This quarterly column is written by Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates, Baton Rouge, LA.
An elderly obtunded patient presents via EMS from a nursing home to the ED with decreased blood pressure, increased pulse, labored breathing, and bradycardia. The patient has multiple chronic problems. The family says their mother’s quality of life is poor. The nursing home advised the paramedics that the patient does not have an advance directive. The emergency provider speaks with the family to determine whether extreme measures are desired to prolong life in the event of life-threatening medical emergency. The family states they would like to initiate an advance directive.
This is a common scenario in an ED. If performed and documented appropriately, advance care planning (ACP) can now be billed by the emergency provider in addition to an evaluation and management level. For example, the patient described above might have received a comprehensive evaluation and management level 99285 by the emergency provider as well as discussion with the family of advance directives for a period of 20 minutes.
The advance directives discussion is identified by Current Procedural Terminology (CPT) as: CPT code 99497 (ACP, 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 professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate; and an add-on CPT code 99498 (ACP, 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 professional; each additional 30 minutes [list separately in addition to code for primary procedure]).
The Centers for Medicare & Medicaid Services (CMS) made the CPT codes for ACP separately payable by Medicare. The change in policy was implemented through the annual Medicare Physician Fee Schedule Database (MPFSDB) update.
A unit of time for ACP is attained when the midpoint of the 30-minute service is passed or 16 minutes, according to CMS. CPT 99497 and 99498 are separately payable under the Medicare Physician Fee Schedule (MPFS). The national Medicare reimbursement amount for 99497 is $79.50 and 99498 is $74.47. Note that this service cannot be billed in addition to critical care, because it is also a time-based code.
In addition, CMS also is including voluntary ACP as an optional element of the annual wellness visit (AWV). ACP services furnished on the same day and by the same provider as an AWV are considered a preventive service. Therefore, the deductible and coinsurance are not applied to the codes used to report ACP services when performed as part of an AWV.
Voluntary ACP means the face-to-face service between a physician (or other qualified healthcare professional) and the patient discussing advance directives with or without completing relevant legal forms. An advance directive is a document appointing an agent and/or recording the wishes of a patient pertaining to his or her medical treatment at a future time should he or she lack decisional capacity at that time. When voluntary ACP services are furnished as part of an AWV, coinsurance and deductible would not be applied for ACP. Both the ACP and AWV also must be billed together on the same claim form. To have the deductible and coinsurance waived, modifier 33 (preventive services) must be billed.
The laws governing advance directives vary from state to state, so it is important patients complete and sign advance directives that comply with state law. Also, advance directives can contain different titles depending on the state. Some examples of advance directives include:
- healthcare proxy;
- durable power of attorney for healthcare;
- living will;
- Medical Orders for Life-Sustaining Treatment (MOLST).
These are time-based codes, with 99497 to be billed for the first 30 minutes, and 99498 for each additional 30 minutes. Because the purpose of the visit is the discussion, no active management of the patient’s problem(s) has to be performed during the time of these visits.
Additionally, these code(s) can be billed with the ACP services, if applicable, for the following services:
- new and established patient office visits (99201-99215);
- observation initial, subsequent, and discharge care codes (99217-99220, 99224-99226);
- initial, subsequent, and discharge hospital service codes (99221-99233, 99238-99239);
- observation or inpatient admit and discharge on the same date (99234-99236);
- outpatient and inpatient consultations (99241-99255);
- ED visit codes (99281-99285);
- initial, subsequent, and discharge nursing facility care codes (99304-99316);
- annual nursing facility assessment code (99318),
- new, established, and discharge domiciliary or rest home visit codes (99234-99337),
- new and established patient home visit codes (99341-99350);
- initial and periodic preventive medicine codes (99381-99397);
- Transitional Care Management Service codes (99495-99496).
However, these codes cannot be billed with:
- critical care codes, as they are also time-based codes (99291, 99292);
- inpatient neonatal and pediatric critical care codes (99468-99476);
- initial and continuing intensive care services (99477-99480).
