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:

  1. 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.
  2. 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:

  • CMXV20 and CMXV35 compensate physicians for a number of activities, not just for time spent face to face.
  • The time to calculate the modifier includes the following activities (which must be completed on the same date of service the patient was seen):
    • 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.
  • The total time claimed:
    • Must only include the physician’s time and not other facility or office staff or residents.
    • Cannot include time spent delivering other billable services, e.g., Pap smears, injections, etc.

Additional information:

CMXV20 and CMXV35 may be claimed by the following specialties:

  • anesthesia
  • cardiac surgeon
  • cardiovascular and thoracic surgery
  • clinical immunology and allergy
  • critical care medicine
  • dermatology
  • diagnostic radiology
  • emergency medicine
  • full-time emergency room
  • gastroenterology
  • general surgery
  • generalists in mental health
  • hematological pathology
  • neurology
  • neurosurgery
  • obstetrics and gynecology
  • ophthalmology
  • orthopedics
  • otolaryngology
  • pathology
  • physical medicine and rehabilitation
  • plastic surgery
  • psychiatry
  • respiratory medicine
  • specialists in mental health
  • thoracic surgery
  • urology
  • vascular surgery

The following HSCs are eligible for the following (as appropriate to the physician's specialty): CMXV20 or CMXV35: 03.03A, 03.03AZ, 03.03B, 03.03BZ, 03.03C, 03.03F, 03.03FZ, 03.07A, 03.07AZ, 03.07B, 03.07C.

CMXV20 or CMXV35 may also be claimed by any physician for the following when the location and time conditions (above) are met:

  • HSCs 03.05CR
  • 03.05DR
  • 03.05ER
  • 03.05F
  • 03.05FA
  • 03.05FB
  • 03.05FC
  • 03.05FD
  • 03.05FE
  • 03.05FF
  •  03.05FG
  • 03.05FH
  • 03.05FR
  • 03.05GR
  • 03.05HR

Other information:

  • CMXV20 may be claimed once the visit service and the management of the patient’s care have reached 20 minutes.
  • CMXV35 may be claimed once the visit service and the management of the patient’s care have reached 35 minutes.
  • Only one modifier may be added to the claim.
  • CMXV15 and CMXV30 may be claimed on relevant HSCs regardless of location.
    These may also be claimed in addition to the 03.01AA after-hours time premium if the service occurs in a regional facility after hours.

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