interference in activities of daily living that developing a management plan would be appropriate.” 

      Many patients with an Axis I diagnosis are stable, or of a lower severity/acuity level so that extra time is not required to provide their care.  It would not be appropriate to bill for these patients.  The Mental Health Management Fee (G14043) is designed to remove the disincentive to providing the time to those qualifying patients who truly need it.  

      While it may be billed once in a calendar year, it is not intended to be an annual fee, as not all patients require a mental health plan each year; many people with depression remain stable or in remission for years. The need for a mental health plan would depend upon the acuity of the patient’s condition. 

      Whether the patient needs an annual plan or not is left to your professional judgement and to trust.  If the annual Mental Health Management Fee is billed for all Axis I patients, the GP Services Committee will have fewer funds to allocate for other areas requiring support.

    6. When can I bill the Mental Health Management Fees (G14045-G14048)?

      The MSP counselling fees (the 00120 series) are limited to 4 visits per patient per calendar year.  Managing patients with a significant mental health diagnosis, however, may require more than 4 counselling visits per year.  The GPSC Mental Health Management fees provide an additional 4 counselling visits per calendar year to provide counselling to these patients.  They are payable only after all 4 MSP counselling fees of the 00120 series have been utilized and only if the GP has billed and been paid for the Mental Health Care Planning Fee.  They are payable to a maximum of 4 times per calendar year, at the same rate as the age-appropriate 00120 series counselling fee.

      Notes:

      1. This fee is payable only if the GP or practice has billed and been paid for the Mental Health Planning Fee (G14043). (A note record is required if billed by another physician sharing care with the MRGP – see # 8 and #15 below.)
      2. These fees are payable only after the standard MSP 00120 series has been fully utilized;
      3. Payable to a maximum 4 times per year per patient.
    7. When can I bill the Mental Health Telephone/Email Management Fee?

      There is evidence that the follow-up of patients with significant mental illness does not always need to be face-to-face or by the physician.  This new fee is payable for 2-way clinical interaction provided between the GP or delegated practice staff (e.g. office RN or MOA) in follow-up on the Mental Health Planning Fee (G14043). 

      Notes:

      1. Not payable unless the GP/FP is eligible for and has paid for the GP Mental Health Planning Fee (G14043) during the same calendar year;
      2. Telephone/Email Management requires 2-way communication between the patient and physician or medical office staff on a clinical level; it is not payable for simple notification of office appointments;
      3. Payable only to the physician paid for the GP Mental Health Planning Fee (G14043) unless that physician has agreed to share care with another delegated physician;
      4. Payable to a maximum of 5 times per calendar year per patient;
      5. G14016, Community Patient Conferencing Fee, payable on same day for same patient if all criteria met.  Time spent on telephone under this fee with patient does not count toward the time requirement for the G14016;
      6. Not payable on the same calendar day as a visit or service fee by same physician for same patient with the exception of G14016;
      7. Chart entry must record the name of the person who communicated with the patient or patient’s medical representative, as well as capture the elements of care discussed;
    8. How would our group practice arrange to be able to ‘share’ these Mental Health Management Fees?

      To make these fees as flexible as possible in the variety of practice styles found in the province, GPSC decided that no specific steps should need to be taken. We will become involved only if a GP who has billed and been paid for the ‘portal’ fee - the GP Mental Health Planning Fee (G14043) – lodges a complaint with GPSC. In that case, we will adjudicate based upon which GP has been paid for fee item G14043.

    9. What is the difference between “assisted living” and “care facilities”?

      There are a wide range of living facilities currently available.  Some, referred to under the terms of this initiative as ‘assisted living’ facilities, provide only basic supports, such as meals and housecleaning, and are unable to provide their residents with nursing and other health support. A “care facility” on the other hand, is defined under the terms of this initiative as being a facility that does provide supervision and support from other health professionals such as nurses.

    10. Why is this incentive limited to patients living in their homes or in assisted living?

      While there may be exceptions, patients resident in a facility such as a Psychiatric Long Term Care Facility or hospital usually have available a resident team of other health care providers to share in the organization and provision of care. Patients residing in their homes or in assisted living usually do not have such a team, and the organization and supervision of care is usually more complex and time consuming for the GP.

    11. Why are there restrictions excluding physicians “who are employed by or who are under contract to a facility and whose duties would otherwise include provision of this care” or to “physicians working under salary, service, or sessional arrangements?”

