Fee Navigator

    Health Service Code 03.04J

    Development, documentation and administration of a comprehensive annual care plan for a patient with complex needs

    NOTE:
    1. A maximum of 15 comprehensive annual care plans per physician per calendar week may be claimed.
    2. May only be claimed by the most responsible primary care general practitioner who has an established relationship with the patient and where the physician intends to provide ongoing care and management of the patient.
    3. May only be claimed once per patient per year and includes ongoing communication as required as well as re-evaluation and revision of the plan within a year.
    4. May be claimed in addition to HSCs 03.03A, 03.03N or 03.04A.
    5. Time spent on the preparation of the complex care plan may not be included in the time requirement for a complex modifier.
    6. "Complex needs" means a patient with multiple complex health needs including chronic disease(s) and other complications. The patient must have at least two or more diagnoses from group A or one diagnosis from group A and one or more from group B in order to be eligible.
      Group A Group B
      • Hypertensive Disease
      • Diabetes Mellitus
      • Asthma
      • Heart Failure
      • Ischemic Heart Disease
      • Chronic Renal Failure
      • Chronic Obstructive Pulmonary Disease
      • Mental Health Issues
      • Obesity (Adult = BMI
        40 or greater Child = 97 percentile)
      • Addictions
      • Tobacco
    7. "Care plan" means a single document that meets the following criteria
      1. Must be communicated through direct contact with the patient and/or the patient's agent.
      2. Must include clearly defined goals which are mutually agreed upon between the patient and/or the patient's agent and the physician.
      3. Must include a detailed review of the patient chart, current therapies, problem list and past medical history.
      4. Must include any relevant information that may affect the patient's health or treatment options, such as demographics (education, income, language) or lifestyle behaviors (addictions, exercise, sleep habits, etc.)
      5. Must incorporate the patient's values and personal health goals in the care plan, with respect to his or her complex needs.
      6. Must outline expected outcomes as a result of this plan, including end-of-life issues when clinically appropriate.
      7. Must identify other health care professionals that would be involved in the care of the patient and their expected roles.
      8. Must include confirmation that the care plan has been communicated verbally and in writing to the patient and/or the patient's agent.
      9. Must be signed by both the physician and the patient or patient's agent. The comprehensive annual care plan is only billable if the care plan form on record is signed by both the physician and the patient or patient's agent.
      10. The signed copy of the care plan form must be retained in the patient's medical record.
    Category:T Test
    Base rate:$190.17

    AMA billing tips:

    • Eligible diagnostic codes for 03.04J are: Group A Hypertensive disease - 401; Diabetes mellitus - 250; COPD - 496; Asthma - 493; Heart failure - 428; Ischaemic heart disease - 413 - 414; Chronic renal failure - 585; Group B Mental health issues - 290-319; Obesity (adult BMI 40 or greater Child 97 percentile - 278; Addictions - 303-304; Tobacco 305.1; For more billing advice and a copy of the template please use the link

    • For information on the definition of chronic renal failure click on the link:

    Fee modifiers:

    No modifiers.

    Governing Rules:

    • 2.3.1

      Unless otherwise specified, services that may be claimed once per year may be claimed 365 days after the previous service date or 366 days in a leap year.

    • 2.5.2

      Unless otherwise specified in this Schedule, HSCs designated with a T category code may be claimed with visits and consultations on the same day.