Pain Management Billing

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Pain Management Billing Family Physicians MSP Counseling (00120) – used where there are associated issues in addition to “uncomplicated” pain management Maximum 4 services per year per patient – not restricted to patient’s own FP Minimum 20 minutes, see preamble definition/requirements Group Medical Visits (13763 [3 pts] – 13781 [> 20 pts]) New sliding scale based on number of patients billed per patient Billed per ½ hour or greater portion to max of 3 units per patient Removes individual face-to-face “service” requirement Not included in HVLIP cap calculations Counselling Counselling is defined as the discussion with the patient, caregiver, spouse or relative about a medical condition which is recognized as difficult by the medical profession or over which the patient is having significant emotional distress, including the management of malignant disease. Counselling, to be claimed as such, must not be delegated and must last at least 20 minutes. Counselling is not to be claimed for advice that is a normal component of any visit or as a substitute for the usual patient examination fee, whether or not the visit is prolonged. For example, the counselling codes must not be used simply because the assessment and/or treatment may take 20 minutes or longer, such as in the case of multiple complaints. The counselling codes are also not intended for activities related to attempting to persuade a patient to alter diet or other lifestyle behavioural patterns. Nor are the counselling codes generally applicable to the explanation of the results of diagnostic tests. Start and end time must be entered in both the billing claims and patient’s chart. Not only must the condition be recognized as difficult by the medical profession, but the medical practitioner’s intervention must of necessity be over and above the advice which would normally be appropriate for that condition. For example, a medical practitioner may have to use considerable professional skill counselling a patient (or a patient’s parent) who has been newly diagnosed as having juvenile diabetes, in order for the family to understand, accept and cope with the implications and emotional problems of this disease and its treatment. In contrast, if simple education alone including group educational sessions (e.g.: asthma, cardiac rehabilitation and diabetic education) is required, such service could not appropriately be claimed under the counselling listings even though the duration of the service was 20 minutes or longer. It would be appropriate to apply for sessional payments for group educational sessions. Unless the patient is having significant difficulty coping, the counselling listings normally would not be applicable to subsequent visits in the treatment of this disease. GENERAL PRACTICE GROUP MEDICAL VISIT A Group Medical Visit provides 1:1 patient care in a group setting. Group Medical Visits are an effective way of leveraging existing resources; simultaneously improving quality of care and health outcomes, increasing patient access to care and reducing costs. Group Medical Visits can offer patients an additional health care choice, provide them support from other patients and improve the patient-physician interaction. Physicians can also benefit by reducing the need to repeat the same information many times and free up time for other patients. Appropriate patient privacy is always maintained and typically these benefits result in improved satisfaction for both patients and physicians. The Group Medical Visit is not appropriate for advice relating to a single patient. It applies only when all members of the group are receiving medically required treatment (i.e. each member of the group is a patient). The GP Group Medical Visits are not intended for activities related to attempting to persuade a patient to alter diet or other lifestyle behavioural patterns other than in the context of the individual medical condition. Unlike previous billing of 00100, all of which counted toward the HVLIP cap of 50 patients per day, the new fee scale does not. It is consistent with the psychiatric group psycho-therapy and the SSC specialist group medical visit schedule.

Does “Chronic Pain” qualify as an eligible mental health diagnosis for the GPSC Mental Health Planning Fee? Chronic Pain qualifies as an eligible mental health diagnosis only when it is present in association with a psychological condition (DSM 307.80, 307.89). When chronic pain is present due only to a physical condition and without associated psychological condition(s), it does not qualify for the GPSC Mental Health Planning Fee (G14043). In addition, if the Mental Health Planning Fee (G14043) is billed for a patient who does have an associated psychological condition, all other criteria of the G14043 Planning Fee must be met.

Pain Management with Adult Mental Health Billing GPSC – fees restricted to FP accepting role of MRP for longitudinal coordinated care of patient for that calendar year Mental Health Planning Fee (G14043) Axis 1 diagnoses only 30 minutes face to face planning visit If longer may also bill 00100 or 00120 depending on time and nature of service (+ 00100 if up to 49 min; or + 00120 if 50 min or more and fulfills counseling preamble requirements) Mental Health Management (G14044-48 – Counseling Equivalent – age related) Maximum 4 services per year per patient once four 00120 used up – restricted to patient’s FP who billed G14043 Same preamble requirements as 00120 *Patient Telephone/e-mail Follow-up fees (G14079) 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 and/or 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, the following:  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. The 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:  a) PHQ9, Beck Inventory, Ham-D for depression;  b) MMSE for cognitive impairment;  c) MDQ for bipolar illness;  d) GAD-7 for anxiety;  e) Suicide Risk Assessment;  f) 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. The patient and/or their representative/family should leave the planning process knowing there is a plan for their care and what that plan is.  Following the successful billing of the Mental Health Planning fee, the GP will have access to 4 additional counselling equivalent mental health management fees per calendar year once the 4 MSP counselling fees have been billed. Patient Eligibility:  • Eligible patients are community based, living in their home or assisted living. Facility based patients are not eligible.  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 I 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.  Payable once per calendar year per patient.  Payable in addition to a visit fee billed same day.  Minimum required time 30 minutes in addition to visit time same day.  G14016, Community conferencing fee payable on same day for same patient, if all criteria met.  Not payable on the same day as G14044, G14045, G14046, G14047, G14048 (GP Mental Health Management Fees).  G14079 GP telephone /e-mail management fee is not payable on the same day.  Not intended as a routine annual fee if the patient does not require on-going Mental Health Plan review and revision.  G14015, Facility Patient Conferencing Fee, not payable on same day for same patient as facility patients are not eligible.  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 whose duties would otherwise include provision of this care.  Successful billing of the mental health planning fee (G14043) allows access to 5 Telephone/e-mail follow-up fees (G14079) per calendar year.over the following 18 months. *Telephone/e-mail Follow-up fees – effective January 1, 2012 the previous 4 different telephone/e-mail fees were simplified into a single fee code G14079 that is billable on any patient who has had one of the GPSC planning incentives or COPD CDM fee billed in the previous 18 months 14033, 14043, 14053, 14063. There is a limit of 5 services per patient regardless how many of the portal fees have been billed.

Does Substance Abuse and/or Addictions qualify as an eligible mental health diagnosis for the GPSC Mental Health Planning Fee? Both Alcohol Dependency (303) and Substance Abuse (non-nicotine) (304) qualify as eligible mental health diagnoses. If the Mental Health Planning Fee (G14043) is billed for a patient with either Alcohol or Substance abuse issues, all other criteria of theG14043 Planning Fee must be met.