ED Coding and Reimbursement Alert

Documentation, diagnosis and duration are all covered in this informative release

The Centers for Medicare and Medicaid Services (CMS) recently released at set of Frequently Asked Questions about billing the Advance Care Planning Services under the Physician Fee Schedule. This helpful document offers guidance on some the nebulous aspects CPT^® codes 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]) in 2016.

CMS has offered helpful additional information to supplement what appears in the CPT^® book describing advance care planning service, says Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, a national ED coding and billing company based in Bedford, MA.  Read on for advice on Medicare documentation and diagnosis requirements.

Can you report ACP Codes in the ED setting?

CPT^® rules set no limits on the number of times ACP you can report for a given beneficiary in a given time period and CMS has not established any frequency limits of its own. Importantly, when the service is billed multiple times for a given beneficiary, CMS will expect to see a documented change in the beneficiary’s health status and/or wishes regarding his or her end-of-life care, says Granovsky.

What Documentation Is Required to Report the service?

CMS directs practitioners to consult their Medicare Administrative Contractors (MACs) regarding documentation requirements. Examples of appropriate documentation include an account of the discussion with the beneficiary (or family members and/or surrogate) regarding the voluntary nature of the encounter; documentation indicating 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.

No specific diagnosis is required to bill the ACP codes.

Can ACP be reported in addition to an ED E/M visit?

CMS adopted the CPT^® codes and provisions for reporting 99497 and 99498. This includes the instructions that these codes may be billed on the same day or a different day as most other E/M services, including the ED E/M codes, explains Granovsky.

Remember that these are time based codes so CMS says you should consult CPT^® provisions regarding minimum time required to report timed services which typically include exceeding the midpoint of the time requirements.

If the required minimum time is not spent with the beneficiary, family member(s) and/or surrogate to bill codes 99497 or 99498, you may consider billing only the ED visit, provided the requirements for billing that E/M service are met.

CMS also adopted the CPT^® guidance prohibiting reporting codes 99497 and 99498 on the same date of service as certain critical care services including neonatal and pediatric critical care, because those are also time based codes, warns Granovsky.

Who Can Perform ACP Services?

CMS is clear in the 2016 PFS final rule that the services described by codes 99497 and 99498 can be provided by physicians or using a team-based approach provided by physicians, nonphysician practitioners (NPPs) and other staff under the order and medical management of the beneficiary’s treating physician.

The CPT^® code descriptors say the services can be furnished by physicians or other qualified health professionals. For Medicare purposes, this is consistent with allowing these codes to be billed by the physicians and NPPs whose scope of practice and Medicare benefit category include the services described by the codes and who are authorized to independently bill Medicare for those services. Therefore, only these practitioners may report codes 99497 or 99498.

The ACP services described by codes 99497 and 99498 are primarily interactions between patients and physicians or their proxies; so CMS expects the billing physician or NPP to manage, participate and meaningfully contribute to the provision of the services in addition to providing a minimum of direct supervision.

The usual Medicare payment rules regarding ‘‘incident-to’’ services apply with these codes as well. So that when the services are furnished “incident-to” the billing physician or practitioner all applicable state law and scope of practice requirements must be met and there must be a minimum of direct supervision in addition to other incident-to rules.

Note: “Incident-to” rules don’t apply in the ED setting when the emergency physician does not typically employ the other members of the healthcare team.

Does the beneficiary have to be involved or even physically present to bill ACP? Can I bill if I spent the required time talking with family?

It could be common in the ED setting to have the advance care planning discussion with a family member without the patient able to participate meaningfully, if at all. CMS confirms the language in the CPT^® code descriptors that you can only report 99497 and 99498 for time spent with the beneficiary, family members, and/or surrogate. If the beneficiary is not present or able to participate in the discussion, you should document that the beneficiary is impaired and unable to participate effectively and that ACP was instead conducted face-to-face with family or other legal surrogate(s).

Since ACP services are voluntary, Medicare beneficiaries (or their legal proxies when applicable) need to be given a clear opportunity to decline to receive ACP services. Beneficiaries, family members, or surrogates may receive assistance for completing legal documents from others outside the scope of the Medicare program in addition to, or separately from, the physician or NPP. CPT^® code descriptors indicate “when performed,” so completing an advance directive form is not a requirement for billing the service, says Granovsky.

CMS Offers Additional Resources for ACP information

The CMS FAQs draw on the final rule policies for ACP outlined in the CY 2016 PFS final rule (80 Fed. Reg. 70955 through 70959, available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html).

For additional information, CMS refers readers to the final rule and to the Medicare Learning Network Matters article MM9271/CR9271/R216BP and R3428CP (available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/2016-MLN-Matters-Articles.html). CR9271 provides detailed billing instructions when ACP is furnished as an optional element of the AWV.