Complex Care Initiative

The Complex Care set of incentives (G14033, G14039) compensate GPs for the time and skill needed to work with co-morbid or complex care patients i.e. those who have two or more distinct but potentially interacting problems. Care for these patients includes the development of plan and liaison with the patient. The qualifying conditions are:

      • Chronic renal failure with eGFR values consistently less than 60.
      • Congestive heart failure.
      • Chronic respiratory condition (asthma, COPD, emphysema, chronic bronchitis, bronchiectasis, pulmonary fibrosis, fibrosing alveolitis, cystic fibrosis, etc.).
      • Cerebrovascular disease.
      • Ischemic heart disease, excluding the acute phase of myocardial infarct.
      • Chronic neurodegenerative diseases (multiple sclerosis, amyotrophic lateral sclerosis, Parkinson’s disease, Alzheimer’s disease, stroke or other brain injury with a permanent neurological deficit, paraplegia, or quadriplegia, etc.).
      • Chronic liver disease with evidence of hepatic dysfunction.

These fees are payable only to the general practitioner or practice group that accepts the role of being most responsible for the guideline-informed care of these patients. By billing this fee, the practitioner or practice accepts this responsibility for the ensuing calendar year.


The Complex Care Initiative in action

Mrs. J is a 68-year-old woman with diabetes, asthma, and Parkinson’s disease. She has made an appointment to see you in January for her annual review of her care plan that was set up the previous year. You note that the two conditions causing the most complexity are diabetes and asthma, as her Parkinson’s is well controlled with medication. You also note that her new Dual Diagnostic code is R250. 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. You also note that her Diabetes CDM (14050) anniversary is coming up at the end of January.

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-up of her asthma but that there is no sign of acute infection so you advise her to continue with the increased Flovent. You see her again seven days later and her peak flows have improved. You advise her to stay on this higher dose for the next two 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 regular dose. You see her again in March for her CPX and over the rest of the year for follow up of her complex conditions:  in July and October for planned proactive care of her complex conditions and in December twice due to an asthma flare-up. In addition, you see her in September for a bladder infection and treated appropriately.

Mrs. J’s Diagnostic Code for her Complex Care Management under all options is A250. Diagnostic code for her complex care management for these visits and phone management is A250. If she was also seen for other conditions, such as a problem with her osteoarthritis or acute illness, each of these visits would be billed under the office visit 16100 with the appropriate diagnostic code. Under the revised complex care management fee, all care -- face-to-face and up to four telephone/two-way email care for the complex conditions -- are billed on a fee-for-service basis.