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Advance Care Planning and Medicare

Advance Care Planning and Medicare

Question

What is Advance Care Planning and does Medicare pay for it?

Answer

Advance Care Planning (ACP) is a face-to-face discussion between a physician or other qualified health professional and a patient/family member/surrogate about the care the patient would want to receive if they become unable to speak for themselves.  ACP includes the explanation and discussion of advance directives including completion of such forms if the patient desires.

As of January 1, 2016 the Centers for Medicare and Medicaid Services (CMS) provides coverage for ACP.  For additional information on billing see CMS’ list of Frequently Asked Questions about billing advance care planning (ACP) services to the Physician Fee Schedule (PFS) under CPT codes 99497 and 99498.

Providers performing ACP should know that:

  • Medicare pays for ACP as either: A separate Part B service when it is medically necessary (co-pay or cost sharing applies) or an optional element of a beneficiary’s Annual Wellness Visit (AWV)
  • Some patients may need ACP multiple times in a year if they are quite ill and their circumstances change. Others may not need the service at all in a year.
  • Appropriate documentation for ACP includes an account of the discussion with the patient/ family member(s)/surrogate regarding the voluntary nature of the encounter; documentation indicating the explanation of advance directives (along with completion of those forms, when performed); who was present; and the time spent in the face-to-face encounter.
  • In addition to advanced directives, providers may want to consider introducing the concept of Physician (or Medical) Orders for Life-Sustaining Treatment (POLST or MOLST) or Physician Orders for Scope of Treatment (POST). This document, which varies by state, is a medical order signed by a medical professional and used for treatment.  Used together with the Living Will/Advance Directive the POLST is appropriate for patients who are seriously ill or frail and are towards the end-of-life.  It specifies what medical treatments a patient does and does not want in the event of a medical emergency.

References:

CMS ACO FAQs

CMS Fact Sheet for ACP

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