Advance care planning is an essential process in determining a patient's wishes for end-of-life (EOL) care. It was not until January 1, 2016, when the Centers for Medicare & Medicaid Services provided reimbursement for Medicare beneficiaries for advance care planning (ACP).1 Current data show one in three U.S. adults has some type of advance directive.2
The current codes
There are two ACP current procedural terminology (CPT) codes (see ACP CPT codes). Each code is time-based and has specific requirements to meet the code. The location where the discussion takes place may be in the ambulatory or inpatient setting. The provider who initiates and/or assists with updating or reaffirming the discussion does not need to be the patient's primary care provider. The CPT codes may be billed with the annual wellness visit codes (G0402, G0438, and G0439), but they also may be billed separately or with an evaluation and management code.3
The ACP services are part of the covered benefit if discussed at the time of an annual wellness visit. If the code is submitted at the time of any other CPT code service or by itself, a coinsurance payment would be anticipated. To date, there is no limit on the number of times the CPT codes can be submitted. The ICD-10 code used for the discussion would be related to the chronic condition and should be reflected in the clinical documentation. The CPT code description recommends using a standard form to document advanced care wishes; the form does not need to be completed on the same day of the visit the CPT code is submitted.
In 2000, Dr. Richard Balaban recommended a four-step framework to assist the clinician on how to guide the conversation for EOL care.4,5 The framework identified four steps that could be developed as a template in the electronic medical record: initiating discussion, clarifying prognosis, identifying EOL goals, and developing a treatment plan.5 There are examples of standard forms available online for review, such as healthcare proxy, durable power of attorney for healthcare, a living will, or completion of a medical order for life-sustaining treatment, or California's provider orders for life-sustaining treatment.6
Summary
Medicare beneficiaries now cover EOL discussions if they are part of an annual wellness visit. If these patients become part of a different visit, then coinsurance may apply. It is important for NPs to understand the coding guidelines to ensure the use of information and education provided. NPs should check with their individual organization's coding education department for policies and procedures related to CPT codes.
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