CMS: Providers need a 'relevant' diagnosis for advance care planning

by Roy Edroso on Apr 13, 2016

CMS said in an April 13 provider call that to bill advance care planning (ACP) without a preventive service, you need to show the service is “relevant to the patient’s disease state,” which would seem to mean it requires a diagnosis code.

ACP became a Medicare payable service this year. Whether billing it requires a diagnosis code has been a subject of debate among practices. In the CMS call with Dr. William Rogers, director of CMS' Physicians Regulatory Issues Team, and other CMS officers, the agency referred to its most recent FAQs for ACP, chronic care management and transitional care planning. The ACP FAQ includes this:

10. What diagnosis must be used?

No specific diagnosis is required for the ACP codes to be billed. 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).

In the comment period of the call, a caller said her practice had billed ACP with diagnoses such as neoplasms and had the claims accepted but had also billed it with “the Z code for counseling” and had those claims denied. The caller asked what she should do with a “healthy older person” who just wanted the ACP service.

While admitting that “I don’t know that we explicitly weighed in on what kind of diagnosis would be required to be medically necessary [for ACP billing],” a CMS spokesman said that for CMS to pay for ACP “as a treatment service – that is, outside preventive or screening services – it would have to be relevant to the patient’s disease state in order to be considered reasonable or necessary.”

CMS officers also discussed the upcoming Open Payments review and dispute process, which begins on April 1; Medicare preventative services; and Medicaid and opioid use.

This post has been edited to reflect uncertainty about the identity of the CMS spokesperson quoted on this phone call.

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