Pulmonology Coding Alert

Work through this COPD case study reporting 99497 and 99498.

Are you prepared to capture your deserved pay for advance care planning (ACP) services? ACP can actually take a lot of emotional burden off the caregiver, and make the patient feel more in control. That said, getting reimbursed for your ACP services may not be as easy as it seems. Here's a case study on how to fit advanced care planning into the jig-saw puzzle of coding and billing.

Codes for advance care planning: When your physician offers advance care planning services, turn to these two codes:

• 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 first 30 minutes; and
• +99498 (...each additional 30 minutes [List separately in addition to code for primary procedure]) for each additional 30 minutes.

According to CPT^® guidelines, 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." CPT^® notes for reporting 99497 and +99498 state that "no active management of the problem(s) is undertaken during the time period reported."

Try Your Hand at This COPD Scenario

Here is an example of a case. Let's see how you go about coding for this scenario:

Mr. Bill developed severe chronic obstructive pulmonary disease (COPD) after 40 years of smoking. At age 72, he is unable to walk from his bedroom without stopping to "catch his breath." He is on multiple medications and visits his physician for the evaluation and management of this disease, including adjusting medications as appropriate. In addition to discussing short-term treatment options, the patient expresses interest in discussing long-term treatment options and planning, such as the possibility of a lung transplant, hospice support and withdrawal of care.

The first step in coding for this patient is selecting one of the following diagnosis codes indicating COPD that describes the condition most accurately.

ICD-10-CM codes for COPD: Here are a few appropriate codes to choose from:

• J44.0 (Chronic obstructive pulmonary disease with acute lower respiratory infection)
• J44.1 (... with [acute] exacerbation)
• J44.9 (... unspecified)

In the scenario, the appropriate code would be J44.9, because the documentation does not show any evidence of a lower respiratory tract infection or an acute exacerbation. In other cases, you may also use the emphysema (J43.-) and chronic bronchitis (J41.-) codes, as these conditions coexist in a COPD, says Jeff Berman, MD, FCCP, executive director of the Florida Pulmonary Society. Look into the documentation to identify these diagnoses, as progressive cases may benefit from advanced care planning.

Add the CPT^® code next: You would bill a standard E/M code for the E/M services – one of the patient encounter codes for disease and medication management for an established patient such as 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient...). Your choice of encounter codes depends on how on much time the provider spent with patient, Berman says.

This provider also discusses advance care planning, acknowledging the patient's desire for care and treatment if he suffers a health event that adversely affects his decision-making capacity, so you will report one or both of the ACP codes depending upon the duration of the ACP service.

Example: Suppose that, in addition to the medical management, the provider spends a half-hour discussing long-term treatment options and wishes related to future care and treatment in the face of an adverse event. Bill the appropriate E/M codes with 99497 for the first 30 minutes of the ACP discussion. Bill additional increments of time provider spent on ACP discussion that day with the add-on code 99498. If on a later date, the patient takes a follow-up one hour appointment for a more detailed ACP discussion, report both 99497 for the first 30 minutes and 99498 for the next 30 minutes.

Documentation: Here are the following components physicians need to note when having advance care planning conversations about end-of-life decisions:

• Evaluation to determine patient risk, benefits, and alternatives
• Discussion of patient's beliefs, values, and goals
• Discussion of care options
• Forms the patient completes.
• Time spent the discussion.

Solve the Hospice Coding Dilemma At Last

How do you handle the coding issues if this COPD patient goes to a hospice for care of his terminal illness? Read on to find out.

Basics: Hospice care provides comprehensive services for patients who do not wish to opt for continued curative treatment. These services include counseling, palliative medications, nursing care, and assistance to family caregivers.

Hospice care discussions: "Prior to making the decision for hospice, the pulmonologist or nurse practitioner may try to identify the goals of care," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. "If hospice is a consideration, the provider may attempt to explain the expected course of hospice election, so that the patient is fully aware of what this means."

Suppose the patient is unlikely to survive beyond six months if the illness is to progress in its natural course. For such a patient to qualify for hospice care coverage, the physician's documentation must support this consideration and expectation. If the patient survives beyond six months, your physician and hospice team will need to recertify the eligibility for hospice care.

Old way: "Prior to the [ACP] codes, most payers would view this type of discussion as 'not separately billable" from the standard E/M related to medical care, or only payable to the hospice, if a hospice provider addressed these issues with the patient," Pohlig says.

New way: Now that ACP is a recognized service, providers can also claim for the initial steps of familiarizing the patient to a personalized choice, Pohlig says. However, "once the patient's wish is realized, and it is time for the patient to initiate the hospice benefit, ACP is no longer an option, and the pulmonologist may no longer be involved in the patient's care," she adds.

Others can bill too: Nurse practitioners and physician assistants can also bill for advance care planning. Plus, a non-physician practitioner (NPP) can provide the service directly for a reduced reimbursement rate (85 percent of the physician fee schedule). CMS also makes special mention that 'incident to' rules apply when one furnishes these services as part of an established care plan incidental to the services of the billing practitioner. This means that the provider who initially performed the service will have to be actively involved in the treatment, and provide direct supervision to the NPP.