Although the ED does not generally provide the AWV, the initial AWV with personalized prevention plan of service (PPPS) provides for the following services to an eligible beneficiary by a health professional:
- establishment of an individual’s medical/family history;
- establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual;
- measurement of an individual’s height, weight, body mass index (BMI) (or waist circumference, if appropriate), blood pressure (BP), and other routine measurements as deemed appropriate, based on the beneficiary’s medical/family history;
- detection of any cognitive impairment that the individual may have as defined in this section;
- review of the individual’s potential risk factors for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression, which the health professional may select from various available standardized screening tests designed for this purpose and recognized by national medical professional organizations;
- review of the individual’s functional ability and level of safety based on direct observation, or the use of appropriate screening questions or a screening questionnaire, which the health professional may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations;
- establishment of a written screening schedule for the individual, such as a checklist for the next five to 10 years, as appropriate, based on recommendations of the United States Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices (ACIP), as well as the individual’s health status, screening history, and age-appropriate preventive services covered by Medicare;
- establishment of a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are under way for the individual, including any mental health conditions or any such risk factors or conditions that have been identified through an initial preventive physical examination (IPPE), and a list of treatment options and their associated risks and benefits;
- furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management, or community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition;
- any other element(s) determined appropriate by the secretary of Health and Human Services through the National Coverage Determination (NCD) process.
The AWV will include:
- establishment of, or update to, the individual’s medical and family history;
- measurement of his or her height, weight, BMI (or waist circumference);
- BP measurement.
The goal of the service is to assure health promotion and disease detection and to foster the coordination of the screening and preventive services that already may be covered and paid for under Medicare Part B.
Effective Jan. 1, 2016, when ACP services are provided as part of an AWV, providers would report as applicable the following:
- G0438 AWV, including a PPPS, first visit;
- G0439 AWV, subsequent AWV;
- 99497: First 30 minutes is used to report face-to-face service between a provider and a patient, family member, or surrogate in counseling and discussing advance directives — with or without completing relevant legal forms;
- 99498 (for each additional 30 minutes, as applicable).
HCPCA G0438 and G0439 PPPS require that the initial AWV providing PPPS provides for the following services to an eligible beneficiary by a health professional:
- establishment of an individual’s medical/family history;
- establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual;
- measurement of an individual’s height, weight, BMI (or waist circumference, if appropriate), BP, and other routine measurements as deemed appropriate, based on the beneficiary’s medical/family history;
- detection of any cognitive impairment that the individual may have as defined in this section;
- review of the individual’s potential risk factors for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for patients without a current diagnosis of depression, which the health professional may select from various available standardized screening tests designed for this purpose and that are recognized by national medical professional organizations;
- review of the individual’s functional ability and level of safety based on direct observation, or the use of appropriate screening questions or a screening questionnaire, which the health professional may select from various available screening questions or standardized questionnaires designed for this purpose and that are recognized by national professional medical organizations;
- establishment of a written screening schedule for the individual, such as a checklist for the next five to 10 years, as appropriate, based on recommendations of the USPSTF and ACIP, as well as the individual’s health status, screening history, and age-appropriate preventive services covered by Medicare;
- establishment of a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are under way for the individual, including any mental health conditions or any such risk factors or conditions that have been identified through an IPPE, and a list of treatment options and their associated risks and benefits;
- furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management, or community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition;
- any other element(s) determined appropriate by the secretary of Health and Human Services through the National Coverage Determination (NCD) process.
The AWV will include:
- establishment of, or update to, the individual’s medical and family history;
- measurement of his or her height, weight, BMI (or waist circumference);
- BP measurement.
The goal of the service is to assure health promotion and disease detection and fostering the coordination of the screening and preventive services that already may be covered and paid for under Medicare Part B.
Critical Access Hospitals (CAHs) also may bill for these professional services using bill type 85X with revenue codes 96X, 97X, and 98X. Method II payment will be based on the lesser of the actual charge or the facility-specific MPFS.
Of note to providers, the deductible and coinsurance does not apply when ACP is not furnished as part of a covered AWV.
If performed and documented appropriately, advance care planning can now be billed by the emergency provider in addition to an evaluation and management level.
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