Oncology & Hematology Coding Alert

Question: Our physician does advance care planning for various patients. How can we report this planning if it is done as part of annual visit to the physician? Is it acceptable to waive the deductible and coinsurance for these services?

New York Subscriber

Answer: You should first determine if advance care planning (ACP) was performed during an annual wellness visit (AWV). This will help you to determine whether you should apply a patient's deductible to the ACP service, and also whether to bill the patient a coinsurance amount.

Check if ACP was optional element of AWV: If your physician performs the ACP service as an optional element of an AWV, you should report both the AWV and the ACP. You should also waive the deductible and coinsurance for both services. According to CMS, 'ACP services furnished on the same day and by the same provider as an AWV are considered a preventive service. Therefore, the deductible and coinsurance are not applied to the codes used to report ACP services when performed as part of an AWV.'

If ACP is not part of AWV: If you furnish an ACP service outside of an AWV visit, you should collect the coinsurance and apply the visit to the deductible. ACP services can be provided in conjunction with other evaluation and management services, but it is only when ACP is provided in conjunction with an AWV that you can waive the deductible and coinsurance.

Append modifier 33: Consider this example: A patient may present to your physician for the annual wellness visit and seek to discuss creating an advance directive to denote his wishes if he ever lacks the capacity to make those decisions on his own. You'll report G0438 (Annual wellness visit; includes a personalized prevention plan of service [PPPS], initial visit) for the AWV, as well as 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 ACP service, together on the same claim form. For any additional service beyond 30 minutes, you submit code +99498 (....... each additional 30 minutes [List separately in addition to code for primary procedure]). You should append modifier 33 (Preventive services) to 99497 and +99498 to ensure that the deductible and coinsurance are waived.

Check for more information: To read more about coding and billing for ACP services, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9271.pdf.