1. Advance Care Planning: Update 2017
Reetu Grewal, MD
Community Health and Family Medicine
UF COM, Jacksonville

2. No Financial Disclosures

3. The Ideal Situation

4. History
Completion rates of Advance Care Planning documents remains low, about 18-36% complete an ACP document*
Most patients expect their physicians to initiate ACP**
*DHHS report 2014
*Pew Research Center 2013
**Ramsaroop, SD, Reid MC, Adelman RD. Completing an advance directive in the primary care setting: what do we need for success? J Am Geriatr Soc. 2007; 55(2):

5. New Codes
As of January 1, 2016 CMS has created 2 codes to cover advance care planning in the outpatient setting
Payment varies by geography
Subject to 20% copay
CPT Code
Facility Payment
Non-Facility Payment
99497 (1st 30 min)
$79.54
$85.99
99498 (Additional 30 min)
$74.52
$74.88

6. Who Can Bill? Any provider that can bill Medicare Part B
Physicians, PAs, ARNPs, Clinical Nurse Specialists, Nurse Midwives
Subject to Incident-to rules
Facility and non-facility setting

7. When Can You Bill? When billed in addition to a preventive visit
Use modifier 33 (Preventive service) to avoid copay
Can be billed in addition to any E/M service
Can be billed as a standalone visit
so you would bill your preventive or e/m code plus the advance care planning code

8. When Can You Bill?
Can be billed by multiple providers on the same patient
Can be billed more than once per patient per calendar year
Subsequent visits are billed with 99498
CMS monitoring useage
so primary care physicians and specialists can all bill for this on the same patient; inpatient and outpatient can both bill on the same patient if they become hospitalized

9. Which Code To Use? Time based billing
1st 30 minutes: (greater than 15 minutes)
Additional 30 minute increments: 99498
Can bill both for 1 visit if time spent is appropriate
Time is based on amount spent on ACP, not total visit time
Documentation should reflect time spent for ACP
we’ll go through some examples later so you can see which codes are appropriate
so if you have a 30 minute discussion on acp your documentation should reflect that time spent, the level of detail should be greater if you’re spending an hour

10. What Documentation is Required to Bill?
Discussion regarding choosing a healthcare surrogate
The types of medical care preferred
The comfort level that is preferred
At a minimum...cpr, fluids, interventions

11. Optional Documentation
How the patient prefers to be treated by others
What the patient wishes others to know
Were any forms completed?

12. ACP Template Advance Care Planning conversation facilitated by _____
_______were present for conversation
Forms Reviewed (DNR, Honoring Choices Florida, 5 Wishes, Outside Living Will, other)
A discussion regarding choosing a Health Care Surrogate was held. Reviewed definition and responsibilities of health care surrogate with those present for conversation, including that a health care surrogate is a person designated to make decisions for the patient if the patient cannot speak for him or herself.
Health care surrogate designated:
Comments regarding discussion:
for those of you who work at uf health can find it in epic under .acp

13. ACP Template cont. The types of medical care preferred:
The comfort level that is preferred:
How the patient prefers to be treated by others:
What the patient wishes others to know:
Were forms completed:
Total Time Spent in Coordination of ACP:

15. Example 1 Ms. Jones is a 69 yo F who presents for her annual physical.
During the visit you discuss advance care planning, she does not currently have a designated healthcare surrogate
20 minutes of the visit are spent on ACP conversation
Bill physical code (G0439)
Use modifier 33 to prevent patient receiving a bill

16. Example 2
Mr. Smith is a 70 yo M who presents to his pulmonologists’ clinic after prolonged hospitalization for COPD exacerbation
His COPD has progressively worsened over past several years, he has already had 4 hospitalizations this year alone for COPD; ACP is introduced and Mr. Smith has lots of questions
Of the 2 hour visit, 1.5 hours was spent on ACP
Bill and and 2 units of 99498

17. Example 2 continued
1 month later Mr. Smith returns for a follow up visit, and wants to review some of the decisions he has made
30 minutes are spent discussing ACP
Bill and 99498
He then comes to see his primary care physician as a follow up and reviews his chronic conditions and his ACP decisions, and files his documentat with his pcp
15 minutes are spent discussing ACP
Bill and 99497
subsequent discussion with pulmonologist so even though only 30 minutes were spent; 15 minutes with pcp but first discussion with that provider so used

18. Questions?