Oncology & Hematology Coding Alert

Hint: Always document specifics in advance directives.

In the Oncology & Hematology Coding Alert volume 21 number 11, you learned about time and documentation requirements for Advanced Care Planning (ACP) services in the article, “Here’s How to Find Your Way Through the Advance Care Planning Coding Maze.”

Check out these three additional points to make sure you collect for your physician’s services when he discusses end-of-life decisions with Medicare beneficiaries.

Always Remember 99497/+99498

During ACP services, the treating physician spends face-to-face time with the patient, family member(s), or healthcare power of attorney to discuss advance directive planning, according to the 2016 CPT^® Assistant article, Vol. 26, No. 2.

Although ACP can include completing relevant legal forms, this is not necessarily a requirement, according to the 2020 CPT^® manual.

The 2020 CPT^® manual gives you two code choices for ACP services. They 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)
• +99498 ( … each additional 30 minutes (List separately in addition to code for primary procedure)).

“At least 16 minutes is needed for ACP planning in order to bill 99497,” says Kaitlyn Eversole, CPC, CFPC, Medical Coder III at Healthcare Resource Solution in Evansville, Indiana. “Medicare covers this as a preventive service when billed with G0438 or G0439. It is not allowed with G0402, as ACP is a requirement for Welcome to Medicare.”

ACP services are voluntary. Patients must be asked if they are interested in discussing ACP services, because they have the option to decline. “This is true, unless the patient is unresponsive. Based on state guidelines, this service can be discussed with another family member/caregiver. This is the only E/M service that does not require the patient to be present,” Eversole says.

Important: A physician cannot bill for ACP if he provides the services over the telephone. Only face-to-face time is counted.

Define Advance Directives

Although most people have said they would rather die at home, only one-third of adults have an advance directive containing their end-of-life care wishes. Fewer than 50 percent of terminally ill patients have an advance directive in their medical records.

Official definition: The 2020 CPT^® manual defines an advance directive as a legal document designating an agent to represent the patient, which contains the patient’s written wishes for his treatment should he be unable to communicate his wishes.

Healthcare proxies, durable power of attorney for healthcare, living wills, and medical orders for life-sustaining treatment (MOLST) are some examples of written advance directives, per the 2020 CPT® manual.

The patient can change his proxy at any time, according to Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Florida.

Mac emphasizes the importance of the proxy/surrogate being completely aware of the patient’s wishes.

“It’s a matter of carrying out a patient’s goals or values — their beliefs,” Mac says. “You need to know whether or not they want to be maintained on life-sustaining equipment, and if they are not able to make that decision, do you have someone who can make those decisions, and are they aware of those decisions?”

Note: Remember an advance directive only goes into effect if the patient is “incapacitated and unable to communicate, regardless of age,” according to 2014 CPT^® Assistant, Vol. 24, No. 12.

Tip 3: See What Happens During ACP

ACP discussions might include the following topics, according to 2016 CPT^® Assistant, Vol. 26, No. 2:

• The current condition of the patient’s disease
• The progression of the patient’s disease
• Treatments available
• Cardiopulmonary resuscitation/life sustaining measures
•  Do not resuscitate orders (DNRs)
• The patient’s life expectancy based upon his age and any comorbidities
• The treating physician’s clinical recommendations, including reviews of the patient’s past medical history and medical documentation/reports, and the patient’s response to prior treatments.

Mac suggests practices have a check-off form for ACP discussions, including making sure the patient knows who his proxy is. This will help to keep both the physician and patient on task.

Document the specifics, Mac says.

“There are different levels, so it’s not just all black and white,” Mac says. “There are so many different ways of looking at it.”

A patient may not mind having a vent, but another patient may have a problem if he is going to be on life-sustaining equipment, Mac says. He may want to be kept alive on a vent but doesn’t want to be resuscitated if his heart stops beating. Or he may not want to be kept alive if he is in a coma and not aware of what’s going on around him.

There is a difference between do not resuscitate and if the patient minds being intubated, Mac adds.

Other details like letting the patient know prior to any procedure that a certain outcome may occur if they unplug or remove the intubation is also important and should be very specific, Mac says.

Check these things off and get the patient to sign off on it — to indicate they understand and have discussed it with their providers, Mac says.

“Patients should be encouraged to discuss their specific wishes completely and fully with whomever the proxy is — whether it’s a spouse, or children, or whomever else,” according to Mac. “Because the wishes could be misinterpreted.”

It’s also very important that patients understand they can change their directives at any time, Mac says.

Important: Physicians should not shy away from having ACP conversations with their patients. If the physician doesn’t feel qualified for every aspect of ACP, there are reference materials available through the various medical societies to make these conversations more common around the healthcare community.