Primary care practices perform countless tasks every day for which the payment is: nothing, zero, nada. CMS continually states that it wants to support primary care, and in the past few years has added payment for some non-face-to-face services, including Care Plan Oversight, Transitional Care Management and Chronic Care Management. In 2015, the AMA developed new codes to pay for discussions of end of life planning, but in 2015, CMS didn’t allow them as payable services. However, starting in January, 2016, CMS will recognize and reimburse physicians and Non-Physician Practitioners to provide this service, using CPT codes 99497 and 99498.
These are time-based codes. 99497 is for the first 30 minutes, and 99498 is an add on code, for each additional 30 minutes. These codes were defined in the 2015 CPT book.
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 professional; first 30 minutes, face- to-face with the patient, family member(s) and/or surrogate); and an add-on CPT code 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 professional; each additional 30 minutes (List separately in addition to code for primary procedure))
This service is a face-to-face service, but the beneficiary does not need to be present. The CPT code is defined as “with the patient, family member(s) and/or surrogate.” Forms may be completed, but they aren’t required. When CPT says “when performed” the service may be reported even if that portion of the service was not performed. The service may be performed on the same day as an E/M service, except for adult or pediatric critical care, and in the office or in a facility, such as a hospital or nursing home. CPT describes it as being performed by a physician or “other qualified health professional” and CMS states by a physician or “non-physician practitioner” within their scope of practice. This means physician, NP or PA. The service may be performed during a global period or in the same month as TCM or CCM.
CMS has not developed a national coverage determination. Individual Medicare Administrative Contractors will develop their own policies. CMS hasn’t placed frequency limits on the service, realizing that as a patient’s condition changes, the physician and patient and family may need to re-discuss these critical issues. There is not a limit on the specialty designation of the physician or NPP who provides the service. The service may be performed in an RHC or an FQHC, but those centers will be paid their all-inclusive rate for a visit, and won’t receive any additional payment. A Medicare patient will be responsible for a co-pay and deductible for the service, unless it is performed on the same day as a wellness visit, (G0438 or G0439). In that case, append modifier 33 to the ACP code and the patient will not be charged a co-pay or deductible. Document the time spent in the discussion (exclusive of other E/M services that day) in the medical record.
Payment is modest: about $80 for 99497.
Follow the links below to six helpful ICD-10 articles I’ve written:
A-Z: 26 Important ICD-10 Tips
Countdown to a Meltdown, or a Yawn
ICD-10: Three New Coding Challenges
ICD-10: Coding for Hypertension and Heart Disease
ICD-10: How to Avoid these 5 Costly Problems
ICD-10: Exact Symptom Location Becomes a Huge Deal
Here is the link to the CMS FAQ document about specificity and ICD-10. They clarified that when they said “family” they meant “category” because ICD-10 doesn’t use the term family in coding. (I theorized that if the code was in a page or two of the right code it would be okay, but that’s not what they meant, was it?) Just a reminder, we use diagnosis coding for two reasons on a claim form. The first is to establish the medical necessity to get a claim paid. The second is to tell the payer how sick the patient is, and the acuity of our entire population of patients. This is important for risk based contracts and ACOs. Even an unspecified code establishes the medical necessity for an office visit, but that doesn’t mean you should use it. You should report the condition you are treating specifically. And, if the service you are performing has a Medicare LCD or NCD, or a private payer coverage policy, you will need a specific, covered indication.
As for private payers, who knows?
CMS and the AMA have agreed to offer physician practices a grace period on code specificity of ICD-10 for the first year. The link to the announcement from the AMA is below, and you’ll notice it mentions “family” of codes. ICD-10 is divided into categories and subcategories. I’m not sure how the CMS Contractors will interpret “family.”
If I see any clarification or wise words from other consultants, I’ll add them here.