      This incentive has been designed to remove the disincentive that exists under current fee for service payments to provide more time-consuming complex care to a patient, instead of choosing to see a greater number of patients of a simpler clinical nature.  The physician’s time is considered to be already compensated if he/she is under a contract “whose duties would otherwise include provision of this care”, or is being compensated by a salary, service, or sessional arrangement.

    12. Am I eligible to bill for the Community Patient Conferencing Fee (G14016) in addition to receiving the Mental Health Care payment(s)?

      Yes.  The mental health care payment(s) relates to services provided to the patient.  The new “Mental Health Management Fees” (G14045-G14048) for non-face-to-face care still relates to the services provided to the patient.  If it is appropriate for some of this care to be provided by phone, then the physician is compensated for this.  If as a result of the Mental Health Planning visit (G14043), follow up Mental Health Management visit (G14045-G14048) or as a result of the Mental Health Telephone/Email Management (G14049), the physician needs to conference with allied health professions about the care plan and any changes, then the services provided in conferencing with other health care professionals is payable over and above the mental health care payments.  It is payable on the same day as long as all criteria are met.  The time spent on the phone with the patient for the Mental Health Telephone/Email Management (G14049) does not count toward the total time billed under the Community Patient Conferencing Fee (G14016).

    13. Am I eligible to bill for the Chronic Disease Management Fee(s) (G14050/G14051/G14052) in addition to these Mental Health Initiative fees?

      Yes, patients with mental health diagnoses still often have co-existing medical conditions.  For those patients with Diabetes and/or Congestive Heart Failure, the CDM payment(s) G14050/G14051 are payable in addition to the Mental Health Care payment(s).  Additionally, if the patient does not have Diabetes and or CHF, but does have hypertension, the CDM payment for this (G14052) is payable in addition to the Mental Health Initiative payment(s).  These are payable on the same day as long as all criteria are met.

    14. Why is the Mental Health Telephone/Email Management Fee (G14049) restricted to the GP that has been paid for the Mental Health Planning Fee (G14043)?

      This fee is designed to allow greater flexibility in providing follow-up to a plan that has been created.  The GP that has been paid for the Mental Health Planning Fee has also accepted the responsibility of being Most Responsible for that patient’s care for mental health diagnoses for that calendar year.  The Mental Health Plan requires work, the shouldering of responsibility, and has considerable value.  This fee is therefore restricted to the GP that has created the mental health plan.

    15. If the GP Mental Health Management fees (G14045-G14048) and the GP Mental Health Telephone/Email Management fees (G14049) are restricted to the GP who has been paid for the Mental Health Planning Fee (G14043), what do group practices do when they share the care of the patient?

      An exception has been made, allowing another GP to bill for this fee with the approval of the Most Responsible GP (MRGP).  This allows flexibility in situations when patient care is shared between GPs.  In this circumstance, the alternate GP must submit the claim with a note record indicating he/she is in the group of the MRGP and is sharing the care of the patient. 

      If a disagreement arises about the billing of this service, GP Services will adjudicate based upon whether the Most Responsible GP, i.e. the GP paid for the Annual Complex Care Fee, approved or did not approve the service provided.  GP Services feels that this provides the maximum flexibility while still maintaining responsibility.

    16. Can I access the Mental Health Management fees if I have billed for the Mental Health Planning fee but have not yet been paid for it?

      Adjudication of any billings for Mental Health Management fees will depend upon whether the GP is eventually paid for the Mental Health Care Planning Fee.  In other words, if a GP bills for the Mental Health Planning Fee (G14043) and provides—and bills for— a follow-up Management service under G14045, G14046, G14047, G14048, or G14049 prior to receiving payment for G14043, payment for those follow-up Management billings will be made only if G14043 is subsequently paid to that GP.  Until that time any follow-up services will show as “BH” on the remittance.

    GPSC Palliative Care Planning and Management Fees

    The Palliative Care Incentive is a new payment initiative that is intended to compliment the existing conferencing component of end-of-life care when sharing care with other health care professionals. To date, the GPSC has developed the community and facility patient conferencing fees which appropriately compensate the family physician for their role in conferencing with other team members in supporting the care needs for these patients.

