The regulations of the EBM are sometimes complicated. In this way, the insured person or basic flat rate is paid identically, regardless of whether an insured person comes to the practice once or ten times for treatment. With the following regulations, you can increase your fee in EBM or GOÄ for the chronically ill.
The definition of a chronically ill is for billing of the fee schedule items (GOP) 03220/04220 in general practitioner care in the EBM (uniform assessment standard) somewhat clearer than in § 2 of the Chronicler guideline of the Federal Joint Committee (G-BA). The specifications in the EBM are binding for the SHI billing of this GOP (see EBM regulation for chronic sufferers). Among other things, EBM requires a long-lasting, life-changing illness. According to the chronic guideline, a serious illness is required or, for example, a degree of disability or a level of care.
Chronic regulation EBM
The chronicler numbers 03220/04220 to 03222/04222 can only be billed to:
- Presence of at least one long-lasting, life-changing illness and
- need one continuous medical treatment and care.
Continuous medical treatment is given if, in the period of the last four quarters, including the current quarter, there has been at least one doctor-patient contact in accordance with 4.3.1 of the General Provisions per quarter in at least three quarters in the same for the same confirmed chronic disease(s). practice has taken place. Personal doctor-patient contact must have taken place in at least two quarters. In a quarter, personal doctor-patient contact can also take place as part of a video consultation in accordance with Annex 31b to the BMV-Ä.
timings
Long-lasting is defined in the EBM in such a way that the GOP 03220/04220 can be billed for the first time as a surcharge to the flat rate for insured persons if the identical illness can be proven to have existed in the three previous quarters. Very important: If a chronically ill patient has several long-lasting, life-changing diseases, care must be taken to ensure that the coding of the treatment diagnosis in the billing is consistent.
example case
Consider an elderly man with metabolic syndrome. At least according to the guideline, as a diabetic, he should be seen once a quarter and his HbA1c should be checked, among other things. For the billing of the chronic GOP, it does not matter whether you code E11.9- or one of the diabetes complications as the fourth digit in the billing. However, if you only encode the hypertension with I10.9-, there can be problems. Because experience has shown that hypertensive patients do not take their illness so seriously and only contact the practice when the prescribed N-III pack has been used up. In other words, the hypertensive usually only comes to the practice every second quarter. This causes problems with the 4-3-2 rule.
4-3-2 rule
The long-lasting, life-changing illness must exist in four quarters. This is what the 4 in the 4-3-2 rule stands for. As described in the time specifications, the chronic GOP can be billed for the first time in the fourth quarter of 2022 if hypertension has been diagnosed since the first quarter of 2022. In the last four quarters, at least one doctor-patient contact (APK) must have taken place in three quarters, which means the 3 in the 4-3-2 rule. The 2 stands for two quarters, in each of which a personal APK must have taken place. As a result of Corona, a video consultation can replace the personal APK in one of these quarters.
The pitfall of the 4-3-2 rule lies in the imprecise coding. In our example case with type 2 diabetes, with treatment in accordance with the guidelines, you have a personal APK every quarter and no problems with billing the chronic GOP. Provided that diabetes was coded as the treatment diagnosis.
Back to the example case
Back to our example. Type 2 diabetes will be diagnosed and coded in QI/2022. In Q II there is a personal APK and the prescription of long-term medication. In Q III the patient does not come to the practice. In Q IV there is another personal APK, with continued prescription of the long-term medication under which the patient is well adjusted. Thus, the 4 as well as 3 and 2 of the 4-3-2 rule are fulfilled. In Q III he was not in the practice, but based on the prescription and the diagnosis it is clear that the type 2 diabetes also existed in Q III.
Let’s now look at Q IV/2022. If the patient only comes to the practice for a follow-up prescription, the insured person’s flat rate cannot be billed and accordingly the chronic GOP as a surcharge cannot be billed either. In the example chosen, this is certainly not medically justifiable if a type 2 diabetic does not see a doctor for a year. Mind you, you should only issue a prescription if you are sure of the condition of the person concerned. In the case of diabetes in particular, it is incomprehensible why, without having seen the patient, one would take the risk of issuing a prescription and waiving the insurance flat rate.
A large proportion of the recourses due to the chronic GOP in recent times came about because multimorbid patients were coded for a long-standing illness such as hypertension in one quarter and another such as type 2 diabetes in the next quarter. Then the 4-3-2 rule is not fulfilled for both diseases. While a follow-up prescription without a personal APK seems justifiable for a well-adjusted hypertensive patient, a type 2 diabetic should actually be examined every quarter.
The diagnosis
There is no official list of long-lasting, serious illnesses. This would give the contract doctors more leeway, emphasized an employee of a statutory health insurance association (KV). However, for example, the KV Schleswig-Holstein in one Attachment to the fee distribution scale (HVM) in descending order of chronic diseases with ICD-10 coding listed. If such a list exists regionally, one can be sure that correctly made and coded diagnoses will also be accepted when billing the Chronic GOP.
Problem-oriented family doctor discussion
The GOP 03230/04230 only applies to primary care and is particularly important for the chronically ill. Let’s take the example. If diabetes is newly diagnosed or worsens significantly, appropriate education is necessary. This usually lasts more than ten minutes. The call according to GOP 03230/04230 can be billed per completed ten minutes. It is important that the patient file contains at least a brief note of what the conversation is about. The call can only be billed to a limited extent. 64 points are paid into a virtual fee account for each treatment case. After the end of the quarter, the billed GOP 03230/04230 are paid with a maximum of 128 points. If a contract doctor has billed the 03230/04230 more frequently, the virtual fee account is distributed to the billed call GOP. If there is a large difference between the planned and billed call GOP, there may be problems with the plausibility check, since each billed call GOP is included in the daily and quarterly profile with ten minutes, regardless of the fee paid for it.
Unexpected visit
In addition to urgently requested home visits according to GOP 01410 et seq., there are GOP 01100 and 01101 for unforeseen use in the evening or at night. Very important: The GOP 01102 is a surcharge for an activity on Saturday from 7 a.m. to 7 p.m. So if you hold surgery hours on Saturdays or call in patients, you can calculate this surcharge.
GOÄ
In the GOÄ (fee schedule for doctors) it is a bit more complicated. There is neither the family doctor chronicler GOP nor the problem-oriented discussion. Longer conversations can either be mapped using the increase factor or, especially in the case of chronically ill people, using the discussion according to No. 34. However, No. 34 with a minimum duration of 20 minutes can only be billed twice within six months. The basic requirement is that a permanently life-changing or life-threatening disease has been newly diagnosed or has significantly worsened.
The continuous care of the chronically ill can also be settled with No. 15 towards the end of the calendar year. Unlike the chronicler GOP of the EBM, however, this requires medical and social measures. Social measures are often forgotten.