Advance Care Planning: What you need to know about getting paid

Advance Care Planning: What you need to know about getting paid

Health care professionals are well suited to have end-of-life discussions and perhaps have been counseling their patients about end-of-life issues and options for care all for free.  But end of life conversations and discussing patients’ preferences and values about treatment options require both time and skill. Whether advance care planning is done in the acute care or outpatient settings, a qualified health care professional can be paid for spending time discussing end-of-life decisions and advance directives with a patient, family member or healthcare surrogate. A qualified health care professional is a physician (any specialty), nurse practitioner, physician assistant, and clinical nurse specialist. In January 2016, CMS approved two CPT codes, 99497 and 99498 for reimbursement of advance care planning when components of the conversations are properly documented.

The CPT codes  99497 and the add on code 99498 are used to report the face-to-face service between the NP or PA, patient, family member, or healthcare surrogate for counseling and/or discussing medical treatment options and future care options regarding end-of-life care with or without completing the related advance directive. The 99497 is used for the first 30 minutes when the discussion includes an explanation of advance directives or education and counseling.  99498 is used for each additional 30 minutes of the encounter. The codes are time-based which means you must specifically document the time spent offering these services. You must document the time the conversation started, when it stopped, and the total amount of time spent in the face to face encounter. Appropriate documentation includes an account of the discussion with the patient (and or family, or surrogate), who was present, education for patient and family about the illness, available options, decisions about what types of treatment the patient wants, and decisions about a healthcare surrogate.

Example documentation:

9:00 a.m. I met with Doris (patient) and spouse at the bedside and discussed the current medical concerns. We discussed the patient’s advance stages of COPD, comorbid conditions and current deterioration despite aggressive medical management. Education and counseling were provided about the illness and available treatment options. We also discussed end of life concerns. Doris expressed a preference for palliative care and comfort measures. She does not wish to go on a ventilator or continue aggressive medical options, such as CPR to sustain life. Doris completed an advance directive and designated her spouse as health care surrogate. During the visit patient’s spouse became tearful but is accepting of Doris’ wishes for a “DNR”. Emotional support and active counseling provided to patient and spouse. Additional social work and chaplain support offered. The nurse notified of discussion and DNR code status. Time ended 10:05 a.m.

Total time: 65 minutes spent face to face discussing advance care planning and completing advance directive. CPT codes 99497 and 99498. J44.1

Tips

CMS follows time rules for advance care planning. This means you must spend more than 50% of the time face to face with the patient, or at least 16 minutes of the 30 minutes discussing patient’s preference for end of life care to bill.

No specific diagnosis is required to bill ACP codes, however, it is appropriate to report a condition for which you are counseling the patient (i.e., ICD 10: J44.1)

Medicare pays for ACP as a separate Part B medically necessary service and an optional element of a patient’s Annual Wellness Visit. When performing advance care planning in the office clearly note that the patient was informed that the service is voluntary and that regular Part B liabilities (deductible, 20% copay) would apply.  If the ACP is done at the time of an annual wellness visit there is no copay, however, the code is billed with a modifier -33 (preventive services).

Advance Care Planning Fact Sheet. Centers for Medicare & Medicaid Services (CMS) Medicare Learning Network at https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/advancecareplanning.pdf

For additional information:

Advance Care Planning. CMS Outreach and Education. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/ICN909289.html

Bio Lolita Melhado PhD, APRN, FNP-BC, ACHPN is a leader, educator, researcher, and author. She earned a PhD in nursing research and MSN in primary health care. Dr. Melhado served on the e-learning curriculum development committee for the Center to Advance Palliative Care. She has presented on numerous topics in palliative care and advance care planning. Dr. Melhado is the Vice President of Clinical Programs at OneAccord Health

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