Billing for Advance Care Planning
Beginning January 2016, Medicare will reimburse practitioners for having advance care planning discussions about written directives and POLST forms. The two CPT codes payable by Medicare are 99497, which is used for the initial encounter, and 99498, which is used if the initial encounter runs overtime.
These two codes are time-based and may only be used if the appropriate amount of time is spent with the decision-maker. The time must be face-to-face either with the patient or, if the patient is unable or unwilling to participate, with the patient’s decision-maker. The codes may be used only for face-to-face encounters, not for telephone encounters.
The face-to-face encounter with the patient or decision-maker must be for the purpose of having “the conversation” about an Advance Directive and/or about the POLST form, but the encounter does not have to include completion of a document. As long as you discuss the document, you may use the codes.
Exactly How Much Time Do I Have to Spend?
It’s a little silly that the AMA and United States government should tell us how much time to spend with people discussing an Advance Directive, but there we have it. Each code requires that you spend 30 minutes face-to-face with the decision-maker. For the first 30 minutes you use the 99497 code, and for each additional 30 minute interval you use the 99498 code.
So, does this mean you have to spend 30 minutes discussing the directive? Not exactly. According to the AMA CPT manual, for time-based coding a “unit of time is attained when the midpoint is passed.” This means that once your discussion of a directive or POLST form extends beyond 15 minutes, you may use the 99497 code. In other words, if the conversation lasts anywhere between 16 and 30 minutes, you can use the 99497 code.
But what if you go beyond the 30 minutes? That’s when the second code, 99498, comes in. And just as with the 99497 code, this 30-minute “overtime” code may be used once your discussion has extended more than 15 minutes beyond the original 30-minute period. In other words, if you spend 46 minutes discussing an Advance Directive of POLST form, you may bill for two 30-minute periods, using the 99497 code for the first one and the 99498 code for the second one.
How Many Times Can I Use the Codes?
Medicare has put no limit on the number of times you may have the conversation and bill using the codes. Each time you begin the conversation you will use the 99497 code. If the conversation extends beyond the first 30 minutes, you will use the 99498 code (and for each subsequent 30 minutes).
Let’s look at the hospital or nursing home setting first. Assume you admit a patient with CHF. After you complete your History and Physical, you spend about 20 minutes discussing the POLST form with the patient. The patient asks that you continue the discussion the following day with family present. For this visit, your billing would be as follows:
On the second day you visit the patient and after the examination and discussion of plan of care, you continue the ACP conversation with the family present. This time, the conversation extends to 50 minutes (yikes!). Let’s see how you would use the ACP codes here.
You would use the 99497 code to bill for the first 30 minutes, and because your discussion extended more than half way through the second 30 minutes, you would use the 99498 code to bill for a second full 30-minute period. You would submit your primary CPT code first and then these other two:
|ACP follow up:||99498||$||75|
|ACP follow up:||99498||$||75|
If the conversation continues beyond 50 minutes and into the next half hour, you may continue to use the 99498 code as needed for each additional 30-minute period. Keep in mind there is no limit on how often you can use these codes, as long as you are discussing an advance care planning document. And remember, the conversation does not need to end with the completion of a POLST form or an Advance Directive. You just need to be discussing it.
If you meet this family the following day to discuss an Advance Directive or POLST form, you may use the same codes as above. You must always start with the 99497 code for the first 30 minutes, and then use the 99498 code for each additional 30-minute period.
What Should Be Documented?
Although Medicare has not stated exactly what needs to be documented during this encounter, at a minimum, practitioners should record who was present and what documents were discussed (Advance Directive and/or POLST), as well as information on the overall diagnosis and prognosis. However, no specific diagnosis is required to use these billing codes.
- To be clear, document
- What document(s) you discussed (Advance Directive, POLST, or both)
- Who you discussed them with
- How much time you spent
- Any other relevant content concerning preferences or care
In What Settings Can ACP Codes Be Used?
The ACP codes can be used in any medical setting except the intensive care unit. Hospital, nursing facility, office, and home are all appropriate settings.
Who Can Use the ACP Codes?
Both physicians and nurse practitioners can use the ACP codes.
Do Deductible and Coinsurance Amounts Apply to this Code?
The usual Part B deductible and coinsurance apply except when ACP occurs during the annual wellness exam. If the ACP codes are used during the AWV, the deductible and coinsurance are not applied, and there is no fee to the patient, as this is considered by Medicare to be “preventative” intervention.
Does the Patient Have to Be Present? Can I Do this by Phone?
If the patient does not have capacity to make decisions, he or she does not need to be present for the conversation. However, the decision-maker does need to be present, and this must be a face-to-face encounter. ACP codes may not be used for telephonic or telehealth conversations.
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