Advance Care Planning

Question

What is "advance care planning" and does Medicare cover it?

Answer

Advance care planning involves multiple steps designed to help individuals a) learn about the health care options that are available for end-of-life care; b) determine which types of care best fit their personal wishes; and c) share their wishes with family, friends, and their physicians. In some cases, patients who have already considered their options may need only one advance care planning conversation with their physician. However, experts state that frequently, beneficiaries may require a series of conversations with their physician or other health professionals to understand and define their end-of-life wishes clearly.

Starting January 1, 2016, Medicare will cover ACP as a separate service provided by physicians and other health professionals (such as nurse practitioners) who bill Medicare using the physician fee schedule. Medicare will cover ACP provided in medical offices and facility settings, including hospitals.

Question

Are the advance care planning services CPT® codes retroactive for use to the date CPT® established them?

Answer

No. CPT®; established two new codes in 2015 to describe advance care planning services. However Medicare did not allow separate payment for these codes for claims with dates of service in 2015, as CMS stated, these services were bundled as part of an E/M visit. As noted above, CMS changed the policy and providers may begin billing for these services for dates on or after January 1, 2016 with the following CPT® code 99497 and or 99498.

Question

Are the legal forms required to be completed and signed in order to bill the advance care planning services CPT® codes?

Answer

No, you can use these ACP CPT® codes to report the face-to-face service, with or without completing the relevant legal forms. CPT® describes an advance directive 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." Some examples of these forms are a health care proxy, durable power of attorney for health care, living will, and medical orders for life-sustaining treatment.

Question

What is Medicare paying for advance care services in 2016?

Answer

CMS has assigned a total of 2.40 relative value units (RVUs) to 99497 and 2.09 RVUs to 99498 in the non-facility setting (e.g., physician office), which translates to $85.99 and $74.88, respectively, using the 2016 Medicare conversion factor (unadjusted for geography, sequestration, and any applicable Medicare payment adjustments). In the Hospital outpatient setting CMS has assigned CPT® 99497 to APC group 5011 with a national payment rate $54.41 and CPT®99498 a status indicator of "N" consistent with the add-on code policy as the payment for the add-on code is considered packaged into the primary procedure 99497. Providers in the hospital setting should report the add-on code for appropriate coding and for capturing appropriate volumes and costs of these services, even if there is no current separate payment as information is used for future hospital rate setting. Payment in general may still depend on local coverage determinations by the Medicare Administrative Contractors (MAC), as medically appropriate ICD-10-CM codes and frequency limits would be at the discretion of the MACs.

Question

Can I bill both an E/M visit and advance care planning on the same date of service?

Answer

Yes, CMS offers the following example of how a physician might provide and bill for advance care planning. A physician sees a 68-year-old male with heart failure and diabetes who takes multiple medications. She provides evaluation and management (E/M) of these two diseases, including adjusting medications as appropriate. In addition to discussing the patient's short-term treatment options, the physician learns of the patient's interest in discussing long-term treatment options and planning. The patient inquiries about the possibility of a heart transplant if his congestive heart failure worsens. The physician and patient also discuss advance care planning for care and treatment if he suffers a health event that adversely affects his decision-making capacity.

In this example, the physician would report a standard E/M code and one or both of the advanced care planning codes, depending on the duration of the service. The physician would NOT count the time spent on the E/M portion of the visit toward the time used to code 99497 and 99498. Per CPT®, no active management of the problem or problems is undertaken during the time period for which these two codes are reported.

Note that the advance care planning service described in the example above would not necessarily have to occur on the same day as an E/M service. It can be billed as a stand-alone service. A 25 modifier does not need to be appended to the E/M service.

Question

Answer

No. CPT® makes clear in exclusionary parentheticals that advance care services would not be billable on the same date as any adult or pediatric critical care services. CPT provided the following list of codes that may not be billed with ACP services. Those CPT services are 99291, 99292, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479, and 99480.

Question

Can I bill advance care planning on the same date of service as inpatient care services?

Answer

Yes. ACP during an inpatient hospital visit is not excluded. Again, the physician would NOT count the time spent on the E/M portion of the visit toward the time used to code 99497 and 99498. A 25 modifier does not need to be appended to the E/M service.

Question

Are the advance care planning services subject to a co-payment, deductable or co-insurance?

Answer

In general, as with most other physician services, beneficiaries are subject to cost sharing for ACP provided by their physician or health professional, (e.g., co-payment, co-insurance, deductible). However, if Medicare beneficiaries desire ACP during their annual wellness visit, physicians and other health professionals may provide it during that visit and bill Medicare separately for it. However, beneficiaries will not have any cost sharing liability for advance care planning provided in conjunction with their annual wellness visits.

Question

Can we bill for ACP that takes 16 minutes?

Answer

Yes. The CPT® time rule applies for any service in the CPT manual that does not have a parenthetical that states otherwise. In this case, providers would follow the CPT time rule convention that states, "A unit of time is attained when the midpoint is passed." We would like to point out that ACP services should not be rushed. Therefore, while CPT would allow coding at 16 minutes, we anticipate many of these services will take closer to the 30 minutes or more.

Question

Can more than one provider or specialist(s) provide advance care planning in any given year(s), what are the frequency limitations?

Answer

We are currently not aware of any national or local frequency limitations by any of the National Correct Coding Initiative or Medically Unlikely Edits. Medicare Administrative Contractors (MACs) have the authority to place frequency limits, therefore we suggest that you check with your local payers and MACs.

More information on the Advance Care Planning service can be found at the CMS website.

LDCT Lung Cancer Screening

Question

How does the CMS clarification statement on LDCT screening programs apply to "stand-alone" screening programs in which the shared decision making visit team is part of the Radiology practice?

Answer

Such programs should be allowed under the CMS clarification provided the results of the services offered by the program are used in the management of the Medicare beneficiaries care. A shared-decision making visit followed by a proper communication of results and recommendations should meet the CMS criteria.

Question

CMS has issued a clarification statement to clarify which physicians can order screening and provide a shared decision making service, however the MLN Matters article is still in circulation. How should ATS members use this clarification statement from CMS to assure compliance officers that all physicians are able to participate in the lung cancer screening benefit?

Answer

While the clarification issued by CMS should provide ample assurance that all physicians can participate in the LDCT lung cancer screening benefit, we understand that until the MLN Matters article is retracted or corrected, many compliance offices will be reticent to move forward. The ATS has contacted CMS to request a retraction or correction of the MLN Matters article.