    Preparation and advance care planning are a critical first step once it has been determined that a patient’s condition is terminal. With the GPSC Palliative Care Incentive payment, family physicians will be encouraged to take the time needed to work through the various decisions and plans that need to be determined to ensure the best possible quality of life for dying patients and their families. A new “Palliative Care Planning fee” will compensate the family physician for undertaking and documenting a care plan that will include the following components:

    • A statement of the patient's primary medical diagnosis;
    • A statement that the patient is medically palliative based on the physician's medical diagnosis AND the patient's agreement to no longer seek treatment aimed at cure;
    • A list of the potential health care needs and the plan for managing these needs. As an example this may include Home and Community Care support services such as home support, home nursing care, personal care, after-hours palliative care, respite and/or hospice care; access to palliative medications, and supplies and equipment through the Provincial Palliative Benefits Program;
    • A detailed, current plan for symptom management, including completing the application form and process to access the Palliative Benefits Program when appropriate;
    • A list of the clinical indicators on when referral/access to specialist palliative care services may be needed;
    • A copy of the patient's most current advance directive if available; and
    • Completion and retention of forms to support a planned natural home death when this is part of the patient goal (Notification of a Planned Home Death; No CPR form, etc.).
    • Physicians and patients are encouraged to ensure these documents will be available to the local emergency room in the event of patient attendance there.

    In addition, 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.

    G14063 Palliative Care planning fee ............................................ $100.00

    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, with life expectancy of up to 6 months, and who consent to the focus of care being palliative rather than treatment aimed at cure. 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. Facility-resident patients are not eligible for this initiative.

    This fee requires the GP to conduct a comprehensive review of the patient’s chart/history and assessment of the patient’s current diagnosis to determine if the patient has a life-limiting condition that has become palliative and/or remains palliative. It requires a face-to-face visit and assessment of the patient. If the patient is incapable of participating in the assessment to confirm and agree to their being palliative, then the patient’s alternate substitute decision maker or legal health representative must be consulted and asked to provide informed consent.

    Notes:

    1. Requires documentation of the patient’s medical diagnosis, determination that the patient has become palliative, and patient’s agreement to no longer seek treatment aimed at cure;
    2. Patient must be eligible for BC Palliative Care Benefits Program (not necessary to have applied for palliative care benefits program);
    3. Payable once per patient once patient deemed to be palliative. Under circumstances when the patient moves communities after the initial palliative care planning fee has been billed, it may be billed by the new GP who is assuming the ongoing palliative care for the patient;
    4. Payable in addition to a visit fee billed on the same day;
    5. Minimum required time 30 minutes in addition to visit time same day;
    6. G14016, community patient conferencing fee payable on same day for same patient if all criteria met;
    7. Not payable on same day as G14015, facility patient conferencing fee;
    8. Not payable on same day as G14017, acute care discharge planning;
    9. Not payable on the same day as G14069 (Palliative Care Telephone/E-mail management fee)
    10. G14050, G14051, G14052, G14053, G14033, G14034 not payable once Palliative Care Planning fee is billed as patient has moved from active management of chronic disease to palliative.
    11. G14043, G14044, G14045, G14046, G14047, G14048, G14049 the GPSC Mental Health Initiative Fees are payable once G14063 has been billed provided all requirements are met, but are not payable on same day.

    G14069 Palliative Care Telephone/E-mail follow up management fee ........................ $15.00

    This fee is payable for 2-way communication with eligible patients 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). This fee is not to be billed for simple appointment reminders or referral notification.

    Notes:

    1. Payable to a maximum of 5 times following successful billing of Palliative Care Planning fee G14063;
    2. Telephone/e-mail Management requires 2-way communication between the patient and physician or medical staff on a clinical level; it is not payable for simple notification of office appointments;
    3. Payable only to the physician paid for the Palliative Care Planning fee (G14063) unless that physician has agreed to share care with another delegated physician;
    4. Not payable on the same day as a visit fee;
    5. Not payable on the same day as G14063, Palliative care planning fee
    6. G14016, Community Patient Conferencing Fee, payable on same day for same patient if all criteria met. Time spent on telephone under this fee with patient does not count toward the time requirement of G14016;
    7. Not payable on same day as any of G14043, G14044, G14045, G14046, G14047, G14048 or G14049, GPSC Mental Health Initiative fees.
    8. Not payable on same day as G14015, Facility Patient Conferencing Fee;
    9. Not payable on same day as G14017, Acute Care Discharge Planning Conferencing Fee;
    10. Chart entry must record the name of the person who communicated with the patient or patient’s medical representative, as well as capture the elements of care discussed.

    Eligibility for G14063 and G14069

    • Eligible patients are community based (living in their home, with family or assisted living).
    • Payable only to the General Practitioner or practice group that accepts the role of being Most Responsible for longitudinal coordinated care of the patient for that calendar year;
    • Not payable to physicians who have been paid for any specialty consultation fee in the previous 12 months;
    • Not payable to physicians who are employed by a health authority or agency or who are under contract whose duties would otherwise include the provision of this care;
    • Not payable to physicians working under a salary, service contract or sessional arrangements and whose duties would otherwise include the provision of this care.

