Discussing death, dying, and advance care planning

Advance care planning, which promotes the understanding and sharing of a person's values, life goals, and preferences regarding future medical care, can be done at any age or any stage of health. Its main goal is to ensure that patients receive medical care consistent with their values, goals, and preferences during serious and/or chronic illness.

Engaging patients and their potential surrogate decision makers (family members, friends, companions, etc.) in these discussions is a crucial component of patient- and family-centered care. Advance care planning can help identify a surrogate decision maker and explore the patient's opinions about medical care, then translate these opinions into medical care plans.

Clinicians and their teams may want to identify which patients and families to prioritize for advance care planning initiatives. All patients seen in the outpatient setting should be encouraged to engage in the advance care planning process. Discussions, patient and family resources, and/or decision aids can be more in-depth for those with serious illness, ideally beginning early in the disease course and repeated or revisited as needed.

The responsibility of engaging patients in advance care planning should not fall solely on the physician. Multidisciplinary teams should work together in a coordinated fashion to engage patients and families and should be trained to initiate brief conversations that assess a patient's readiness to discuss the advance care planning process. Health care teams should expect to incorporate advance care planning over multiple visits.

Additionally, existing clinic programs can be modified to support advance care planning. For example, advance care planning interventions (counseling, education, support, and person-centered advance care planning tools) can be added to existing programs that address other needs such as tobacco cessation, chronic disease management, exercise, and nutrition programs. Also, advance care planning can be added to routine preventive care processes, such as Medicare Annual Wellness Visits.

The usual payment rules regarding “incident to” services apply to advance care planning, 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 and there must be a minimum of direct supervision in addition to other “incident to” rules.

The following codes should be used to bill for advance care planning:

• CPT Code 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
• CPT Code 99498: Each additional 30 minutes (list separately in addition to code for primary procedure)

Clinicians should consult their Medicare Administrative Contractors (MACs) regarding documentation requirements. Examples of documentation include an account of the discussion with the beneficiary/family/surrogate regarding the voluntary nature of the encounter, an indication of the explanation of advance directives (along with completion of those forms, when performed), who was present, and the time spent in the face-to-face encounter.

There are no limits on the number of times advance care planning can be reported in a given time period. Moreover, there are no place-of-service limitations on the advance care planning codes.

ACP offers an advance care planning toolkit. In addition, ACP Practice Advisor offers a new module, “Practical Advice for Advance Care Planning.” Those who have signed up for ACP Practice Advisor and successfully complete the module can claim 20 CME and/or 20 MOC credits.