Primary Care Coding Alert

Once you’ve answered the quiz questions on page 67, compare your answers with the ones our experts have provided below.

Answer 1:
Two CPT^® codes and one add-on code describe, or otherwise include, 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
• 99483 — Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home, with all of the following required elements: … Development, updating or revision, or review of an Advance Care Plan … Typically, 50 minutes are spent face-to-face with the patient and/or family or caregiver.

Answer 2:
“ACP can be billed by any type of physician or qualified healthcare professional [for example, a nurse practitioner or physician assistant] and some other types of providers [for example, a hospital] who can discuss the need for advanced planning and answer questions they may have,” says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC,  revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

Providers can perform ACP services in any setting, with the only exceptions being hospice and intensive care units (ICUs). “This is because it is really no longer ‘advance’ planning if you are already in the ICU or hospice,” Bucknam reminds coders.

Coding caution: “We also need to note that ‘incident-to’ rules apply and need to be adhered to,” says Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California. Per Centers for Medicare and Medicaid (CMS) guidelines, “the usual PFS payment rules regarding ‘incident-to’ services apply, so that when the services are furnished incident-to the billing physician or practitioner all applicable state law and scope of practice requirements must be met” (Source: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQ-Advance-Care-Planning.pdf).

Answer 3:
“Yes, and yes,” says Bucknam. For example, “if the patient talks to the physician, or other providers, and then doesn’tmake an ACP and then comes back and talks to a provider again, the service can be billed again,” Bucknam notes. And they can be billed with other E/M services, though “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,” Bucknam reminds coders.

Coding caution: Remember, CPT^® guidelines state that “A single physician or other qualified health care professional should not report 99483 more than once every 180 days.” And any time a provider bills for ACP “the documentation should show a change in the patient’s health status or changes in their wishes regarding their end of life care to meet medical necessity requirements,” suggests Johnson.

Answer 4:
For services provided under 99497 and 99483, “you should document that the provider had a discussion with the patient, some information about what was discussed, and whether the patient made any decisions,” says Bucknam. “If other people were part of the discussion, it may be helpful to also document any concerns they have expressed,” Bucknam adds.

Documentation of an advance directive or life-sustaining treatment is not required for 99497 (the CPT^® descriptor notes that you only need to document it “when performed”).

For 99483, documenting that your provider has implemented or revised an advance directive, a care plan and palliative care requirements, along with the results of cognitive and behavioral testing the provider has performed on the patient and identification of caregivers, are among a lengthy list of clinical responsibilities laid out in the code’s descriptor that you will need to record.

Additionally, as the ACP codes 99497 and +99498 are time-based, “carriers will look for documentation of the time the provider spent face to face with the patient,” says Johnson. That means you will need to document that the provider has spent at least 16 minutes performing the services outlined in 99497 and at least 46 minutes before you can report +99498 in addition to 99497.