It is common for hospitalists to have advance care planning discussions and address advance directives with patients (and families) during an admission for a serious life-threatening condition or end-stage chronic disease.
On Jan. 1, 2016, Medicare began paying for advance care planning services to encourage such conversations and compensate clinicians for the time spent having them. Advance care planning involves discussion of advance directives with the patient, family members, or surrogates. Discussions may include hospice care, end-of-life care options, power of attorney for health care decisions, living wills, and physician orders for life-sustaining treatment (POLST).
A POLST (sometimes called MOLST, MOST, or POST) is a medical order covering the specific treatments the patient wants as the end of life approaches. Generally, POLST is reserved for individuals with serious conditions or extreme debility near the end of life.
Current Procedural Terminology 4th Edition (CPT-4) provides two codes for advance care planning:
- 99497, advance care planning, first 30 minutes
- 99498, advance care planning, each additional 30 minutes
The advance care planning must be face-to-face counseling and discussion of advance directives with the patient, family members, and/or surrogates. The total time spent must be documented in the record. The CPT-4 time convention allows billing of code 99497 for 15 to 44 minutes spent face-to-face. If 45 to 74 minutes is spent, code 99498 should be assigned in addition to code 99497.
These are “add-on” codes billed separately in addition to other evaluation and management (E/M) services. However, they cannot be reported on the same date of service as critical care codes (e.g. 99291, 99292). There are no site-of-service limitations, so advance care planning services can be billed for inpatient, observation, and outpatient settings. The condition for which the patient is being counseled should be included on the claim for that date of service, but no specific diagnosis is required for the codes to be billed.
Medicare states that advance care planning services are “voluntary,” meaning an opportunity to decline the services must be given and documented in the record. Advance directive forms may be completed, but this is not a requirement. If the patient or his or her representatives elects to complete advance directive forms, they may do so at any other time with assistance from individuals other than the clinician.
Medicare advises clinicians to consult their Part B Medicare Administrative Contractor (MAC) for its documentation requirements, but the agency suggests including (in addition to time spent and the voluntary nature of the services) an account of the discussion, an indication that advance directives were explained, and who was present.
Advance care planning services may be provided more than once. Medicare has not established any frequency limitations but does say that it “would expect to see a documented change in the beneficiary's health status and/or wishes regarding his or her end-of-life care.”
The 2017 national facility-based physician fee relative value units (RVU) for advance care planning are as follows:
- 99497 RVU = 2.17
- 99498 RVU = 2.02
Let's look at a hypothetical example of advance care planning. An 82-year-old man with a long history of type 2 diabetes, myocardial infarction, severe systolic heart failure, stage 4 chronic kidney disease, and marked debility is admitted with severe dyspnea, acute pulmonary edema, and respiratory failure. An echocardiogram shows an ejection fraction of 15%.
The patient requires 60% supplemental oxygen to maintain oxygen saturation greater than 92%. Aggressive management of heart failure is instituted, and administration of diuretics achieves some symptom relief but is complicated by increased creatinine. Hemodialysis is recommended, but the patient declines. Oxygen dependence continues at 4 L/min. The patient is highly dependent according to an activities of daily living assessment.
With patient consent, the hospitalist documents a 20-minute conversation with him and his two daughters about hospice care, advance directives, and therapeutic options. The patient and family choose hospice care and seek assistance with advance directives. In addition to billing for an inpatient visit performed earlier that day, the hospitalist should assign code 99497 (30 minutes of advance care planning) for the 20 minutes of face-to-face time.
In summary, hospitalists are commonly called upon to provide advance care planning services to help patients and families make end-of-life decisions and consider, among other things, advance directives. CPT-4 provides two codes: 99497 for the first 30 minutes (ranging from 15 to 44 minutes) and 99498 for each additional 30 minutes, which is coded in addition when total time spent is 45 minutes or more.
Total time spent specifically on advance care planning must be face-to-face with the patient, family, and/or surrogates, and it must be documented in the record. Although Medicare contractors may have more specific documentation requirements, Medicare identifies certain elements typically expected including time spent, the voluntary nature of the services and patient consent, an account of the discussion, an indication that advance directives were explained, and who was present.