Medicare Compliance & Reimbursement

But does no national coverage determination mean no reliable payments?

Conversations with a patient about his mortality aren’t the happiest chats, but they’re even worse if you cannot bill for the extra time and effort that they take. But soon you’ll likely get deserved reimbursement for advance care planning (ACP), thanks to the reimbursement proposal of the two CPT^® codes 99497 and 99498, which were introduced this year.

On July 8, the Centers for Medicare & Medicaid Services (CMS) released the 2016 Medicare Physician Fee Schedule proposed rule, which is the first update to the physician payment schedule since the repeal of the sustainable growth rate (SGR) through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). And one of the most game-changing provisions in the proposed rule is the American Medical Association’s (AMA’s) recommendation to make ACP services a separately payable service under Medicare.

ACP Doesn’t Only Benefit Patients

“Making separate payment for ACP will help ensure that we understand our patients’ care preferences, and we are delighted that it has been included in the 2016 Physician Fee Schedule,” American Geriatrics Society (AGS) president Steven Counsell, MD, AGSF, said in a recent statement. The AGS, along with a myriad of other partner professional organizations, have been lobbying CMS to provide greater support to advance ACP.

ACP is a “comprehensive, ongoing, patient-centered approach to future health care choice communication that experts warn still is not reaching enough patients,” according to Wayne McCormick, a professor of medicine with the University of Washington, Department of Medicine, Division of Gerontology and Geriatric Medicine at Harborview Medical Center.

Impact: “A growing body of evidence suggests that ACP can contribute to improved health outcomes (e.g., reductions in hospitalizations and intensive treatment) and also lead to deeper appreciation of patient desires, including ensuring that an individual dies in his or her preferred setting,” McCormick says. “Some studies even link ACP to increased patient satisfaction with quality of care, and with less risk for stress, anxiety, and depression among caregivers and surviving relatives.”

Get to Know the 2 New Codes

The proposed rule specifically names two ACP 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, senior vice president of public policy and advocacy for Washington, D.C.-based Leading Age, in a July 10 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.”

According to the American College of Physicians, these discussions include addressing the patient’s:

• Current disease state;
• Disease progression;
• Available treatments;
• Cardiopulmonary resuscitation;
• Life-sustaining measures;
• Life expectancy considering the patient’s age and comorbidities;
• Clinical recommendations from the treating physician;
• Past medical history;
• Medical documentation/reports; and
• Responses to previous treatments.

Enjoy Flexibility When Coding ACP Services

Scenario: In the proposed rule, CMS included an example of how ACP services could occur in conjunction with treating or managing a patient’s presenting condition: A patient who is receiving treatment for heart failure and diabetes sees his physician for evaluation and management (E/M) of these two diseases.

Along with discussing short-term treatment options, the patient may want to discuss long-term treatment options like a heart transplant. In this case, you would report a standard E/M code for the E/M service and one or both of the ACP codes depending on the duration of the ACP service.

Understand: The ACP services in this scenario would not necessarily need to occur on the same day as the E/M service. This gives you more flexibility to bill for ACP services, even when the healthcare professional provides E/M services on the same day as ACP services or during separate visits — or even during the patient’s annual Medicare-covered wellness visit, said American Academy of Family Physicians (AAFP) board chair Reid Blackwelder, MD, in a recent letter to CMS Acting Administrator Andy Slavitt.

One Problem Could Throw a Wrench in the Works

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 Blackwelder. 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. Therefore, CMS should begin the process of making a national coverage determination for ACP services right away.

The proposed rule had a 60-day public comment period, which ended on Sept. 8, after which CMS will finalize the policies contained in the rule to take effect starting in 2016.

Resources: To view the proposed rule, go to www.federalregister.gov/articles/2015/07/15/2015-16875/medicare-programs-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions. CMS also released a fact sheet on the proposed rule, which is available at www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-07-08.html.