Criteria:
Complexity modifiers may only be billed for the time spent on management of the patient's care for the total time spent, providing the time was spent on the same day the patient was seen. For example:
- Day one - Physician reviews chart, sees patient, completes referral letter on the same day. Total time spent managing patient care: 35 minutes. Therefore, the complexity modifiers CMXV15, CMXV20, CMXV30, CMXV35, CMGP OR CMXC30 as appropriate may be claimed in addition to the visit service.
- Day one - Physician reviews chart and sees the patient. Total time spent: 25 minutes.
Day two - Physician completes referral letter. Total time spent: 10 minutes. The time spent completing the referral letter may not be included in the time spent on day one – the physician may only claim for 25 minutes of time.
All of the following criteria must be met:
- This modifier describes time spent managing patient care.
Activities that contribute to managing the patients care include:- Writing a referral letter.
- Charting.
- Reviewing the chart.
- Reviewing but not waiting for lab/DI results.
- Talking with and examining the patient.
- Anything else the physician does in relation to the patient's care on the same date of service.
- The total time claimed:
- Must only include the physician’s time and not other facility or office staff or resident physicians.
- Cannot include time spent delivering other billable services, e.g., injections, etc.
- This modifier is used to indicate a complex patient consultation or visit requiring that the physician spend 15 (CMXV15) or 30 (CMXV30) minutes or more on managing the patient's care.
This modifier can only be claimed by:- Community medicine, geriatric medicine, occupational medicine, radiation oncology (03.03A, 03.03AZ, 03.07A, 03.07AZ, 03.07B).
- Cardiology, endocrinology/metabolism, hematology, infectious diseases, internal medicine, medical oncology, nephrology, pediatric cardiology, pediatrics and rheumatology (HSCs 03.03A, 03.03AZ, 03.03F, 03.03FZ, 03.07A, 03.07AZ, 03.07B ).
(Pediatrics may also submit for 03.05JK.)
These fee codes may not be claimed for the following:
- Uninsured services.
- Non-physician time.
- Review of diagnostic information received on a day when patient not seen.
- Time spent delivering another billable service.
Additional information:
- CMXV15 may be claimed once the visit service and the management of the patient’s care has reached 15 minutes. Only one modifier may be added to the claim.
- CMXV30 may be claimed once the visit service and the management of the patient’s care has reached 30 minutes.
- CMXV15 and CMXV30 may be claimed on relevant HSCs regardless of location.
- 03.01AA after-hours time premium may be claimed in addition to these modifiers if the service occurs in a regional facility after hours.