Recent audits have revealed that physicians may be claiming fee item 14033 (complex care) when there is no confirmed diagnosis of a second chronic condition.
Fee item 14033 was developed to compensate GPs for the management of complex patients residing in the community who have documented confirmed diagnoses of two chronic conditions from at least two of the eight categories listed below.
Eligible complex care condition categories:
1. Diabetes mellitus (type 1 and 2).
2. Chronic kidney disease.
3. Heart failure.
4. Chronic respiratory condition (asthma, emphysema, chronic bronchitis, bronchiectasis, pulmonary fibrosis, fibrosing alveolitis, cystic fibrosis, etc.).
5. Cerebrovascular disease, excluding acute transient cerebrovascular conditions (e.g., TIA, migraine).
6. Ischemic heart disease, excluding the acute phase of myocardial infarct.
7. Chronic neurodegenerative diseases (multiple sclerosis, amyotrophic lateral sclerosis, Parkinson disease, Alzheimer disease, brain injury with a permanent neurological deficit, paraplegia or quadriplegia, etc.).
8. Chronic liver disease with evidence of hepatic dysfunction.
There must be supporting documentation in the patient’s medical record (i.e., a diagnostic test or consultation report) for both chronic conditions to meet the criteria to bill fee item 14033. Submitting a claim under 14033 when there is no confirmed diagnoses for both conditions could be considered deliberate misbilling. Deliberate misbilling can result in de-enrollment from the Medical Services Plan. Also, indicating a false diagnosis may have a negative impact on the patient, such as denied insurance or other benefits.
For more information on complex care, visit www.gpscbc.ca.
—Keith J. White, MD
Chair, Patterns of Practice Committee
This article is the opinion of the Patterns of Practice Committee and has not been peer reviewed by the BCMJ Editorial Board. For further information contact Juanita Grant, audit and billing advisor, Physician and External Affairs, at 604 638-2829 or email@example.com.
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