Home Health & Hospice Week

Lack of NCD potential problem.

The 2016 Medicare Physician Fee Schedule proposed rule specifically names two Advance Care Planning codes that physicians or other qualified healthcare professionals can bill:

• CPT® code 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 professional; first 30 minutes, face-to-face with the patient, family member(s) and/or surrogate.
• CPT® code 99498 — …each additional 30 minutes (List separately in addition to code for primary procedure).

“What these additional codes provide is the ability for clinicians to spend the necessary time to discuss the risks and benefits of all treatment options and to explore what the patient (or designated decision-maker) thinks is best for them, and to bill for the time spent in these important discussions,” noted Dr. Cheryl Phillips with Leading Age in a recent analysis.

“But it is important to note that this means more than just filling out a form and checking a box,” Phillips added. “Such advance care planning discussions must first focus on the individual’s values and preferences, their understanding of their illness and options, and include a dialogue about care preferences.”

Caveat: Although establishing separate payment for these CPT® codes and ACP services is a step in the right direction, CMS has not yet made a national coverage determination, lamented American Academy of Family Physicians board chair Reid Blackwelder, MD. In the proposed rule, CMS gives CPT® codes 99497 and 99498 status indicator “A,” which indicates that Medicare has not made a national coverage determination — and without a national policy, Medicare contractors can make local coverage decisions.

CMS should “prevent what will quickly become inconsistent local interpretations, which will be particularly confusing for physician practices that serve patients in two or more local coverage areas,” Blackwelder warned in AAFP’s comment letter. Therefore, CMS should begin the process of making a national coverage determination for ACP services right away, he urged.