Medicare’s decision to reimburse for Advance Care Planning (ACP) services marked a significant step in healthcare, effective January 1st. This initiative, while welcomed, has brought forth numerous queries from healthcare providers, particularly concerning the specifics of implementation and billing. To address these questions, the Centers for Medicare & Medicaid Services (CMS) has released clarifications, aiming to streamline the understanding and application of these new guidelines. One frequently asked question revolves around the necessity of a diagnosis code for billing ACP services. This article delves into the CMS guidelines to clarify the diagnosis code requirements for advanced care planning reimbursement, ensuring providers can confidently navigate these changes.
The foundation of Medicare’s reimbursement for ACP lies in two distinct Current Procedural Terminology (CPT) codes, each designed to capture different durations of service:
- 99497: This code is designated for “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.” This code covers the initial 30 minutes of face-to-face ACP discussion.
- +99498: Described as “Each additional 30 minutes (List separately in addition to code for primary procedure),” this add-on code is used for each subsequent 30-minute increment beyond the initial period.
In their clarifications, CMS addressed several key aspects of these codes, offering crucial insights for healthcare providers:
- Time-Based Billing: CMS adheres to CPT guidelines, stipulating that the midpoint of a time unit must be reached to bill for that unit. This means a minimum of 16 minutes must be spent to bill for the initial 30-minute code (99497), and similarly for the additional time code (+99498).
- Frequency Limits: Notably, CMS has not imposed any limitations on how frequently these services can be billed. This allows for ACP to be an ongoing process, revisited as needed based on the patient’s evolving health status and preferences.
- Service and Specialty Flexibility: The ACP codes are not restricted by place of service or physician specialty. This broad applicability ensures that various healthcare settings and professionals can offer and bill for these vital services.
- Documentation Requirements: Specific documentation requirements are to be determined by Medicare Administrative Contractors (MACs). Providers should consult their local MAC for detailed guidance on necessary documentation.
- Advance Directive Completion: Crucially, billing for ACP services does not hinge on the completion of an advance directive. The discussion and planning are billable services in themselves, regardless of whether a formal document is finalized.
- Concurrent Billing: ACP services can generally be reported alongside other evaluation and management (E/M) services, broadening opportunities for reimbursement. However, there are exceptions, particularly with certain critical care services, where concurrent billing may be restricted.
- Diagnosis Code Specificity – Not Required: In a significant clarification, CMS explicitly stated that no specific diagnosis code is required when billing with advance care planning codes. This is a key point, simplifying the billing process and emphasizing that ACP is a service valuable for all patients, irrespective of their current health status or specific diagnosis. This flexibility recognizes the proactive nature of ACP, which is beneficial for healthy individuals as well as those with chronic or serious illnesses.
For a deeper understanding, CMS directs providers to the final rule on the 2016 Medicare physician fee schedule and Medicare Learning Network Matters article MM9271. These resources offer comprehensive details and context for the implementation of ACP billing.
In conclusion, the introduction of Medicare reimbursement for Advance Care Planning is a positive development, promoting patient-centered care and shared decision-making. The clarification that no specific diagnosis code is mandated for billing ACP services removes a potential barrier and simplifies the process. This encourages providers to engage in these crucial conversations with patients, ensuring their preferences are understood and honored, ultimately leading to more personalized and effective healthcare. By understanding these guidelines and leveraging the provided CPT codes, healthcare professionals can confidently integrate and bill for advance care planning, enhancing the quality of care they deliver.
