What is Advanced Care Planning?
Discussing end-of-life decisions with patients and their family members or caregivers can be difficult and uncomfortable. However, it is essential when patients face chronic conditions that may not allow them to decide on their own one day. Advance care planning (ACP) involves a discussion (face-to-face service and using telehealth services) between physicians or other qualified health care professionals (QHP), patients, family members, and caregivers, preparing for future decisions about medical care if a person becomes seriously ill or unable to communicate their wishes to healthcare providers, family members and caregivers.
These conversations with the medical providers, family and caregivers are the most important part of advance care planning, documentation and using proper billing codes. Many people also choose to put their preferences in writing by completing legal documents called advance directives. These services can happen in hospitals, doctor’s offices, skilled nursing facilities, and patients’ homes.
Per CMS, As part of this discussion, you may discuss advance directives with or without helping a patient complete a legal form. An advance directive appoints an agent and records patients’ medical treatment wishes based on their values and preferences. You can generally find them on your state attorney general’s office website.
- Living wills
- Medical orders for life-sustaining treatment
- Healthcare proxy
- A durable power of attorney for healthcare
- Psychiatric advance directives
What has changed this year?
On March 9th, MLN updated the Advanced Care Planning fact sheet on correctly documenting and billing Advance Care Planning services. The published guidance is listed below:
- Added medical orders for life-sustaining treatment and psychiatric advance directives as examples of advance directives (page 3)
- Added clarification on documentation and time-based coding requirements (pages 3–5)
- Added payment information for Federally Qualified Health Centers and Rural Health Clinics (page 5)
- Added additional resources (page 6)
The guidance was initiated due to an OIG (Office of Inspector General) investigation of CPT codes 99497 and 99498 in CY2019. A report published in November 2022 recommends that CMS educate providers on documentation and time requirements for ACP services to comply with Federal requirements. In addition, CMS should instruct the MACs to recoup $33,332 for ACP services paid in error for claims in our sample.
During compliance audits, we any service is billed, we are looking to ensure documentation meets reporting requirements, which means documentation shows the medical necessity, and supports CPT codes being billed with the necessary MDM or total time requirements. If other services are billed along with these codes, did the documentation support both codes being billed? Where is there room for education or training to avoid and mitigate any risk identified?
Who can report ACP codes?
The following is a list of providers that can report ACP codes; note that non-physicians must legally be authorized and qualified to provide ACP in the state where the services are furnished.
- Physicians (any specialty)
- Clinical nurse specialist (CNS)
- Nurse practitioners (NPs)
- Physician assistants (PAs)
Organizations and physician-based practices should review both documents and ensure they follow documentation and billing guidelines/requirements.
Advance directives are legal documents that guide medical care, such as DNI (Do Not Intubate), DNR (Do Not Resuscitate), a living will and durable power of attorney. The two most common advance directives for health care are the living will and the durable power of attorney for health care.
A living will: A living will is a legal document that tells doctors how you want to be treated if you cannot decide about emergency treatment. In a living will, you can say which common medical treatments or care you wish, which ones you want to avoid, and under which conditions each of your choices apply.
A durable power of attorney for health care: A durable power of attorney is a legal document that names your health care proxy. This person can make health care decisions if you cannot communicate these yourself. Your proxy, a representative, surrogate, or agent should know your values and wishes. A proxy can be chosen in addition to or instead of a living will.
CPT Codes 99497 and 99498 are time-based codes, and the total time for the services should be documented in the medical record. The codes should not be reported or billed for discussions that are 15 minutes or less; if the midpoint of 16 minutes is reached, then that is one billable unit that can be billed. MLN states that if the time requirement is less than 15 minutes, then Bill a different Evaluation and Management (E/M) service, like an office visit (if you meet the other service’s requirements). These codes can also be used/billed with additional Evaluation and Management codes (E/M) with the appropriate modifier (25) or (33), depending on the scenario and other E/M codes being billed.
Modifier 25 is a significant, separately identifiable evaluation and management service by the same physician or another qualified healthcare professional on the same day of the procedure or other benefit. Therefore, time spent providing other separately identifiable services should not be included in the time spent and reported for ACP codes.
Modifier 33 is When the primary purpose of the service is the delivery of an evidence-based service by a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. However, the modifier should be used for only one reported service identified explicitly as preventive.
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 surrogate
99498 (Add on code) – 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).
Physicians and QHP must document their ACP discussion with a patient, family member, caregiver, or surrogate. Documentation should include the following whether forms are signed that day or not:
- The voluntary nature of the visit
- The explanation of advance directives
- Who was present
- The time spent discussing ACP during the face-to-face encounter
- Any change in health status or health care wishes if the patient becomes unable to make their own decisions
Diagnosis codes are essential to reporting ACP codes; physicians, QHP, and coders should report the conditions and problem(s) discussed with the patient using an ICD-10-CM code. This code shows an administrative exam or an exam diagnosis when the ACP services are part of the AWV or IPPE. However, MLN states they need not report a specific diagnosis to bill ACP.
Documentation of these services is essential; forms filled out should be noted in the documentation and scanned into the EHR. Ensure the correct CPT and diagnosis codes are reported along with the appropriate modifier, depending on the episode of care and other services provided during that visit. Physicians and QHP should be mindful of double dipping and carve out any time to report another service. Traditional Medicare, as well as Medicare Advantage insurance, pays for ACP services. Physicians, QHP, coders, billers, and Administrative staff would want to ensure they keep abreast of any guideline changes yearly by reviewing the CPT book, guidelines, and payor policies.
To schedule training on documentation and coding guidelines for ACP for your organization or private practice providers, email us today at email@example.com, schedule a call or visit the website and fill out the “contact us” form.