CMGP Complexity Modifier

Criteria:

All of the following criteria must be met:

• The CMGP modifier applies to general practitioners only.
• The CMGP modifier may be claimed if the physician spends a full 15 minutes or more managing a patient’s care.
• The modifier is claimable in full 10-minute units after the first 15 minutes have elapsed. (See “Table: Claiming the CMGP modifier” below for details.)
• Additional CMGP modifiers may only be claimed after a full 10 minutes have elapsed.
• The CMGP modifier may only be claimed in addition to the following codes: 03.01J, 03.03A, 03.03AZ, 03.03B, 03.03BZ, 03.03C, 03.03CV, 03.03N, 03.03P, 03.03Q, 03.07A, 03.07AZ, 03.07B..
• The time used to calculate the modifier includes the following activities (which must be completed on the same date of service that the patient was seen):
  • Writing a referral letter.
  • Charting.
  • Reviewing the chart.
  • Reviewing but not waiting for lab/DI results.
  • Talking to and examining the patient.
  • Anything the physician does in relation to the patient's care.

Examples

If the physician spends of total of:

• 18 minutes managing the patient’s care (including charting), the claim could look like this:
  03.03A (modifier) CMGP01.
• 40 minutes (including the visit and managing the patient’s care), the claim could look like this: 
  03.03A (modifier) CMGP03.  

These fee codes may not be claimed for the following:

The total time claimed:

• Must only include the physician’s time and not the time of other facility or office staff or residents.
• Cannot include time spent delivering other billable services, e.g., pap smears, injections, etc.
• The time claimed cannot include time spent:
  • Delivering uninsured services.
  • Developing a Comprehensive Care Plan (03.04J).

The time spent completing a procedure for a patient cannot be used to calculate the time for the CMGP modifier. For example, a patient might ask a physician to examine a sebaceous cyst, and the physician decides to excise the cyst.

If the time spent examining the cyst was under 15 minutes, and the time removing the cyst took 25 minutes, the claim to the Alberta Health Care Insurance Plan would use health service codes 03.03A and 98.12C.

The complexity modifier could not be claimed, as the time spent delivering the visit portion of the service was under 15 minutes.

Additional information:

The table below will help you to determine the number of units of the CMGP modifier you may claim for the total time spent.

This time includes the face-to-face visit part of the visit and the allowable activities mentioned above.

The CMGP modifier is payable up to 10 units, or 105 minutes or more of time.

Table: Claiming the CMGP modifier

CMGP may be claimed:  

• On relevant HSCs regardless of location.
• In addition to the 03.01AA after-hours’ time premium (if the service occurs in a regional facility after hours).

Related fee codes:

03.01J, 03.03A, 03.03AZ, 03.03B, 03.03BZ, 03.03C, 03.03N, 03.03P, 03.03Q, 03.07A, 03.07AZ, 03.07B

Governing rules:

Please review the information in the Schedule of Medical Benefits (SOMB):

Review the SOMB 

• Look under “Fee Modifier Definitions,” modifier type CMPX.

Need more help?

• Access the Fee Navigator
• Access the Schedule of Medical Benefits
• Read the Allied Health practitioner’s resource guide
• Read the Physician's resource guide
• Register for billing seminars
• Contact us with any billing questions