Helping Plan For End of Life Circumstances Is Likely The Most Compassionate Thing Primary Care Providers Can Do For Their Older or Chronically Ill Patients

The founder of Innovative Health Media, a long time veteran of the ICU and ER, has an extensive history of working with patients as they transitioned.  His stories of families arguing instead of holding the hand of their loved one as they transition haunts me.  He says, “The one thing practically guaranteed at end of life moments is that emotions are going to run high and are often hot.”  Many family relationships are destroyed as siblings and other family members fight over these important end of life decisions that should be included in an Advance Directive.  Nothing is more compassionate than ensuring the issues regarding a person’s end of life are managed prior to this time when family emotions are most stressed and fragile….and getting reimbursed by Medicare for doing so makes it a win-win.

In 2015, I had my own personal experience with the need for Advance Care Planning. After a long and hard fought battle against leukemia, my mother succumbed to the disease.  Having worked with seniors since 2011, I knew how important an Advance Directive could be and taking my advice, my mom created hers before she became too ill to make those difficult decisions.  Not only did her Advance Directive give us insight into what she wanted, but more important, it quashed a multitude of family concerns regarding her transitioning.  Losing my mother was one of the most painful experiences of my life but because she took the time to make her wishes known, she ensured her passing was easier on her family than it could have been.

Background:

Medicare began funding Advance Care Planning (ACP) in January 2016.  There are two codes used to reimburse practices for ACP.  CPT code 99497 is the code used for the first 30 minutes of an advance care planning visit.  The reality is not every visit can be done in 30 minutes.  Emotions, concerns and need for education all play a role in ensuring this visit is done properly.  Therefore, Medicare also allows CPT code 99498 to be added to the visit to reimburse for an additional 30 minutes if/when it is necessary.

Originally, ACP was to be an aspect of the Medicare Annual Wellness Visit. There is debate whether or not that is the best time to implement this visit but for those who wish to, “CMS is also including voluntary ACP as an optional element of the AWV. ACP services furnished on the same day and by the same provider as an AWV are considered a preventive service. Therefore, the deductible and coinsurance are not applied to the codes used to report ACP services when performed as part of an AWV. Additionally, when ACP services are furnished on the same day and by the same provider as an AWV, they are reimbursed under the [Medicare Physician Fee Schedule] rates”

Coinsurance:

“The deductible and coinsurance for ACP will only be waived when billed on the same day and on the same claim as an AWV (code G0438 or G0439) and must also be furnished by the same provider. Waiver of the deductible and coinsurance for ACP is limited to once per year. Payment for an AWV is limited to once per year. If the AWV billed with ACP is denied for exceeding the once per year limit, the deductible and coinsurance will be applied to the ACP.”

Quality Measures:

Advance Care Planning is quality measure #47 in both MIPS and PQRS which define the measure as:  Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.

Similar to the Quality Measure, an ACP visit does not have to result in a completed Advance Directive.  Discussion of the options and explaining why an ACP is important and relevant for the patient is enough to meet the criteria for reimbursement.  Appropriate documentation is necessary to back up your reimbursement claim, especially if an Advance Directive is not completed. 

How to Implement Advance Care Planning:

There are a variety of state laws and regulations that dictate how an Advance Directive is structured.  These laws and regulations differ from state to state.  To ensure patients are receiving the best service and to ensure the practice will receive credit for implementing Advance Care Planning for MACRA/MIPS, it is essential that the practice have a consistent and reliable method of performing and documenting the ACP visit and ensuring the patients receive appropriate advice and information.  The state the practice is operating in may have Advance Care Planning manuals for patients, or the practice may wish to participate in a digital ACP such as mydirectives.com .  The CDC has developed a list of references for patients and practices to work with.  We recommend you choose one that best fits the needs of your practice.

Incorporating ACP as part of a Wellness Program:

It may seem odd that ACP would be a part of a wellness program but the way Medicare has historically approached ACP is very much in line with its objectives for quality based care vs reactive care.  Although somewhat of a political issue, ACP was originally part of the Medicare Annual Wellness Visit.  This part of the service was discontinued before the ACA was enacted but it does show us that Medicare considers Advance Directives to be an integral part of a patient’s wellness program.

Advance Care Planning comes with a variety of emotional responses which must be taken into consideration when developing the program in a primary care practice.  Medicare allows ACP to be part of the Annual Wellness Visit but it can also be a separate visit altogether.  The copay/deductible for this visit are only waived if the ACP visit is performed on the same day and by the same provider as the AWV and is submitted on the same claim, otherwise the patient must pay for the copay/deductible.  

If ACP is done as part of the wellness visit, we suggest only offering this in Subsequent AWV visits.  The Initial AWV is too long and detailed to ask a patient to sit through an additional 30 minutes to an hour discussing ACP.

Most of the ACP visit should be done by your wellness team rather than the provider.  In hospital settings, ACP is often done by a social worker or chaplain.  In the PCP environment, your nurses should be able to recognize and support the emotional elements as well as the legal aspects of this visit.  Toward the end of the ACP, the nurse should take the patient to see the provider. 

Unlike the AWV, a nurse may not complete the entire visit,  the provider must be involved.  The provider should review the information put together by the wellness staff and answer any questions the patient and their family may have.  If an Advance Directive was completed, the provider should ensure the directive is indeed in line with the patient’s wishes and that it is documented in the electronic health record system.  

Most states require an Advance Directive to be notarized to be valid, and if a patient travels out of state it is best to have a notarized Advance Directive for it to be recognized in other states and outside the country.  Unfortunately, a staff member of the provider is typically not allowed to notarize the document so it will be up to the patient or their family to get the document notarized after the visit.

Federally Qualified Health Centers:

FQHCs bill through the Prospective Payment System (PPS).  This system is an all-inclusive flat fee per visit.  Unlike regular Fee for Service providers, Advance Directives may not be bundled with other services such as the AWV or regular visits in the same day to get paid for both services.  If the FQHC wishes to bill for ACP 99497, the visit must be a stand alone visit.  This visit is fully reimbursed at the PPS rate for the visit.  Medicare does not reimburse FQHCs for the additional 30 minute visit (99498.)  Medicare has not waived the copay when ACP is a stand alone visit therefore FQHC patients will have a deductible/copay for the separate ACP visit.  

Conclusion:

Advance Care Planning not only meets certain quality measures and adds an additional revenue stream to the practice, it is also a wonderful way to help your patients improve end of life circumstances.  

Most patients feel comfortable enough with their primary care provider to trust their advice, judgement and direction regarding difficult health decisions.  For that reason, primary care is the perfect place to begin a discussion of how they wish their end of life transition to look.  Most primary care providers went into this field to make a difference for their patients.  There are few ways to better show compassion to patients than offering the peace of mind allowed through this service.

To learn more about how we can help you develop a wellness program or integrate advance care planning into your practice visit our blog Building a Medicare Prevention/Wellness Program is Difficult, We Want To Help

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