Advanced Care Planning (ACP): Is now the right time to plan for later?

ACP can occur anytime, according to the author.

We’d like to think that our loved ones will always be healthy, independent, and able to make decisions for themselves, but things can change suddenly.

They might have an accident or a serious illness and no longer be able to speak. When that happens, doctors often turn to patients’ loved ones to speak for them. If that happens, will you (the physician) know what care they would want?

Talking with loved ones and your patients now and helping them plan for future medical needs is the best way to make sure that their wishes will be respected. But talking about this is not always easy.

Many healthcare dollars are spent during the ends of patients’ lives, at least in part because many patients have not thought about or discussed how they would like to be treated – or not treated – during the final stage of their lives. While some patients have living wills or advanced directives created in the context of a hospital admission or during estate planning, others may never have considered what they will want. 

What is Advanced Care Planning?

Advanced care planning (ACP) is a service to help patients consider and prioritize their treatment goals. It is a process that helps the patient decide and document what kind of care they would want to accept or decline if they have a health crisis and are not able to communicate or make decisions. This is important for everyone who is 18 or older.

While many practices have been discussing end-of-life issues with patients without receiving reimbursement, now physicians or other qualified professionals may bill for these discussions. Effective Jan. 1, 2016, Medicare covers discussions related to ACP.  

ACP can occur at any time. It can be done at the same time as an annual wellness visit (AWV) or as part of an evaluation and management (E&M) visit, or in transition care management (TCM) or chronic care management (CCM).

Implementation

Some patients may have existing documents produced through ACP, such as a living will, advanced directive, or medical power of attorney. Over time, as the patient ages and conditions change, these documents may all need to evolve to accommodate these changing circumstances. Some words of advice:

• When scheduling an appointment, ask patients to bring any of these relevant documents with them to serve as a guide during ACP discussions with the physician.
• Store these documents either as part of the medical record or in a separate place.
• Use a standard format to guide the discussion. Each state has a standard form, and you can search for it at your state medical association website or the American College of Physicians website.

Although it is important to document wishes during an initial discussion with a patient, it is not intended to be a one-time decision. As a patient moves from hypothetical to actual health status changes, ACP becomes an ongoing process that needs periodic review – meaning that after the initial planning appointment, an annual review of end-of-life planning documents can help guide plans as patient conditions and/or attitudes change. 

Billing for Advanced Care Planning

The two CPT® codes describing ACP services are the following: 

• 99497 – Advanced 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 professionals; first 30 minutes, face-to-face with the patient, family member(s) and/or surrogate.
• 99498 – Advanced 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 professionals; each additional 30 minutes. (List separately in addition to code for primary procedure.)

ACP CPT codes became effective Jan. 1, 2016. The work relative value unit (RVU) for 99497 is 2.40, with an estimated payment of $85.99, and the work RVU for 99498 is 2.09, with an estimated payment of $74.88 (adjusted based on geography).  

Now, one issue that has been a concern of late is that Medicare (the Centers for Medicare & Medicaid Services, or CMS) has not made a national coverage determination (NCD) regarding the service. In the absence of a national Medicare policy, contractors are responsible for local coverage decisions (LCDs). Also, in the absence of a formal CMS policy, and with sporadically written policies for commercial insurance payors and no formal payor direction, offices have been struggling with the over-utilization question.

Have you ever heard the phrase “too much of a good thing”? My professional opinion is that not every patient may qualify or be interested in this service “now.” It is not that these aren’t useful and needed conversations, but the patient has to want the service, be comfortable with the conversation as it relates to the current status of their medical condition(s), and be aware that there is a share of the cost for which they will be responsible. Many patients may respond when the subject is brought up with “I am feeling fine, so we don’t need to talk about this now. We can wait and handle things as they come up.” You will need to be sensitive to those responses, and again, only move forward when the patient agrees to the discussion and the charges.

Furthermore, this is a physicians’ service, however “incident to” rules apply when it is furnished by a non-physician practitioner or other qualified staff member (such as a PA, NP, or licensed social worker) incident to the services of the billing clinician, including a minimum of direct supervision. ACP may be provided by any specialty, including the primary care physician, cardiologist, oncologist, and/or other specialists.

A key recommendation is to introduce this service to established patients who are declining in health, and those whom the physician believes may not be able to participate in these discussions personally within the next two years. For these patients, ACP would be not only the responsible thing to do, but best practices tell me that it can contribute to positive feedback from overall patient satisfaction surveys, as you are adding value services to your patient population that they may not have even considered necessary.

Now that payors are allowing for reimbursement for ACP, for discussions you are more than likely already having with a good percentage of your patients, it is important that you do it right, compliantly, and capture your due revenue.

Programming Note:

Listen to Terry Fletcher live today during Talk Ten Tuesday, 10-10:30 a.m. ET.

References:

Advance Care Planning (ACP) as an Optional Element of an Annual Wellness Visit (AWV)

American College of Physicians (ACP Tool Kit)