Changes made in two Current Procedural Terminology codes

On October 30, 2015, the Centers for Medicare and Medicaid Services (CMS) released the final 2016 Physician Fee Schedule which includes the historic reimbursement for two Current Procedural Terminology (CPT) codes for advance care planning. These codes are effective for use for services provided on or after January 1, 2016. In funding these codes, CMS is acknowledging the importance of voluntary patient-provider consultations about personal goals, values and treatment preferences.

Still Gaps

Unfortunately, there is a sizeable gap between the care Americans say they want in the last phase of life and what actually occurs. While the reasons for this disconnect are complex, physicians, health policy makers, and others in our health system agree that encouraging voluntary and informed patient and family decision-making is the basis of high-quality, person-centered care.

The Institute of Medicine’s report on Dying in America highlights many barriers to effective advance care planning:

  • A natural reluctance to explore issues of dying.
  • A fragmented health care system that makes end-of-life discussions someone else’s issues.
  • Poor quality and rushed communication when conversations take place.
  • Inadequate support for advance care planning which includes clinician training, reimbursement and record keeping.

In funding CPT codes for advance care planning, CMS has made an important decision to begin reimbursing providers for advance care planning conversations. Below are three things all healthcare professionals need to know about this important decision.

First, the CPT codes and description of the reimbursable services:

CPT Code Description Approximate Reimbursement
99497 First 30 minutes of face-to-face discussion with patient and/or surrogate to discuss advance care planning $81.58 in Non-Facility

$75.96 in Facility

99498 Use for each additional 30 minutes of conversation $71.44 in Non-Facility

$71.13 in Facility

Second, Medicare beneficiaries will have deductible and copay for advance care planning services unless the conversation occurs during the Annual Wellness Visit and the documentation of the advance care planning conversation supports the CPT code billed.

Third and most importantly, facilitating high quality advance care planning is a skill that requires education, training and support. Hospice of the Bluegrass is committed to supporting medical professionals who want to learn more about advance care planning.

New Initiative

Improving care for those facing serious illness is all of our responsibility. There is no substitute for good policy and CMS has taken an important first step in reimbursing providers for advance care planning conversations.

While the reimbursement of these codes is important, there is more work to be done. There is another important policy initiative to bring attention to and that is The Care Planning Act of 2015. This piece of legislation proposes to create a Medicare benefit called Planning Services for those with serious illness. The benefit would provide a team-based discussion of goals of care and values, explanation of disease progression and treatment options, a documented care plan based on an individual’s goals and preferences, care coordination services, education, resource development, as well as other important provisions. To learn more on this important piece of legislation visit: http://www.congress.gov/bill/114th-congress/senate-bill/1549.

Research has shown that individuals who have discussions about end-of-life care have less invasive medical treatments, improved patient and family satisfaction and higher quality of life. The implementation of these codes is an important step to encourage dialogue between providers, patients and families and to ensuring that patients receive care that aligns with their goals and preferences and receive care that is wanted or coordinated.

-Liz Fowler is president and CEO of Hospice of the Bluegrass.

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