Cardiology Coding Alert

Hint: Remember the importance of time.

As you may recall, Medicare started paying for voluntary advance care planning (ACP) services at the beginning of last year. This means you can now collect for your cardiologist's services when he discusses end-of-life decisions with Medicare beneficiaries.

It's especially common for cardiologists to perform ACP services for heart failure patients. To ensure you don't miss out on a possible reimbursement, review three ACP frequently asked questions.

FAQ 1: Learn the Ropes of 99497 and +99498

The 2017 CPT^® manual gives you two codes to report ACP services: 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) and +99498 (... each additional 30 minutes [List separately in addition to code for primary procedure]).

During ACP services, the treating physician spends face-to-face time with the patient, family member(s), or healthcare power of attorney to discuss advance directive planning, according to the 2016 CPT^® Assistant article, Vol. 26, No. 2.

Although ACP can include completing relevant legal forms, this is not necessarily a requirement, according to the 2017 CPT^® manual.

ACP services are always considered voluntary.

"Patients must be asked if they are interested in discussing ACP services," says JoAnne Sheehan, CPC, CPB, CPPM, COC, CPC-I senior instructor and coach at Certification Coaching Organization, LLC in Oceanville, New Jersey. "They have the option to decline."

Caution: A physician cannot bill for ACP if he provides the services over the telephone. Only face-to-face time counts, Sheehan adds.

FAQ 2: Characterize Specifics of ACP Discussions

ACP discussions can include the following topics, according to 2016 CPT^® Assistant, Vol. 26, No. 2:

• The current condition of the patient's disease
• The progression of the patient's disease
• Treatments available
• Cardiopulmonary resuscitation and life sustaining measures
• Do not resuscitate orders (DNRs)
• The patient's life expectancy based upon his age and any comorbidities
• The treating physician's clinical recommendations, including his reviews of the patient's past medical history and medical documentation/reports, and the patient's response to prior treatments.

Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Florida, suggests that practices have a check-off form for ACP discussions, including making sure the patient knows who his proxy is. This will help keep both the physician and patient on task.

Document the specifics, Mac says.

"There are different levels, so it's not just all black and white," according to Mac. "There are so many different ways of looking at it."

A patient may not mind having a vent, but another patient may have a problem if he is going to be on life-sustaining equipment, Mac says. He may want to be kept alive on a vent, but doesn't want to be resuscitated if his heart stops beating. Or he may not want to be kept alive if he is in a coma and not aware of what's going on around him.

There is a difference between do not resuscitate and if the patient minds being intubated, Mac adds.

Other details like letting the patient know prior to any procedure that a certain outcome may occur if they unplug or remove the intubation is also important and should be specific, Mac says.

Check these items off and get the patient to sign off on it - to indicate that they understand and have discussed it with their providers, Mac says.

"Patients should be encouraged to discuss their specific wishes completely and fully with whomever the proxy is - whether it's a spouse, or children, or whomever else," according to Mac. "Because the wishes could be misinterpreted."

It's also important that patients understand that they can change their directives at any time, Mac says.

FAQ 3: Factor in the Value of Time

Since 99497 and +99498 are time-based codes, you must note that a unit of time is attained when the mid-point is passed, says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

The physician must spend at least 16 minutes in ACP before he can report 99497, and he must spend at least 46 minutes before he can report +99498 in addition to 99497, according to Moore.

"The definition of time in ACP codes 99497 and +99498 indicates the first 30 minutes and each additional 30 minutes," Sheehan says. "From a CPT^® perspective, the time requirement for this service is met when the midpoint is passed, which is 16 minutes."

The documentation within the medical record should illustrate this time frame to substantiate the codes selected. The documentation not reflecting the start and stop time of the service could be one of the biggest errors she sees with reporting 99497 and +99498, says Najwa N. Liscombe, BHSA, CPC-CPC-I, CMA , coding reimbursement analyst III at the University of Florida College of Medicine and Community Health and Family Medicine in Gainesville, Florida.

The guidelines do not stipulate that start and stop time must be recorded, however, because these are time-based codes, time must be mentioned, according to Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med in Pittsburgh.

It should not be approximate or mentioned using time descriptors like "a lot of time," "a lengthy period," and the like, Hauptman adds.