Oncology & Hematology Coding Alert

Get reimbursed for services you may be offering for free.

According to a poster session at the American Society of Clinical Oncology’s (ASCO’s) 2021 Quality Care Symposium, too many hematology and oncology physicians are failing to report advance care planning (ACP) services to Medicare as

separate services. The session, presented by ASCO’s Coverage and Reimbursement Steering Group, concluded that oncologists and oncology practices need to “receive coding and reporting education and guidance on administrative processes to successfully manage ACP services,” (https://old-prod.asco.org/ news-initiatives/policy-news-analysis/advance-care-planning-crucial-component-cancer-care).

If your practice needs such guidance, here’s what you need to know to get credit — and reimbursement — for these crucial elements of a cancer patient’s total care.

Know the Codes and How to Document Them

CPT^® lists two codes that describe ACP services:

• 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)

Here’s what you should do to document them.

Document time: As 99497 and +99498 are time-based, you will need to document the provider has spent at least 16 minutes performing the services outlined in 99497 before you can submit the code for reimbursement, and at least 46 minutes before you can report one unit of +99498 in addition to a unit of 99497.

Document service: For services provided under 99497/+99498, you should document:

• The voluntary nature of the visit
• Who was present
• Explanation and discussion of advance directives (legal documents conveying the patient’s instructions for their treatment should the patient become incapable of communicating them)
• Any change in health status or healthcare wishes if the patient becomes unable to make their own decisions
• The time spent discussing ACP during the face-to-face encounter

Document legal form completion: You should also document the patient’s completion of any forms reflecting their end-of-life wishes, including:

• A living will
• Medical orders for life-sustaining treatment
• A health care proxy
• A durable power of attorney for healthcare

Psychiatric advance directives (Medicare Learning Network Advance Care Planning Fact Sheet: www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/advancecareplanning.pdf)

Remember: You are not required to document the completion of legal forms for 99497 (the CPT^® descriptor notes that you only need to document the completion “when performed”). So, the key to good ACP documentation is not to simply note that patients have filled out the appropriate legal paperwork — if they have chosen to do so — but to document a provider has discussed the relevant issue with the patient and their family, 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.

Know You Can Bill ACP Services With Other Services

With office/outpatient E/M: In many cases, you can bill an ACP discussion separately from evaluation and management (E/M). For example, suppose your provider sees a patient for an E/M to manage a current cancer treatment. At the time of treatment, the provider believes the cancer has the potential to become terminal, so the provider decides this is an opportune moment to discuss end-of-life care issues with the patient and a family member attending the appointment.

In this situation, along with reporting the appropriate units of 99497/+99498 to reflect the amount of time the provider spent in ACP discussion with the patient and family member, you will be able to bill the appropriate code from 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient…) for the office/outpatient E/M. In this case, “modifier 25 [Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service] may be needed,” says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

With Medicare IPPE/AWV: The Medicare Learning Network Advance Care Planning Fact Sheet clarifies that ACP services can also be billed separately with a Medicare annual wellness visit (AWV), coded with G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit) or G0439 (Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit), or the initial preventive physical exam (IPPE) aka the “Welcome to Medicare” visit coded to G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment).

The fact sheet notes that Medicare will pay for ACP either as a medically necessary Medicare Part B service or as an optional element for G0438, G0439, or G0402. It also notes that Medicare will waive ACP coinsurance and the Part B deductible when the ACP is offered by the same provider and delivered on the same day as G0438 or G0439 and billed with modifier 33 (Preventive services). And if Medicare denies a patient’s AWV for exceeding the once-per-year limit, they will still “pay for the ACP as a separate Part B medically necessary service” …. and “apply the deductible and coinsurance to the ACP service.”

For further study: Consult ASCO’s Advance Care Planning Services Practice Administration and Reimbursement Guide by going to https://practice.asco.org/sites/default/files/drupalfiles/2021-08/ACP-Services-Resource-2021-08-06.pdf, and the Medicare Learning Network Advance Care Planning Fact Sheet.