How to bill end-of-life discussion codes correctly

Q: Are the advance care planning codes in place now in 2016?

A: While advance care planning (ACP) codes were added in 2015, the Centers for Medicare & Medicaid Services (CMS) has now determined the payment rates for each. See the chart below for the payment rates.

As a reminder, the codes include completion of any relevant legal forms (i.e., Living Will, Health Care Proxy, Health Care Durable Power of Attorney, and Medical Orders for Life Sustaining Treatment), if applicable.

For patients who would like to have this conversation with their physician or practitioner, this can be an opportunity to discuss the individual choices for the patient both before an illness progresses and during the course of treatment.

Advance care planning will be separately paid when reasonable and necessary for the diagnosis or treatment of injury or illness

It can be billed:

• On same day as an Evaluation and Management (E/M) code.  

• If coding the E/M by time, the documentation must clearly distinguish that the ACP time is not overlapping the counseling/coordination of care time for the E/M code. Medicare deductible and coinsurance apply.

• On the same day as the Medicare Welcome Visit.  (CMS hasn’t clarified yet whether  coinsurance and/or deductible apply.)

• As a voluntary, separately payable part of Annual Wellness Visit (AWV. Append modifier -33 to ACP code. Remember that deductible and coinsurance do not apply.)

• During period covered by Transitional Care Management, Chronic Care Management, or global surgery.

• As a stand-alone service (Medicare deductible and coinsurance apply).

• The physician or qualified healthcare provider (QHP) must document the time spent discussing advanced care planning with the patient. You can use a team approach using clinical staff, but keep in mind: The physician or QHP must be the individual discussing the patient’s medical problems and answering questions; and 

• The billing physician or QHP must manage, participate and meaningfully contribute to the provision of ACP services, in addition to providing a minimum of direct supervision of clinical staff who may provide some of the service.

CMS confirmed that a unit of time for advance care planning is attained when the midpoint of the 30-minute service is passed. This means that the half-hour requirement for each code would be met when 16-30 minutes have been met and documented. Of course, if you are billing the add-on code, the full 30 minutes for code 99497 would be required prior to starting the time for 99498.

These codes may be reported by more than one physician or QHP, typically of different specialties, or may be needed when the patient develops a new problem or has an exacerbation of an existing problem.

Q: I recently did a one-hour home visit evaluation for the first time. What is the 2015 code for the initial home visit and subsequent visits?

A:  With the overall population aging and the number of very sick patients expected to grow significantly, home visits are a way to stay involved in the patient’s care and keep them out of the hospital, which is a top priority for payers. Patients with multiple chronic conditions are likely candidates for home visits as long as they don’t need continual care of a nursing home or skilled nursing facility.

The chart below lists the new and established home visit CPT codes and the level of service needed for the history exam and/or medical decision making.  The average face-to-face time associated with each of these codes can be used when billing the visit based on time, meaning greater than half the visit time is spent counseling and/or coordinating care for the patient.  

These codes exclude physician supervision services provided to patients under home health agency or hospice care (99374-99378).

While home visit E/M codes tend to pay a little more than do office visit E/M codes, there are some tips to keep in mind when documenting and billing home visits.

Leave box 32 of the CMS-1500 form blank when services are provided in the patient’s home. Although box 32 (or electronic equivalent) is where you put the address of the facility or office where the services were performed, services performed in the patient’s home is the exception. 

Select place of service code 12 (patient’s home) so your carrier knows to refer to the patient’s address. This code should be reported in box 5 (patient’s address) of the CMS-1500. You don’t have to repeat the address information.

Specify medical necessity and note external factors affecting the patient. Make sure your documentation is clear as to why the home visit is necessary and the acuity of the patient’s condition. Include the reason the patient can’t be seen in the office on that day.  

Consider more than clinical factors when documenting your note, such as    a pertinent change in the patient’s environment. For example, while a patient with severe osteoarthritis can safely travel to the office in the summer, winter months may be a different story. Make sure your note states the contraindications of the patient traveling to the office in the winter.

Create a prominent area in documentation to explain why the patient was seen at home. A separate section should be added to explain why the patient needed to be seen in his/her home rather than in the office on that particular day.  All clinical and non-clinical factors should be included in addition to your rationale for establishing medical necessity.  

Show how chronic conditions change over time. If you visit the patient in his/her home on a regular basis, be sure that each note shows how the patient’s condition has changed.  Stay away from cloned or copied documentation that does not explain how the patient’s condition has improved or deteriorated.