Primary Care Coding Alert

Hint: Coinsurance and deductible don’t apply when ACP is part of AWV.

If you have been wondering how to bill for advance care planning (ACP) when your clinician performs the service, you will need to know the codes that you can report for the service. You can also look for help from a new MLN Matters article that clarifies how and when to use these codes when these services are provided as part of an annual wellness visit.

Report These Two Codes for Advance Care Planning Services

When your FP performs advance care planning for a patient, you report one or both of these two codes, depending on the time your clinician spent in performing these 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])

“Per CPT^®, because advance care planning codes 99497 and 99498 are time codes, it is important to note that a unit of time is attained when the mid-point is passed,” observes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “That means you must spend at least 16 minutes in advance care planning before you can report 99497, and you’ll need to spend at least 46 minutes before you can report +99498 in addition to 99497,” Moore adds.

According to CPT^®, you’ll use 99497 and +99498 to report a face-to-face service between a “physician or other health care professional and a patient, family member, or surrogate in counseling and discussing advance directives, with or without completing relevant legal forms.” Note that the CPT^® notes for reporting 99497 and +99498 state that “no active management of the problem(s) is undertaken during the time period reported.”

Definition: An advance directive is a legal document designating an agent that represents the patient and contains the written wishes of the patient for his treatment if he is unable to communicate said wishes. An example of an advance directive might be a durable power of attorney for health care form or health care proxy.

“Note that you do not have to complete an advance directive to report these codes,” Moore says. “The CPT^® descriptor says that completion of such forms is included ‘when performed’ but does not make form completion a prerequisite for reporting the services.” Similarly, MM9271 (referenced below) states, in part, “Voluntary ACP means the face-to-face service between a physician (or other qualified health care professional) and the patient discussing advance directives, with or without completing relevant legal forms.”

Reimbursement Update: Effective Jan. 1, 2016, you can collect about $86 for 99497 and about $75 for +99498 under Medicare.

Learn What You Need to Look for in the Documentation

“Advance care planning is part of many discussions with patients, but the requirements to properly bill 99497 and +99498 are more significant,” says Janean Walker, CPC, CEMC, a consultant at Medical Revenue Solutions in Grain Valley, Mo. “Training physicians how to have advance care planning conversations about end of life and what needs to be documented may be the biggest hurdle.” The recommended documentation should include the following:

• Evaluation to determine patient risk, benefits, and alternatives
• Forms
• Discussion of patient’s beliefs, values, and goals
• Discussion of care options
• Time spent discussing.

POS Update: According to National Government Service (NGS), a Medicare administrative contractor (MAC), it was denying payment for claims for 99497 and +99498 due to an incorrect place of service (POS). Initially, NGS was limiting payment for these codes to office (11) and independent clinic (49) and denying claims with other POS codes. NGS has now clarified that they have updated their systems to accept the following POS codes: 04, 11-14, 19-23,31-34,49, 51-55,57,61-62,65, and 71.

According to NGS, you will not have to resubmit affected claims or request an appeal if your claim was denied due to POS. NGS has clarified that it will begin a mass adjustment to claims that were denied in error. If NGS is not your MAC, you may want to check with your MAC regarding any limits on POS it is imposing.

Gauge Whether AWV Is Involved

To determine whether you should apply a patient’s deductible to her ACP service, and also whether to bill the patient a coinsurance amount, you should first read through the notes to determine whether the ACP was performed during an annual wellness visit (AWV), CMS says in MLN Matters article MM9271.

If your provider performs the ACP service as an optional element of an AWV, you should report both the AWV and the ACP and waive the deductible and coinsurance for both services. “ACP services furnished on the same day and by the same provider as an AWV are considered a preventive service,” the article notes. “Therefore, the deductible and coinsurance are not applied to the codes used to report ACP services when performed as part of an AWV.”

Exception: On the other hand, if you furnish an ACP service outside of an AWV visit, you should collect the coinsurance and apply the visit to the deductible, the article notes. “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,” Moore notes.

Example: A patient presents for his annual wellness visit and asks the doctor to also 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 for the ACP service, together on the same claim form. You should append modifier 33 (Preventive services) to 99497 to ensure that the deductible and coinsurance are waived.

Resource: 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.