Reimbursement

Medicare, Medicaid, and most private insurance companies pay for hospice care. Beneficiaries who elect the Medicare hospice benefit agree to forgo curative treatment for their terminal condition. For conditions unrelated to their terminal diagnosis, Medicare and other payors continue to cover items and services outside of hospice.

Reimbursement for Advance Care Planning

Advance Care Planning Guidelines: What is Advance Care Planning (ACP)?

Advance Care Planning allows you as a physician to help your patients reflect on their future health and care wishes if they cannot communicate or give consent in the future. It includes having discussions with family and friends, especially substitute decisionmakers, who will provide consent for them if they are incapable.

Why Advance Care Planning and Physician Communication are Important:

• Improves quality of life and quality of end-of-life care
• Reduces stress and anxiety for patients, families, and caregivers
• Improves communication between patients, families, and the health care team
• Patients trust their physicians
• Physicians have knowledge and expertise about their patients’ illnesses
• Reduces strain on the health care system

Who Can Provide ACP Services?

• Annual opportunity covered by Medicare if beneficiaries elect to do so
• Allowed by CMS as voluntary separately payable element of Medicare patient’s annual wellness visit
• Allowed to be billed by physicians and NPs
• Allowed in variety of settings, depending on condition of patient
• Allowed in both facility and non-facility settings
• Not limited to particular physician specialties
• No additional training required as part of additional payment standards

Description of CPT Codes and Payment for Advance Care Planning:

Two Current Procedural Terminology Codes for Advance Care Planning. Physicians (MDs and DOs), nurse practitioners (NPs), and physician assistants (PAs) are the only providers who can use these codes.

99497 – ACP 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 care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.

99498 – ACP 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 care professional; each additional 30 minutes (List separately in addition to code for primary procedure).

Payment for ACP Services:

CPT code 99497: 1st 30 minutes
Non-facility payment $87.00
Facility payment $80.24

CPT code 99498: each additional 30 minutes
Non-facility payment $75.88
Facility payment $75.51