Advance Care Planning in Medicare: Year One

On January 1, 2016, Medicare began reimbursing physicians for Advance Care Planning (ACP), using the following CPT Codes:

CPT Code 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

 

CPT Code 99498 – each additional 30 minutes (List separately in addition to code for primary

procedure)

 

According to the AMA’s CPT Assistant, advance care planning “involves learning about and considering the types of decisions that will need to be made at the time of an eventual life-ending situation and what the patient’s preferences would be regarding those decisions.”

Paying for ACP incentivizes health providers to have these conversations with their patients and clearly demonstrates the value that Medicare places on this service. According to the Institute of Medicine’s pivotal report, Dying in America, patients often fail to obtain the care they need at end of life, and an uncoordinated and inefficient delivery system incur unsustainably high costs. Broader delivery of advance care planning could help address two key priorities from the report—ensuring that patients’ needs and goals of care are met, while reducing unnecessary costs resulting from uncoordinated care.

What’s remarkable about Medicare’s implementation of ACP reimbursement is how unrestrictive it is for billing providers. There are no limits set on appropriate use of the code related to place of service, diagnosis, frequency, or provider type (any primary care or specialist physician, nonphysician practitioner, or other staff under a treating physician can deliver the service, with no required training), and it can be billed independent of and on the same day as E/M services. The ACP conversation does not even need to be delivered directly to the patient, but can be had with a family member or surrogate instead.

As ACP claims are now being adjudicated, in practice, Medicare has not placed any additional limitations on the general CPT description. The rule authorizing payment of the new codes included no national coverage determination, which means that the regional Medicare Administrative Contractors (MACs) “are responsible for local coverage decisions in the absence of a national Medicare policy.” In early 2016 we contacted the MACs responsible for each of the 10 jurisdictions and learned that none had a specific local coverage determination in place, nor did any have plans to develop one.[1] Since then, CMS released an FAQ document in July explicitly clarifying that qualified providers may bill for ACP with no limitations related to place of service, diagnosis, or frequency, and that while providers should refer to their MAC for minimum documentation requirements, completion of an advance care directive is explicitly not required to bill for the service. Shortly after implementation, one of the MACs was denying ACP claims based on place of service codes, but quickly attributed the problem to system error rather than a deliberate coverage determination and reversed those claims.

For comparison’s sake, consider smoking cessation counseling (CPT codes 99406 and 99407), which CMS made a covered benefit in 2010. It’s similar to ACP since it’s a conversation delivered by a provider and aimed at improving patient health and reducing future costs of smoking-related illness. However, some  reasonable and intuitive limits are placed on billing of the code—Medicare requires that the patient be a smoker with corresponding diagnosis codes reported, cessation counseling attempts can only be billed twice per year, and although some state Medicaid programs permit billing for cessation counseling with the parents of patients with child eligibility coverage, CMS otherwise only pays for counseling directly to patients.

The lack of restrictions on ACP reimbursement is not a simple oversight by CMS, but seems to be a conscious decision to encourage widespread provision of the service. In the Federal Register for the 2016 Physician Fee Schedule that establishes ACP as a covered benefit, CMS acknowledges the comments it received with concerns about lack of a national coverage determination and potential for abuse of the code, but provided the following response:

We believe it may be advantageous to allow time for implementation and experience with ACP services, including identification of any variation in utilization, prior to considering a controlling national coverage policy through the National Coverage Determination process (see 78 FR 48164, August 7, 2013).

 

As the first full year of ACP billing in this laissez faire environment concludes, the claims record will start to reflect any increase and/or variation in utilization of the code. A national survey of both primary care and specialist physicians conducted at the start of the year found that 75% of respondents reported being either much more likely or somewhat more likely to talk with patients about advance care planning thanks to the new Medicare benefit.

If utilization of ACP does in fact increase, it may still be years before robust claims and medical record data indicate whether these conversations impacted end-of-life care decisions and reduced cost to the Medicare program. However, as a final point, it’s worth considering reimbursement in the context of the payment reform transformation currently underway as Medicare and other payers move from fee-for-service models to value-based arrangements.

In the prevailing fee-for-service environment, ACP has been a service with obvious potential benefits for patients and payers, but not necessarily for providers, who may have recognized the importance of ACP conversations but encountered barriers to delivery and have to balance meeting the many demands of their practice and patient panel. In a value-based payment future—where providers will be accountable for quality of care but also able to share in savings realized through better coordination of end-of-life care—patient, provider, and payer will all be organically aligned to place high value on delivery of ACP. Given the high costs and unique demands of end-of-life care, health system embrace of ACP could prove to be a key driver for achieving the triple aim of improved quality of care, patient satisfaction, and reduced costs. Medicare’s addition of the ACP benefit is a critical first step for helping orient providers towards this future.

[1] Thanks to stellar Research Assistant, Sara Constand, for gathering this information.

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