Oncology & Hematology Coding Alert

Submit codes 99497 and +99498 on the same date as chronic care management, and in global surgical periods.

Are you prepared to earn for your physician’s services for advance care planning? Last year, the Centers for Medicare & Medicaid Services (CMS) announced reimbursement of advance care planning services. This was a welcome change for oncology providers. Effective January 2016, neither physicians nor beneficiaries could seek reimbursement from Medicare for advance care planning discussions if these discussions were the sole purpose of the visit. Advance care planning is now a separate billable service.

Codes for advance care planning: When your physician offers advance care planning services, you turn to these two 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) for the first 30 minutes and 99498 (………each additional 30 minutes [List separately in addition to code for primary procedure]) for each additional 30 minutes.

According to CPT^®, you’ll use 99497 and +99498 to report a face-to-face service between a “physician or other health care professional and a patient, family member, or surrogate in counseling and discussing advance directives, with or without completing relevant legal forms.” Note that the CPT^® notes for reporting 99497 and +99498 state that “no active management of the problem(s) is undertaken during the time period reported.” 

Here are five important basic questions that will help you to understand advance care planning services.

1. What does advance care planning mean?

Your physician may discuss with the patient to facilitate informed decision making for palliative care, hospice care, advance directive, and end-of-life care. The discussions for these options comprise advance care planning. Your physician identifies the patient’s preferences for end-of-life care. Beneficiaries are free to alter their care preferences and discussed the desired care with their physicians.

End-of-life care: End-of-life care implies the healthcare the patient with terminal illness receives in days or years before death. Medicare beneficiaries are eligible to receive services like physician services, prescription drugs, diagnostic tests, and home or hospital care.

Medicare covers a comprehensive set of health care services, for both therapeutic and palliative purposes, a patient may receive until death.

Hospice care: Hospice comprises comprehensive services for patients who do not like to opt for continued curative treatment. These services include counselling, palliative medications, nursing care, and assistance to family caregivers. Generally, hospice care is provided in patients’ homes. For the patient to qualify for hospice care coverage, when the patient is unlikely to survive beyond six months if the illness is to progress in natural course, the physician’s documentation must support this consideration and expectation. If the patient survives beyond six months, your physician and hospice team will need to recertify the eligibility for hospice care.

Advance directive? Advance directive is a document which enables a person to make provision for his health care decisions for the future should the patient become unable to make those decisions. These documents may include a living will and a medical power of attorney.

2. When can you bill for advance care planning?

The CMS issued a directive that you can earn for advance care planning services at each “Annual Wellness Visit.” Additionally, you can also bill for these services whenever deemed necessary.

Tip: When billing for advance care planning services, make sure your physician documents the planning was medically necessary and required.

3. Will the service cover for more than one provider?

CMS allows multiple-providers to report the codes for reimbursement. This implies beneficiaries can access more information and make an informed decision about the continuation of treatment and end-of-life care from more than on provider.

4. Can physicians provide advance care planning at any stage of treatment?

You can bill for advance care planning services provided by the physician at any stage of treatment. Your physicians choose to offer these services early in treatment planning as this will help to determine the patient’s available options and preferences. Discussion with their provider will also help avoid any unwanted and futile treatment options as the patient’s disease progresses to an advanced stage. The purpose of the visits is to allow patient involvement in their treatment planning.

Advance care planning can offer better quality of life to the patient who may achieve better symptom control. These services for advanced care may be offered at home.

Bill for advance care with other services: According to the Final Rule, you can report 99497 and 99498 on the same date as other E/M services, transitional care management and chronic care management.  This is also billable during global surgical periods. You cannot, however, report 99497 and +99498 on the same date as certain critical care services, including neonatal and pediatric critical care.

5. Can advance care planning be billed for non-physician providers?

 You can bill advance care planning when delivered by nurse practitioners and physician assistants. These can be provided by a non-physician practitioner (NPP) directly for a reduced reimbursement rate.  CMS also makes special mention that ‘incident to’ rules apply when these services are furnished as part of an established care plan incidental to the services of the billing practitioner with a minimum of direction.

Tip: In the ED setting, where ‘incident to’ rules don’t apply, the advance care planning service must be performed by the physician or NPP reporting the service.

Check for what it pays: The agency assigned 1.50 work RVUs to 99497 and 1.40 RVUs to 99498. Accordingly, this will translate into payments of about $79-85 for 99497 and $70-75 for the add-on code 99498.

CMS Rule: You can read more about the CMS rule “Proposed policy, payment, and quality provisions changes to the Medicare Physician Fee Schedule for Calendar Year 2016” at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-10-30-2.html.