Practice Management Alert

Hint: Don’t double dip on ACP and E/M services.

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) is lasering in on advance care planning (ACP) services. The agency says that Medicare providers weren’t always in compliance with federal requirements when billing for those services — to the tune of $42.3 million, based on their sampling.

“There are providers that are providing this service and billing for it or providing it but not documenting it appropriately, with time,” 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.

Myth No. 1: Only a physician can conduct and then bill an encounter for ACP.

Myth busted: Any qualified health professional (QHP) such as a physician, nurse practitioner (NP), physician assistant (PA), or clinical nurse specialist, can bill for ACP if it falls within their scope of practice.

Myth No. 2: An ACP encounter can be held only with an individual patient.

Myth busted: A patient, family member(s), or surrogate can be present, per the code descriptors.

The relevant CPT^® code descriptors 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) and +99498 (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; each additional 30 minutes (List separately in addition to code for primary procedure).

Myth No. 3: There’s no minimum amount of time for an ACP encounter.

Myth busted: Don’t bill an encounter as ACP if it lasted less than 15 minutes.

“You have to prove you spent 30 minutes with the patient. You can’t bill for anything less than 15 minutes,” Fletcher says.

A Medicare Learning Network (MLN) Fact Sheet is explicit: Reimbursement for ACP encounters should be evaluated by time and are subject to CPT^® rules about minimum time requirements. (See the Fact Sheet here, www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/ downloads/advancecareplanning.pdf)

“You shouldn’t discuss any other active management of a patient’s issues for the time reported when you bill ACP codes. When you perform another service concurrently as a time-based service, don’t include the time spent on the concurrent service with the time-based service. Don’t bill any ACP discussion of 15 minutes or less as ACP services. Bill a different Evaluation and Management (E/M) service, like an office visit (if you meet the other service’s requirements). A unit of time is billable when the midpoint of the allowable unit of time passes,” MLN says.

Check out this chart for more information:

Myth No. 4: Completing forms relevant to ACP means you can bill for ACP services.