Medicare Compliance & Reimbursement

After you’ve answered the quiz questions on page 3, check your responses with the ones below:

Answer 1: The descriptor for 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 its add-on code +99498 (… each additional 30 minutes (List separately in addition to code for primary procedure)) tells you that a physician or other qualified healthcare professional (QHP) needs to explain and discuss advance directives. Surprisingly, completion of ACP forms need only be documented “when performed.” This is echoed in the CPT^® guidelines for the codes, which state in part that the service should consist of “counseling and discussing advance directives, with or without completing relevant legal forms.”

The guidelines go on to provide examples of the written forms alluded to in the descriptor, including healthcare proxies, durable powers of attorney for healthcare, living wills, and medical orders for life-sustaining treatment. However, as each state has different laws regarding end-of-life directives, it is important you know the legal status of any form used in the planning session.

Pro coding tip: The AARP maintains a comprehensive list of advance directive forms, searchable by state.

Answer 2: The first element of ACP services you should document involves the discussion between the physician or QHP and the patient, family member(s), and/or surrogate. “You should document that the provider had a discussion with the patient, some information about what was discussed, and whether the patient made any decisions,” advises Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

The December 2014 issue of CPT^® Assistant suggests that the discussion go through five stages covering the following:

• Stage 1 - Representational assessment: Discussion with the patient and surrogate regarding their understanding of their current medical situation and their perspective on it
• Stage 2 – Patient preferences: Discussion with the patient regarding their treatment preferences based on their own past experiences and the experiences of others
• Stage 3 – Conditions for change: Discussion with the patient and surrogate regarding the nature of the patient’s condition and the patient’s end-of-life wishes and preparing the surrogate to be able to fully represent the patient’s wishes when the time comes
• Stage 4 – Clinical choices: Discussion with the patient of condition-appropriate treatments, possible treatment options, and related choices the surrogate would have to make regarding the patient’s treatment
• Stage 5 – Summarization: Discussion with the patient and surrogate of the importance of ACP and updating the ACP when necessary

As ACP discussions often involve a patient’s surrogate, “it may be helpful to document any concerns they have expressed, too,” Bucknam suggests.

The second element of ACP services you should document is the time. “As 99497 and +99498 are time-based, carriers will look for documentation of the time the provider spent face to face with the patient,” says Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

The December 2014 issue of CPT^® Assistant also reminds you that “a unit of time is attained when the midpoint is passed.” As the time parameter for both 99497 and +99498 is 30 minutes, that means you would bill one unit of 99497 if the ACP discussion lasted from 16 minutes to 45 minutes. You would add one unit of +99498 if the discussion lasted from 46 minutes to 75 minutes, another unit of +99498 for a discussion lasting from 76 minutes to 105 minutes, and so on.

Answer 3: As the descriptors for 99497/+99498 state, “ACP can be billed by any type of physician or QHP and some other types of providers [for example, a hospital] who can discuss the need for advanced planning and answer questions they may have,” says Bucknam.

Additionally, for Medicare patients, “incident-to rules apply and must be adhered to,” says Johnson. So, a nurse practitioner (NP), a physician’s assistant (PA), other nonphysician provider (NPP), or other staff may also furnish ACP services providing “the usual PFS payment rules regarding ‘incident-to’ services apply,” per Centers for Medicare & Medicaid (CMS) guidelines. This means:

• The patient must be established with the physician.
• The physician must have evaluated the patient’s condition during the face-to-face part of an evaluation and management (E/M) visit.
• The physician must have established a plan of care for the patient.
• The physician must manage, participate, and meaningfully contribute to the provision of the services in addition to providing a minimum of direct supervision.
• The NPP must be providing the service to help execute the patient’s care plan in part or whole.

Further, “when the services are furnished incident-to the billing physician or practitioner, all applicable state law and scope of practice requirements must be met,” according to CMS’ ACP guidelines.

Answer 4: Neither CPT^® nor Medicare has any limits on the number of times you can report ACP for a given beneficiary in a given time period. So, “if the patient talks to the physician, or other providers, and then doesn’t make an ACP and then comes back and talks to a provider again, the service can be billed again,” Bucknam notes. But to justify billing the service multiple times for a given patient, “the documentation should show a change in the patient’s health status or changes in their wishes regarding their end-of-life care to meet medical necessity requirements,” suggests Johnson, based on the CMS ACP guidelines.

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