Advance care planning: Administration and reimbursement

Advance care planning is an important component of patient-centered, high-quality care. Per the most recent edition of the American College of Physicians' Ethics Manual, “Physicians should routinely raise advance planning with adult patients with decision-making capacity and encourage them to review their values and preferences with their surrogates and family members … These discussions let the physician know the patient's views, enable documentation of patient wishes in the medical record, and allow the physician to reassure the patient that [they are] willing to discuss these sensitive issues and will respect patient choices.”

Internal medicine physicians are uniquely situated to have these conversations as they share longitudinal relationships with their patients that span multiple encounters, making advance care planning conversations possible before critical illness or hospitalization.

Patients often receive these services during some of the hardest moments of their lives, and physician-led discussions are associated with increased quality of life and mood, longer survival, decreased use of nonbeneficial medical care near death, decreased expenditures, enhanced goal-consistent care, and positive family outcomes. These conversations can be difficult, and to successfully implement them, the College recommends steps such as identifying and preparing appropriate patients and ensuring that time is made available during appointments, that roles for those involved in the conversation are clear, and that clear documentation of conversations occurs.

Receiving Medicare reimbursement for advance care planning can be an additional challenge. To qualify for Medicare reimbursement, it is necessary to understand the service, as well as the coding and billing requirements.

Coding

The two Current Procedural Terminology (CPT®) codes used to report advance care planning services are:

• 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; and
• 99498. 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; each additional 30 minutes (list separately in addition to code for primary procedure).

CPT codes 99497 (base code) and 99498 (add-on code) are time-based codes; 99497 should be used for the first 16 to 30 minutes, with CPT code 99498 being used for each additional 30 minutes. To bill 99497 AND the add-on code, 99498, the advance care planning conversation must last 46 minutes or longer (i.e., at least 16 minutes beyond the initial 30 minutes of primary service).

If the required minimum time is not spent with the patient, family, or surrogate to bill code 99497, the physician may consider billing a different evaluation and management (E/M) service, provided the requirements for billing the other E/M service are met. Note, however, that codes 99497 and 99498 should not be reported by the same physician or other qualified health care professional on the same date of service as the following E/M services: 99291-99292, 99468-99469, 99471-99472, 99475-99480, and 99483. Codes 99497 and 99498 may, however, be billed on the same day or a different day as most other E/M services, and during the same service period as transitional care management services or chronic care management services and within global surgical periods. Both odes 99497 and 99498 should be reported with modifier -25 added, presuming the requirements for use of modifier -25 are met.

Documentation

CMS has not issued specific requirements for documenting advance care planning, but appropriate documentation must include the content and the medical necessity of the advance care planning-related discussion, the voluntary nature of the encounter, the content of any advance directives (along with completion of advance directive forms, when performed), the names of participants in the discussion, and the time spent in the face-to-face encounter.

If a patient is unable to be present, documentation must reflect the reason why. While there may be variations across local and state lines and Medicare Administrative Contractors, relevant legal forms include, but are not limited to, health care proxy, durable power of attorney for health care, a living will, and/or Medical Orders for Life Sustaining Treatment.

Qualified practitioners

Defined under Medicare Part B, practitioners considered qualified to provide advance care planning include physicians of any specialty, nurse practitioners, physician assistants, and clinical nurse specialists. While other team members may participate in the provision of advance care planning under the order and medical management of the beneficiary's treating physician, only these practitioners may report codes 99497 and 99498. All other practitioners, including social workers and psychologists, may not report advance care planning codes independently and must legally be authorized and otherwise qualified to provide the advance care planning in the state in which the services are furnished.

Additional requirements

To appropriately bill for advance care planning, no other active management of the patient's problems should be undertaken during the time period reported. The billing clinician must participate and meaningfully contribute to the provision of advance care planning services, in addition to providing a minimum of direct supervision. The usual Physician Fee Schedule payment rules regarding “incident to” services apply. There is additionally no limit on the number of times that advance care planning services can be reported for a given patient in a given time period. However, if these services are billed more than once, a change in the patient's health status and/or wishes about end-of-life care must be documented.

As a matter of best practice, it is suggested that internal medicine physicians consider breaking the advance care planning conversation up into smaller pieces, rather than trying to tackle everything at once. However, it is important to note that these briefer conversations will not qualify for Medicare reimbursement, which, as discussed, requires at least 16 minutes per visit.

Setting

Advance care planning services can be provided in both the facility and nonfacility settings. This means that advance care planning codes can be reported when services are provided in any care setting, including an office, hospital, skilled nursing facility, home, and via telehealth (based on the specific CMS guidelines in effect at the time of service). The place of service must be included when reporting advance care planning services.

Payment

Medicare pays for advance care planning as either: 1) an optional element of a Medical Wellness Visit (MWV), which includes the Annual Wellness Visit or the Initial Preventive Physical Examination or 2) a separate Medicare Part B medically necessary service. If a patient receives advance care planning services outside of a MWV, it is best practice to inform the patient that the Part B cost-sharing (deductible and co-insurance) applies.

It is important to note, however, that Medicare waives the advance care planning co-insurance and the Part B deductible when the advance care planning is delivered on the same day as a covered MWV (Healthcare Common Procedure Coding System [HCPCS] codes G0438 or G0439), offered by the same physicians or other practitioners as a covered MWV, or billed with modifier -33 for preventive services. If Medicare denies the MWV for exceeding the once-per-year limit, the advance care planning payment can still be paid as a separate Medicare Part B medically necessary service. In this case, Medicare applies the deductible and co-insurance to the advance care planning service.

For example, if a Medicare patient meets with the physician for their annual MWV, there must be an additional, separate 16-minute discussion between the physician and patient regarding advance directives. In this scenario, the physician should report HCPCS code G0438 plus 99497 appended with modifier -33, which indicates that 99497 is a part of a preventive service. Since the advance care planning service is being reported in conjunction with the MWV, the patient's visit is not subject to a deductible and co-insurance.

The COVID-19 pandemic has changed the urgency around advance directives. The grim reality is that more physicians, patients, and families are having these tough conversations, so ensuring appropriate documentation and billing is critical.