Primary Care Coding Alert

While it’s particularly important for your older or terminally ill patients, advance care planning (ACP) is also a great idea for all your patients at any time, even when they are in excellent health, so they can record their wishes for end-of-life care.

The guidelines go on to provide examples of the written forms alluded to in the descriptor, including health care proxies, durable powers of attorney for health care, living wills, and medical orders for life-sustaining treatment. However, as each state has different laws regarding end-of-life directives, it is important you know the legal status of any form used in the planning session.

Pro coding tip: The AARP maintains a comprehensive list of advance directive forms, searchable by state, which you can find at www.aarp.org/caregiving/financial-legal/free-printable-advance-directives/.

What Comprises ACP Services?

Surprisingly, the descriptors and the CPT^® guidelines for 99497/+99498 tell you that the services do not have to result in the production of an advance directive for the patient.

The descriptor simply states that a physician or other qualified healthcare professional (QHP) needs to explain and discuss advance directives, and that completion of ACP forms need only be documented “when performed.” This is echoed in the CPT^® guidelines for the codes, which state in part that the service should consist of “counseling and discussing advance directives, with or without completing relevant legal forms.”

Who Can Offer ACP Services?

As the descriptors for 99497/+99498 state, “ACP can be billed by any type of physician or QHP 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.

Additionally, for Medicare patients, “incident-to rules apply and must 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.

In other words, a nurse practitioner, (NP), a physician’s assistant (PA) or other nonphysician provider (NPP) may furnish ACP services providing “the usual PFS payment rules regarding ‘incident-to’ services apply,” per Centers for Medicare & Medicaid (CMS) guidelines, meaning the patient must be established with the physician; the physician must have evaluated the patient’s condition during the face-to-face part of an evaluation and management (E/M) visit; the physician must have established a plan of care for the patient; and the NPP must be providing the service to help execute the patient’s care plan in part or whole. Further, “when the services are furnished incident-to the billing physician or practitioner, all applicable state law and scope of practice requirements must be met,” according to CMS ACP guidelines

(Source: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQ-Advance-Care-Planning.pdf).

What to Document (1): The Discussion

To document ACP services correctly, “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 Buckam.

The December 2014 issue of CPT^® Assistant suggests that the discussion go through five stages covering the following:

Stage 1 - Representational assessment: Discussion with the patient and surrogate regarding their understanding of their current medical situation and their perspective on it.

Stage 2 – Patient preferences: Discussion with the patient regarding their treatment preferences based on their own past experiences and the experiences of others.

Stage 3 – Conditions for change: Discussion with the patient and surrogate regarding the nature of the patient’s condition and the patient’s end-of-life wishes and preparing the surrogate to be able to fully represent the patient’s wishes when the time comes.

Stage 4 – Clinical choices: Discussion with the patient of condition-appropriate treatments, possible treatment options, and related choices the surrogate would have to make regarding the patient’s treatment.

Stage 5 – Summarization: Discussion with the patient and surrogate of the importance of ACP and updating the ACP when necessary.

As ACP discussions often involve a patient’s surrogate, “it may be helpful to also document any concerns they have expressed, too” Bucknam adds.

What to Document (2): The Time

“As 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.

A timely reminder: The December 2014 issue of CPT^® Assistant also offers the advice that “a unit of time is attained when the mid-point is passed.” As the time parameter for both 99497 and +99498 is 30 minutes, that means you would bill one unit of 99497 if the ACP discussion lasted from 16 minutes to 45 minutes. You would add one unit of +99498 if the discussion went on from 46 minutes to 75 minutes and another unit of +99498 for a discussion lasting from 76 minutes to 105 minutes.

When Can ACP Services Be Billed?

They can be billed with evaluation and management (E/M) services, appending 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) if needed, according to Bucknam.

Also, “if the patient talks to the physician, or other providers, and then doesn’t make an ACP and then comes back and talks to a provider again, the service can be billed again,” Bucknam notes. Neither CPT^® nor Medicare has any limits on the number of times you can report ACP for a given beneficiary in a given time period. However, to justify billing the service multiple times for a given patient, “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 and per the CMS ACP guidelines.