    Acute Care Discharge Conference Fee – Code 14017

    To support the continuity of care and transition from acute care back to the community or to a different facility (acute, supportive care or Long Term Care facility), the GPSC has developed an acute care discharge conferencing fee to appropriately compensate the community based GP to attend and participate in the discharge planning process for patients with complex supportive care needs. Effective June 1, this new fee will be billable in place of the facility patient conferencing fee (G14015) in addition to any visit fee provided they are performed consecutively. Any time spent on a medical visit with the patient does not count toward the discharge planning conferencing fee.

    G14017 General Practice Acute Care Discharge Conference fee

    This fee is billable when a Discharge Planning Conference is performed upon the request of either an Acute Care facility, or by the GP accepting MRP status upon discharge, regarding a patient with complex supportive care needs, for review of condition(s) and planning for safe transition to the community or to a different facility; another acute care facility, or a supportive care or long-term care facility.

    • per 15 minutes or greater portion thereof ........................................................ $40.00

    Eligible Patient Population (refer to Table 1 for details)

    • 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

    Eligible Physician Population

    In order to improve continuity of patient care upon discharge from an acute care facility, this incentive payment is available to all General Practitioners who:

    • Have a valid B.C. Medical Service Plan practitioner number (registered specialty 00) (practitioners who have billed any specialty fee in the previous 12 months are not eligible); and
    • Whose majority professional activity is in full service family practice as described in the introduction; and
    • Is considered the most responsible GP for that patient following discharge from the acute care facility

    Notes:

    1. Refer to Table 1 for eligible populations.
    2. Payable only for patients being discharged from an acute care facility to the community or to a different facility; another acute care facility, or a supportive care or Long Term Care facility.
    3. Must be performed in the acute care facility and results of the conference must be recorded in the patient’s chart in the acute care facility and the receiving GP’s office chart (or receiving facility’s chart in the case of inter-facility transfer) ;
    4. Face-to-face conferencing is required; the only exception is if a patient is being discharged from an acute care facility in a different community, and a chart notation must be made to indicate this circumstance.
    5. Requesting care providers limited to: Facility-affiliated physicians and nurses, GP assuming MRP status upon patient’s discharge, care coordinators, liaison nurses, rehab consultants, social workers, any healthcare provider charged with coordinating discharge and follow-up planning,
    6. Requires interdisciplinary team meeting of the GP assuming MRP status upon discharge and a minimum of 2 other health professionals as enumerated above, and will include family members when appropriate;
    7. Fee includes:
      1. Where appropriate, interviewing of and conferencing with patient, family members, and other health providers of both the acute care facility and community:
      2. Review and organization of appropriate clinical information;
      3. The integration of relevant information into the formulation of an action plan for the clinical care of the patient upon discharge from the acute care facility, including provision of Degrees of Intervention and end of life documentation as appropriate;
      4. The care plan must be recorded and must include patient identifiers, reason for the care plan, list of co-morbidities, safety risks, list of interventions, what referrals to be made, what follow-up has been arranged
    8. This fee does not cover routine discharge planning from an acute-care facility, nor is this fee payable for conferencing with acute-care nurses during the course of a patient’s stay in the acute care facility;
    9. Maximum payable per patient is 90 minutes per calendar year. Maximum payable on any one day is 60 minutes.
    10. Claim must state start and end times of the service.
    11. If multiple patients are discussed, the billings shall be for consecutive, non-overlapping time periods.
    12. Not payable to physicians who are employed by or who are under contract to a facility who would otherwise have attended the conference as a requirement of their employment or contract with the facility; or physicians working under salary, service contract or sessional arrangements.
    13. Medically required visits performed consecutive to the Acute Care Discharge Conference are payable.
    14. Submit the new fee item G14017 through the MSP Claims System under the patient's PHN. The claim must include ICD-9 codes V15, V58, or the code for one of the major disorders.
    15. Not billable on the same day as Facility Patient or Community Patient Conferencing Fees (G14015 or G14016)
    16. Not billable on the same day as any GPSC planning fees (G14033, G14043, G14063 (Palliative Planning Fee)).

    Questions or Comments?

    B.C. Ministry of Health
    Phone (250) 952-3124  Fax 1 800 952-2895

    B.C. Medical Association
    Phone (604) 736-5551 or 1 800 665-2262

    Society of General Practitioners of B.C.
    Phone (604) 638-2943



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