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This update replaces our March 6, 2017 blog “Medical Coding and Billing for Advance Care Planning“.

End-of-life Discussion CodesAs a medical billing and coding company that keeps track of the evolving reimbursement scenario, we had reported on the addition of advance care planning (ACP) in 2016 as a payable service for traditional Medicare beneficiaries. Modern Healthcare recently reported that CMS announced that over 22,000 providers utilized these new billing codes to report end-of-life planning appointments for more than 570,000 beneficiaries in 2016. According to CMS, providers billing end-of-life services earned $43 million in Medicare reimbursement in addition to $50 million in patient deductibles and coinsurance.

Prior to January 1 2016, Medicare had provided coverage for ACP only during an initial visit when patients first enroll in the program. Under the new rule, ACP became a separate billing code. This provides physicians and patients with greater flexibility as it offers the opportunity to discuss the individual options for the patient both before an illness progresses and during the course of treatment. Moreover, the conversations can also be included as part of yearly check-ups.

Over the past year, medical billing and coding service providers knowledgeable about these codes have helped eligible providers receive appropriate reimbursement for end-of-life planning services. The time-based ACP codes are:

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 (QHP); first 30 minutes, face-to-face with the patient, family member(s) and/or surrogate.
+99498 – Each additional 30 minutes (List separately in addition to code for primary procedure).

Here are the key points to be noted about billing ACP codes:

  • Neither CPT nor CMS place any limits on the number of times ACP can be reported for a given beneficiary in a given time period. However, when the service is billed multiple times, CMS requires that there should be a documented change in the beneficiary’s health status and/or wishes about his/her end-of-life care.
  • CMS does not require a specific diagnosis for billing the ACP codes. It would be appropriate to report a condition for the provider is counseling the beneficiary, an ICD-10 code to signify an administrative examination, or a well exam diagnosis when the ACP service is provide as part of the Medicare Annual Wellness Visit.
  • ACP can be billed the same day as an Evaluation and Management (E/M) code.
  • If coding the E/M by time, the documentation must clearly indicate that the ACP time does not overlap the counseling/coordination of care time for the E/M code. Medicare deductible and coinsurance are applicable.
  • ACP can also be billed on the same day as:
    • a Welcome Visit
    • As a voluntary separately payable part of the AWV. Modifier 33, preventive service should be appended to the ACP code. Deductible and coinsurance do not apply.
    • During the period covered by Transitional Care Management (TCM), Chronic Care Management (CCM), or global surgery.
    • As a stand-alone service (Medicare deductible and coinsurance apply).
  • The physician or QHP billing ACP must manage, participate and meaningfully contribute to the provision of the services.
  • The physician or QHP should document the time spent discussing end-of-life care planning with the patient.
  • End-of-life Discussion CodesThe time requirement for the ACP service is as follows: 99497, covers the first 30 minutes of face-to-face conversation and documentation by the provider with the patient, family member(s) and/or surrogate, and at least 16 minutes must be performed and documented. If the service exceeds 30 minutes, 99498 should be used.
  • When the patient develops a new problem or has an exacerbation of an existing problem, these codes may be reported by more than one physician or QHP, typically of different specialties.
  • CPT does not specify exact language to validate billing for ACP. However, it is expected that the provider would submit some documentation validating the medical necessity of the discussion, what was discussed, and what decision was made. CMS guidelines state that providers should consult their Medicare Administrative Contractors (MACs) about documentation requirements, which could include: an account of the discussion with the beneficiary (or family members and/or surrogate) regarding the voluntary nature of the encounter; the explanation of advance directives (along with completion of those forms, when performed); who was present; and the time spent in the face-to-face encounter.

As more and more baby boomers become eligible for Medicare each day, the importance of ACP discussion is increasing. Besides ensuring that patients receive the care they want, hospitals can save money by avoiding unwanted end-of-life treatment. According to a study published by the Critical Care Medicine academic journal in 2016, intensive care costs could be reduced by $1.9 billion if ACP and ICU-based palliative-care consultation are made the standard of care for patients with chronic and serious illness.

However, despite the significance of end-of-life conversations, the Modern Healthcare report points out that these codes were used last year for only 1% of the Medicare population. Providers can accelerate use by learning more about ACP codes and documentation requirements. Outsourcing medical billing and coding can ensure accurate claim submission and optimal reimbursement.