Advance Care Planning: 2016 Medicare Physician Fee Schedule

In late October, the Centers for Medicare & Medicaid Services (CMS) issued the 2016 Medicare Physician Fee Schedule Final Rule updating payment policies, payment rates, and quality provisions for Medicare services furnished on or after January 1, 2016. The ruling covers a wide range of topics including a number of new policies, payment provisions as well as several quality provisions including updates to the Physician Quality Reporting System (PQRS) and the Physician Value-Based Payment Modifier (Value Modifier). In this post, we will examine the new provision for Advanced Care Planning. 

CMS is establishing separate payment and a payment rate for two advance care planning services. The Medicare statute currently provides coverage for advance care planning under the “Welcome to Medicare” visit available to all Medicare beneficiaries, but they may not need these services when they first enroll. Establishing separate payment for advance care planning codes to recognize additional practitioner time to conduct these conversations provides beneficiaries and practitioners greater opportunity and flexibility to utilize these planning sessions at the most appropriate time for patients and their families.

For Medicare beneficiaries who choose to pursue it, advance care planning is a service that includes early conversations between patients and their practitioners, both before an illness progresses and during the course of treatment, to decide on the type of care that is right for them.

CPT Code

Description

National Average Non-Facility Rate

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-care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate

$85.99

99498

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; each additional 30 minutes (list separately in addition to code for primary procedure.)

$74.88

In the Final Rule, CMS provided the following directives on providing and billing for ACP, while also promising to issue further sub-regulatory guidance: 

  • There are no specific performance standards, special training, or quality measures a provider must satisfy to bill for ACP.
  • ACP may be furnished and billed separately on the same day as an evaluation and management (E/M) visit.
  • ACP is subject to cost-sharing requirements, unless furnished in conjunction with the Welcome to Medicare visit or an annual wellness visit.
  • Presently, ACP is not reimbursable if furnished via telehealth.
  • ACP may be furnished “incident-to,” subject to direct supervision.
  • ACP will be a stand-alone billable visit in a rural health clinic (RHC) or Federally Qualified Health Center (FQHC), when furnished by an RHC or FQHC practitioner and all other program requirements are met. If furnished on the same day as another billable visit at an RHC or FQHC, only one visit will be paid.

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