Want to Get Paid for ACP? Medicare Ruling Means You Could in 2016

Posted on 27 Nov, 2015 |comments_icon 4|By Chris Boucher

CMS sets RVUs for 99497, 99498.

If your physician treats a lot of elderly patients, you probably have experience with advance care planning (ACP): treatments options, life expectancy, etc.

In 2015, CPT® introduced ACP 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 professional; first 30 minutes, face-to-face with the patient, family member[s] and/or surrogate) and 99498 (…each additional 30 minutes [List separately in addition to code for primary procedure]). Getting paid for the codes was nigh impossible, however.

That might all change thanks to a recent decision by Medicare.

In late October, CMS released its Final Rule, outlining how it will pay for services under the Medicare Physician Fee Schedule in 2016.

RVUs set: In the Final Rule, the agency assigned 1.50 work relative value units (RVUs) to 99497 and 1.40 RVUs to 99498. This greatly increases the probability that payers will start reimbursing for these ACP codes.

“CMS is establishing separate payment and a payment rate for two advance care planning services provided to Medicare beneficiaries by physicians and other practitioners,” the agency said in a Fact Sheet about the decision.

According to the Final Rule, you can report 99497 and 99498 on the same date as other E/M services, transitional care management and chronic chare management, and you can even bill them during global surgical periods.  You cannot, however, report 99497 and 99498 on the same date as certain critical care services including neonatal and pediatric critical care, the Final Rule indicates.

See also: Check Out Changes to OB Panel, Fetal MRI Coding

Meet Certain Standards Before Coding ACP

Remember, the ACP discussions must meet specific parameters to qualify as codeable services. According to the American College of Physicians, ACP discussions include addressing the patient’s:

  • Current disease state;
  • Disease progression;
  • Available treatments;
  • Cardiopulmonary resuscitation;
  • Life-sustaining measures;
  • Life expectancy considering the patient’s age and comorbidities;
  • Clinical recommendations from the treating physician;
  • Past medical history;
  • Medical documentation/reports; and
  • Responses to previous treatments.

To read the entire Final Rule, visit https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-28005.pdf or read the Fact Sheet at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-10-30-2.html.


Chris Boucher

Chris Boucher has nearly 10 years of experience writing various newsletters and other products for The Coding Institute. His blog will cover several areas of coding and compliance, including CPT® coding, modifiers, HIPAA compliance and ICD-10 coding.

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4 thoughts on “Want to Get Paid for ACP? Medicare Ruling Means You Could in 2016

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