CMS' new FAQs on advance care planning (ACP) contain some clarifications for which providers have been waiting, including guidance on how time should be counted and how frequently the service may be billed.
ACP, in which providers and staff assist beneficiaries with end-of-life issues, was established as a billable Medicare service this year in the 2016 Medicare final physician fee schedule. CPT code 99497 is used for the first half-hour and 99498 for each subsequent half-hour.
The FAQ appeared on March 22. While some of the answers follow what was in the final rule -- for example, that deductibles and coinsurance for ACP are waived only when provided with the annual wellness visit (AWV) and that it cannot be performed with critical care codes 99291-99292 or neonatal and pediatric critical care codes 99466-99480 -- some points had been left unclear or implied before now.
The main points include:
- CPT timed service rules apply. CMS advises that, in counting the time for the ACP codes, providers refer to "CPT provisions regarding minimum time required to report timed services." This suggests that the 30 minutes needed for each code will be counted as reached at the 16th minute. If you aren't hitting these marks, CMS suggests "the practitioner may consider billing a different evaluation and management (E/M) service such as an office visit..."
- No limits to how often you can bill, though "when the service is billed multiple times for a given beneficiary, we would expect to see a documented change in the beneficiary’s health status and/or wishes regarding his or her end-of-life care."
- No place of service limitations.
- NPPs "and other staff" may perform ACP "under the order and medical management of the beneficiary’s treating physician," though CMS "expect[s] the billing physician or NPP to manage, participate and meaningfully contribute to the provision of the services in addition to providing a minimum of direct supervision." Also, normal incident-to rules apply.
- Document reason why beneficiary isn't present if you perform ACP with his or her family members and/or legal surrogate(s) instead, explaining "that the beneficiary is impaired and unable to participate effectively."
- Legal proxies may consent to ACP on the beneficiary's behalf.
- Other documentation requirements up to MACs. But CMS does list "examples of appropriate documentation," including:
- "an account of the discussion with the beneficiary (or family members and/or surrogate) regarding the voluntary nature of the encounter";
- "documentation indicating 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." (But note: "completion of an advance directive is not a requirement for billing the service.")
- ACP and E/M can be performed in the same encounter. It can also be performed in conjunction with transitional care management (TCM), chronic care management (CCM) and "within global surgical periods."
- No diagnosis code needed, though "it would be appropriate to report a condition for which you are counseling the beneficiary, an ICD-10-CM code to reflect an administrative examination, or a well exam diagnosis when furnished as part of the Medicare annual wellness visit (AWV)."