Initiating advance care planning conversations
and capturing reimbursement
Documenting Discussions
Keys to capturing reimbursement
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Documenting the conversation
Key points to include
 Who was involved?
 Start and end time
 What was discussed?
 Patient’s understanding of illness
 Was a decision maker/health care agent
determined?
 Was any advance directive offered or
completed?
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Source: Institute for Healthcare Improvement
Documenting the conversation
Additional factors:
 Spiritual factors
 Reflections on family/personal losses
 Why is patient making the decisions
they are making?
Follow-up plan:
 Were any changes made from previous
discussions?
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Source: Institute for Healthcare Improvement
New CMS advance care billing codes
 99497 – Advance care planning
• explanation and discussion of advance directives
• completion of AD forms, when performed
• physician or other qualified health professional
• first 30 minutes, face-to-face with the patient, family
member(s) and/or surrogate
• approximately $86 outpatient and $80 inpatient
 99498 – each additional 30 minutes
• Approximately $75.
Note: we are sharing our best understanding of these codes at this time, please
be sure to work with your local billing compliance expert.
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Source: Institute for Healthcare Improvement
How to bill: outpatient setting
 If billing for medical management according to
patient’s illness, bill as you normally would.…
• Then also bill based on time for advance care planning
conversation.
• If based on time  do not double count time
 “Incident to” rules apply in the outpatient setting
• Billing provider performs an initial service, a non-billing
team member (e.g. RN, SW) helps deliver part of the
service, with ongoing direct supervision and
involvement of the billing provider
• Consider for “what matters most,” palliative care, or
hospice conversations
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Source: Institute for Healthcare Improvement
“Incident to”
Example: Physician starts an advance care planning
conversation, then says “I’d like to introduce you to our
nurse who will talk with you about choosing a [health
care agent] and think with you about how you might have
a conversation with that person,” then debriefs afterwards
with the patient.
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Note: it’s important to work closely with your local billing compliance expert
How to bill: inpatient setting
 Remember that multiple conversations can be billed
in a single day.
• More than one provider might discuss options with
patients.
• Separate conversations could occur with multiple family
members.
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Source: Institute for Healthcare Improvement
“Qualified health professional”
 Who is a qualified health professional?
• Those who can bill under Part B:
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•
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Medical Doctor
Nurse Practitioner
Physician Assistant
Clinical Nurse Specialist
Nurse Midwife
• In hospice: Employed MD and NP when acting as the
patient’s attending
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Billing questions
 Must these be used in the context of an illness?
• No. In fact, any medical management must be billed
separately.
 Who is paying for these codes?
• Local coverage determination may vary, some private payers
may cover these conversations – ask your local billing expert.
 How much time must be spent to use them?
• More than half of each 30-minute interval
(so to use 99497, >15 min) – confirm with your local billing
compliance expert or fiscal intermediary.
 Does the conversation have to be “in-person”? Does it have to
be with the patient?
Yes, has to be in-person (cannot use for telehealth), but doesn’t
have to with the patient (can be with surrogate or family).
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Source: Institute for Healthcare Improvement
Billing questions
 What are the documentation requirements?
– Start and end times
– Patient/agent/family “given opportunity to decline”
– Details of conversation content (Slides 3 and 4)
 What costs might patients incur from these codes?
– Part B cost sharing, except with Annual Wellness Visit
 How much do payers reimburse for these?
– 99497 = 1.5 RVUs
– 99498 = 1.4 RVUs
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Source: Institute for Healthcare Improvement
Office process
 Include your entire team in a process conversation
• Clinicians
• Administrative staff
• Information Systems
• Software experts
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Source: Institute for Healthcare Improvement
Office process
Questions to consider
 Which of your patients don’t yet have a health care agent?
 Do you have a way of identifying your highest risk patients,
identifying gaps, and tracking progress?
 How reliable are your processes?
 How do you scan and attach a completed advance directive?
 How do you update?
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Source: Institute for Healthcare Improvement
Office process
Additional questions
 Will the documentation be easily available in the future for both
your health care team and your billing staff?
 Is the documentation such that the next provider will know where
to begin the next conversation?
 Do you have a way of managing different versions of the same
information?
 What if a patient changes their health care agent? Will it be clear
to the next provider who the correct health care agent is?
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Source: Institute for Healthcare Improvement
Advance care planning is ongoing
 Death in the family
Moment of reflection
 Divorce
Previously selected surrogate may no longer be valid
 Decade
People and preferences change with time
 Decline
“Would you be surprised if this patient became seriously ill
or died?”
 Diagnosis of serious illness
Difficult decisions may be ahead
 Documents
Ask patients to bring to annual visits or any time they make
changes.
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Remember
 It is important to check with your local
billing compliance expert or fiscal
intermediary.
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Special thanks
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Baptist Memorial Health Care
Methodist Le Bonheur Healthcare
Institute for Healthcare Improvement
Healthy Shelby
Qsource
This material was prepared by the atom Alliance, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO), coordinated by Qsource for Tennessee, Kentucky, Indiana, Mississippi and Alabama, under a contract with the Centers for Medicare & Medicaid Services (CMS), an
agency of the U.S. Department of Health and Human Services. Content presented does not necessarily reflect CMS policy. 16.SSTN.D1.04.002-C
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