Is End-of-life Planning an Optional Medicare IPPE Service?
Q: “End-of-life planning, on agreement of the beneficiary” is listed as a requirement for Medicare’s Initial Preventive Physical Examination (IPPE). Does this mean that end-of-life planning is optional? What documentation is necessary to substantiate the service?
A: The IPPE, or “Welcome to Medicare” visit, is a once-per-lifetime benefit, which must be provided within the first 12 months of the effective date of a patient’s Medicare Part B coverage period. The visit is meant to promote health and to detect and prevent disease, but is not a typical annual exam with which many patients are familiar.
There are seven elements that comprise the IPPE, per the Centers for Medicare & Medicaid Services (CMS):
- Review medical and social history
- Review potential risk factors
- Review functional ability and safety
- Physical exam
- End-of-life planning, on agreement of the beneficiary
- Educate, counsel, and refer on previous five elements
- Educate, counsel, and refer preventive services
CMS explains in The ABCs of the Initial Preventive Physical Examination (IPPE), “You must provide all components of the IPPE prior to submitting a claim for the service.”
Medicare defines end-of-life planning as verbal or written information provided to the patient about:
- The patient’s ability to prepare an advance directive in case an injury or illness renders them unable to make healthcare decisions
- Whether you will follow the patient’s wishes as expressed in an advance directive
Although end-of-life planning is not optional (because it is a required element of the IPPE), confusion arises due to the stated condition, “if agreed by beneficiary.”
Essentially, the provider must offer end-of-life planning as part of the IPPE, but cannot force the patient to discuss it if the patient does not wish to do so.
CMS does not expand on the documentation requirements for end-of-life planning, but practically speaking, the provider should explain to the patient that end-of-life planning is part of the IPPE benefit, for which there is no copay or deductible. If the patient objects to the discussion, the provider should note this in the medical record. If the patient agrees to the discussion, this too, should be documented, along with a summary of the conversation.
If the provider does not document end-of-life planning, it’s assumed this required element was not performed (not documented = not done), and you may not properly report the IPPE.
End-of-life planning may be offered as a stand-alone, time-dependent service, as described using CPT® 99497 Advance care planning 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 and +99498 Advance care planning 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). Per CPT® Assistant (December 2014):
Individuals who may need extra assistance and more skilled facilitation in making future health care decisions include: (1) individuals with end-stage chronic illness, such as congestive heart failure, renal disease, or acquired immune deficiency syndrome (AIDS); (2) individuals who, because of the timing of their illness or injury, have not been considered appropriate for [advanced care planning] ACP, such as those facing emergent and high-risk surgery, or those who experience a sudden event, such as a transient ischemic attack (TIA), and are at risk of repeated episodes; (3) individuals who have ACP needs beyond the more familiar decisions to withhold or withdraw life-sustaining treatment, such as those with early dementia or mental illness; (4) individuals who lack decision-making capacity (developmental disabilities) or authority (minors) and must rely on guardians or parents to make substitute decisions and plan for the inevitable.
CMS, MLN Education Tool, The ABCs of the Initial Preventive Physical Examination (IPPE), April 2017, www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf
CPT® Assistant, December 2014