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Advance Care Planning and Hospice


Beginning January 2016 two new Current Procedural Terminology (CPT) codes for Advance Care Planning (ACP) became effective. Here’s what your hospice agency needs to know:

The New Codes

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. Non-facility payment is approximately $85.99. Facility payment is approximately $79.54*.

99498 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; each additional 30 minutes (List separately in addition to code for primary procedure). Non-facility payment is approximately $74.88. Facility payment is approximately $74.52*.

*These are national rates prior to the application of geographic adjustment, so local rates will differ. These rates do not take into the consideration the two percent reduction to Medicare’s share of the payment due to sequestration.

CPT Manual Definition of Advanced Directives

“A document appointing an agent and/or recording the wishes of a patient pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at that time.”

Examples of Advance Directives

Health Care Proxy,

Durable power of attorney for healthcare,

Living will, and

Medical Orders for Life-Sustaining Treatment/Out of Hospital DNR

The use of these codes requires a face-to-face visit, however, the patient may not be present.

The hospice agency may submit a Part A hospice claim that includes these line items and be reimbursed for ACP services performed by an Attending Physician that works for or is under arrangement with, the hospice.

For a hospice Part A claim, only a physician or nurse practitioner chosen by the patient as the hospice attending can bill for this service under the Medicare hospice benefit.

For ACP services provided under part B, the CPT code descriptors describe services as furnished by physicians or other qualified health professionals, which for Medicare purposes is consistent with allowing these codes to be billed by the physicians and NPs whose scope of practice and Medicare benefit category include the services described ty the CPT codes and who are authorized to independently bill Medicare for those services.

Other qualified health professionals include:

Nurse Practitioner

Physician Assistant

Clinical Nurse Specialist

Nurse Midwife

While CMS issues no specific documentation requirements in the use of the new ACP CPT codes, they will be subject to audit. In fact, Medicare contractors are likely to be watching closely since the codes are new. Practitioners should document in detail all the services performed.

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