Unfortunately, many people who are suffering from a serious illness or are about to die do not have the necessary advance instructions to make their own decisions regarding their health care. Only a third of Americans have these types of documents on file.
A comprehensive advance care planning (ACP) process helps individuals make informed decisions regarding their health care. It involves working with their doctors and other healthcare providers to align their care with their goals and preferences. Unfortunately, many healthcare providers are not billing for this service.
Not only does this prevent patients from receiving the necessary care, but it also hurts the providers’ revenue. Here are the various steps that healthcare providers can take to get reimbursed for providing this service.
Who can provide and be imbursed for these services?
All healthcare providers, including physicians of any specialty, nurse practitioners, clinical nurse specialists, and physician assistants, are eligible to be reimbursed for providing this service through the Medicare program’s ACP CPT codes. The billing codes must be used by the patient’s doctor or other health professionals who are directly involved in the patient’s care.
The Medicare program’s “incident to” rules allow non-billing team members, such as social workers and nurses, to provide some of the service’s benefits under the supervision of a billing provider if all of the practice requirements are met.
What are the CPT codes that are used to bill for the services?
There are two different time-based codes that can be used:
The first time-based code, 99497, provides a 30-minute face-to-face consultation with patients, their relatives, and a healthcare professional who is authorized to provide them with advance instructions. This type of interaction can also include the discussion of various advance directives. Completion of the advance directive is only required “when performed.” It’s not a general requirement for the services
The time-based code 99498 is also included for each additional 30 minutes of face-to-face meetings. It’s listed separately from the code for the primary procedure.
The CMS suggests that a billing entity bill for an evaluation and management service, for example, an office visit, if an individual’s consultation lasts less than 16 minutes. There are no limitations on how frequently or how often an individual can avail of this service, though in order to bill the codes together, the conversation must last at least 46 minutes.
What if the conversations are with telehealth?
Due to the declaration of a public health emergency, the government has allowed healthcare providers to bill for services provided through telehealth. However, there’s still a lot of uncertainty about the reimbursement and coverage for these services.
Which care settings can bill ACP services?
All types of care settings, including hospitals, physician’s offices, and home health agencies, can now bill for these services, provided that all applicable state laws are met. One of the most important factors that healthcare providers must consider when it comes to billing for these services is the place of service (POS), as it must be reported when billing with the codes. Hospice facilities, the program for all-inclusive care for the elderly (PACE), and federally qualified health centers and rural health clinics all have special billing considerations.
Does Private insurance reimburse for ACP services?
Although Medicare Advantage and other private insurance plans can pay for the services of an individual, they must still confirm that their coverage includes the necessary services. If a payer does not reimburse for the services provided under CPT codes 99497 or 99498, then these services will be subject to the carrier’s billing policies.
How much would a patient pay out of pocket for ACP?
Individuals who are part of Medicare’s annual wellness visit (AWV) or preventive services (which are billed with the modifier -33) are not responsible for the out-of-pocket costs associated with the services provided by Advance Care Planning (ACP). However, if an individual chooses to receive these services, they should be informed that there might be an out-of-pocket obligation.