Payment by Medicare for End of Life Planning Begins in 2016

December 9th, 2015

Beginning in 2016, Medicare will begin paying for Advance Care Planning codes also referred to as “End of Life Codes.” 

According to CPT, 99497 is:  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.

99498 is:  Each additional 30 minutes (List separately in addition to code for primary procedure.

National average Medicare allowed for 99497 is $82; and for 99498 is $72 so these codes will boost your bottom line when implemented.

By definition, these codes do not have to be face to face with the patient.  They can be with a patient’s surrogate such as a spouse or child.  (Be careful of HIPAA laws here.  Most states do allow a provider to select a surrogate based on the totality of circumstances.  Check with you malpractice carrier if you are unfamiliar with your state’s rules.)

Although face to face with the patient is not required, face to face remains a component.  There is no payment for handling end of life planning via telephone or mail.  Theoretically, these services would be reimbursed via the chronic care management codes.

Services can be rendered in an office or a facility setting, although they pay a little less in a facility setting.

Diagnosing and treatment are not elements of this code.  These codes are about helping a patient make appropriate arrangement for end of life.

Important terms to understand when using this code include:

  • Advance Directive:   A document which enables a person to make provision for his health care decisions in case if in the future, he becomes unable to make those decisions.   CPT specifically includes Health Care Proxy, Durable Power of Attorney, Living Will and Medical Order for Life-sustaining Treatment as examples. 
  • Other qualified health care professional: An individual who is qualified by education, training, licensure or regulation, who performs a professional service within his scope of practice and independently reports that professional service.  Typically this is an individual with his own license and NPI.

According to the head note in the Advance Care Planning section of CPT, an Advance Directive does not need to be completed in order to use the code; but the specifics of the form must be discussed.

These codes can be billed with most other evaluation and management codes with a modifier.  Pay attention to your documentation when doing this.  As is the rule with all coding, the various services need to be clearly delineated.  Ensure that you document your time elements separately from the evaluation and management services performed on the same day.  No double dipping!

Since advance care planning is an element of the Welcome to Medicare, do not code Advance Care Planning codes on the same day as an initial Medicare wellness visit. 

CMS has not issued national coverage determinations for these codes and has asked local MACs and carriers to do so.

Check with your private insurance carrier and with Medicare Advantage Carriers to see if they will pay these codes.  Also, look at any ACO contract to see if this is something that is part of any agreement you may have with them which would be part of the cost savings aspects and not an a charge that you can bill because of that contract.

Tags: Advance Care Planning, CPT, End of Life, Accountable Care Organizations


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