Medicare Compliance & Reimbursement

Tip: Understand both time and policy parameters to ensure clean claims.

Discussing end-of-life care isn’t easy, but it’s tremendously important — regardless of whether the patient is old and facing a terminal illness or young and healthy. Not only does advance care planning (ACP) pose certain challenges for patients and providers, but compliance issues often arise surrounding these complicated services, too.

Context: In a recent report, the HHS Office of Inspector General (OIG) lasered in on ACP services. The national watchdog says that Medicare providers weren’t always in compliance with federal requirements when billing for those services — to the tune of $42.3 million, based on its sampling.

“There are providers that are providing this service and billing for it or providing it but not documenting it appropriately, with time,” says Terry Fletcher, BS, CPC, CCC, CEMC, SCP-CA, ACS-CA, CCS-P, CCS, CMSCS, CMCS, CMC, QMGC, QMCRC, owner of Terry Fletcher Consulting Inc. and consultant, auditor, educator, author, and podcaster at Code Cast, in Laguna Niguel, California.

Plus: Some clinicians didn’t even realize there were time constraints attached to ACP service codes, and that added to the higher-than-average compliance issues, the OIG report says. “Some providers told us that they did not comply with Federal requirements because they did not know that the time for ACP services had to be distinguished between time spent discussing ACP and time spent on concurrent services or because they were unaware there was a time requirement. Additionally, some providers stated that ACP services should not have been billed,” the report notes.

If you’re struggling with ACP service coding and billing, take a look at these five questions and review the answers to beef up your understanding and cut down on denials.

Question No. 1: Are only physicians allowed to conduct and then bill an encounter for ACP?

Answer: No, any qualified health professional (QHP) such as a physician, nurse practitioner (NP), physician assistant (PA), or clinical nurse specialist, can bill for ACP if it falls within their scope of practice.

Answer: No, not always. In fact, a patient, family member(s), or surrogate can be present, per the code descriptors.

The relevant CPT^® code descriptors are as follows: 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 (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).

Question No. 3: Is there a minimum amount of time necessary to bill for an ACP encounter?

Answer: Yes, there is. First, you should know that ACP services are time-based and factor into the CPT^® code. In fact, you shouldn’t bill an encounter as ACP if it lasted less than 15 minutes, Fletcher says. “You have to prove you spent 30 minutes with the patient. You can’t bill for anything less than 15 minutes.”

A Medicare Learning Network (MLN) fact sheet is explicit: Reimbursement for ACP encounters should be evaluated by time and are subject to CPT^® rules about minimum time requirements. See the Centers for Medicare & Medicaid Services (CMS) guidance at www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/advancecareplanning.pdf.

“You shouldn’t discuss any other active management of a patient’s issues for the time reported when you bill ACP codes. When you perform another service concurrently as a time-based service, don’t include the time spent on the concurrent service with the time-based service. Don’t bill any ACP discussion of 15 minutes or less as ACP services. Bill a different Evaluation and Management (E/M) service, like an office visit (if you meet the other service’s requirements). A unit of time is billable when the midpoint of the allowable unit of time passes,” MLN says.