Coding Corner: How to code the Medicare advance care planning benefit

February 01, 2016
Area(s) of Interest: Payor Issues and Reimbursement Practice Management 

CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.   

As of January 1, 2016, Medicare covers advance care planning (ACP) as a separate service when provided by physicians and other health professionals (such as nurse practitioners who bill Medicare using the physician fee schedule). CMS enacted the new coverage as part of the 2016 Physician Fee Schedule Final Rule.

ACP is a face-to-face service that, as described by the AMA (CPT Assistant, Dec. 2014), “involves learning about and considering the types of decisions that will need to be made at the time of an eventual life-ending situation and what the patient’s preferences would be regarding those decisions.” The services include counseling and discussion of an advance directive, defined in CPT® as “a document appointing an agent and/or recording the wishes of a patient pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at that time.” 

Per CMS, ACP may be reported “when the described service is reasonable and necessary for the diagnosis or treatment of illness or injury.” The Final Rule provides one such example:

For example, this could occur in conjunction with the management or treatment of a patient's current condition, such as a 68-year-old male with heart failure and diabetes on multiple medications seen by his physician for the E/M of these two diseases, including adjusting medications as appropriate. In addition to discussing the patient's short-term treatment options, the patient may express interest in discussing long-term treatment options and planning, such as the possibility of a heart transplant if his congestive heart failure worsens and advance care planning including the patient's desire for care and treatment if he suffers a health event that adversely affects his decision-making capacity. In this case the physician would report a standard E/M code for the E/M service and one or both of the ACP codes depending upon the duration of the ACP service. However, the ACP service as described in this example would not necessarily have to occur on the same day as the E/M service.

CPT Assistant (December 2014) specifies additional circumstances under which ACP may be warranted:

Individuals who may need extra assistance and more skilled facilitation in making future health care decisions include: (1) individuals with end-stage chronic illness, such as congestive heart failure, renal disease, or acquired immune deficiency syndrome (AIDS); (2) individuals who, because of the timing of their illness or injury, have not been considered appropriate for ACP, such as those facing emergent and high-risk surgery, or those who experience a sudden event, such as a transient ischemic attack (TIA), and are at risk of repeated episodes; (3) individuals who have ACP needs beyond the more familiar decisions to withhold or withdraw life-sustaining treatment, such as those with early dementia or mental illness; (4) individuals who lack decision-making capacity (developmental disabilities) or authority (minors) and must rely on guardians or parents to make substitute decisions and plan for the inevitable.

The AMA introduced two new advance care planning codes in CPT® 2015:

  • 99497 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate

  • 99498 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

Code 99497 describes an initial 30 minutes of the provider’s time (face-to-face with the patient, family or surrogate). You should report only one unit of 99497 per date of service. Code 99498 reports each additional 30 minutes of service, beyond the initial 30 minutes (at least 16 minutes must pass beyond the initial 30 minutes to report 99498). For example, for 35 minutes of face-to-face ACP, proper coding is 99497; for 57 minutes of face-to-face advance care planning, proper coding is 99497, 99498 (in addition to the primary E/M service code).

Advance care planning may be provided and reported on the same day, or a different day, as other E/M services; a list of E/M codes with which you may report 99497 and 99498 is included in the CPT® guidelines preceding the code listings. Medicare also allows adding ACP as an optional element, at the beneficiary’s discretion, of the Medicare Annual Wellness Exam. Per CPT® instruction, you should not report advanced care planning on the same date of service as 99291, 99292, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479 or 99480.

Medicare payment for ACP is approximately $85 for the first 30 minutes and $70 for each additional 30 minutes (based on 2016 Relative Value Units, before applying geographic pricing differentials). 

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