Published in the January 2016 issue of Today’s Hospitalist
AS OF JAN. 1, physicians and other qualified providers have two new CPT codes they can report for advance care planning. These codes are long overdue, but at least they’re here.
Advance care planning is intended to address a patient’s wishes for medical care, should there come a time when that patient lacks the capacity to make decisions on his or her own behalf. Advance care planning also gives patients, family members and/or surrogates the opportunity to ask any questions they have related to those wishes.
You don’t need to complete any legal forms “such as an advance directive “to be able to bill advance care planning services. But if you do complete such forms, you can include the time you spend in the amount of time you report.
Before the Centers for Medicare and Medicaid Services (CMS) issued its outpatient prospective payment system final rule for 2016, some commenters recommended that pastoral care counselors, care navigators, care managers and social workers be allowed to provide these services. The CMS also received comments that advance care planning should be able to be provided “incident to” a physician’s services.
But the CMS elected to limit the provision of these services to physicians or other qualified professionals, such as non-physician practitioners. The agency did acknowledge that advance care planning could be provided “incident to” a physician’s service if all “incident-to” criteria are met.
As the CMS stated, “We agree with commenters that advance care planning as described by the proposed CPT codes is primarily the provenance of patients and physicians. Accordingly, we expect billing physicians or NPPs to manage, participate and meaningfully contribute to the provision of the services, in addition to providing a minimum of direct supervision.”
Time-based, face-to-face
Here are the new codes and their descriptions from the 2016 CPT manual:
- 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).”
On the physician fee schedule, the CMS indicates that both of these codes are eligible to be paid. But it hasn’t issued a national coverage determination on these codes, so individual Medicare administrative contractors (MACs) may have their own guidance or payment restrictions.
Check with the MAC in your region for any local guidance.Currently, the CMS has not placed any specialty restrictions on who can provide advance care planning, and these services can be supplied in either a facility or non-facility setting. But the CMS has decided which specific E/M services advance care planning can be reported with. (See “CPT codes and services for advance care planning.”)
Remember to append modifier -25 to the advance care planning code when you report it with another E/M service.While the CMS no longer recognizes inpatient (99251’99255) or outpatient (99241’99245) consult codes, some commercial insurers do “and they may pay for advance care planning services billed with these codes as well.
Now the caveats: You may not report advance care planning services with critical care codes (99291′ 99292) or the code range 99468’99476, which is used for initial and subsequent inpatient neonatal critical are. You also can’t bill them with codes 99477’99480, which involve initial and subsequent intensive care of a neonate or recovery of a low birth weight infant. And for hospitalists who do outpatient moonlighting, advance care planning is now a “voluntary, separately payable” element of Medicare’s annual wellness visit.
If you bill one or both codes with HCPCS codes G0438 or G0439 (initial or subsequent annual wellness visit) AND you separately meet the requirements for advance care planning services (including the expected time duration), bill these services with modifier-33 (preventive service). For advance care planning billed as an adjunct to the annual wellness visit, patients shouldn’t have to pay any Part B coinsurance or deductible.
How to bill
When providing advance care planning, keep two things in mind. First, documentation is key. Include enough detail in your progress note to indicate the parties involved, the nature of the conversation and the decisions made. Second, you must document the face-to-face time spent, and you cannot bill these services unless that face-to-face time exceeds 15 minutes. For example, spending 20 minutes in advance care planning face-to-face is a billable service. But spending only 15 minutes or less is not.And once you surpass the initial 30 minutes, you can bill 99498 “which represents each additional 30 minutes “only if you again exceed a 15-minute threshold. If you spend 40 minutes on advance care planning, for instance, you can bill only a 99497 because the additional face-to-face time did not exceed the second 15-minute threshold.
As with any new codes, advance care planning comes with a lot of questions. Can, for instance, both a primary care physician and a hospitalist bill for advance care planning services for the same patient, one during an office visit and one during a hospitalization? Stay tuned!
Sue A. Lewis, RN, CPC, PCS, has more than 40 years of health care experience.
