Part B Insider (Multispecialty) Coding Alert

Advance Care Planning:

Collect Coinsurance for ACP Visit--Unless You Meet This Exception

Published on Mon Jan 11, 2016

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Whether or not you provide the service during an annual wellness visit makes all the difference.

As most practices are aware, CMS now accepts two codes for advance care planning, but some doctors were in the dark about the rules surrounding how to bill for these services. Fortunately, a new MLN Matters article offers some clarity on what you should do to make sure you’re reporting advance care planning (ACP) properly.

Background: Effective Jan. 1, you can collect about $86 for 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 about $75 for +99498 (…each additional 30 minutes).

Gauge Whether AWV Is Involved

To determine whether you should apply a patient’s deductible to her ACP service, and also whether to bill the patient a coinsurance amount, you should first read through the notes to determine whether the ACP was performed during an annual wellness visit (AWV), CMS says in MLN Matters article MM9271.

If your provider performs the ACP service as an optional element of an AWV, you should report both the AWV and the ACP and waive the deductible and coinsurance for both services. “ACP services furnished on the same day and by the same provider as an AWV are considered a preventive service,” the article notes. “Therefore, the deductible and coinsurance are not applied to the codes used to report ACP services when performed as part of an AWV.”

Exception: On the other hand, if you furnish an ACP service outside of an AWV visit, you should collect the coinsurance and apply the visit to the deductible, the article notes.

Example: A patient presents for his annual wellness visit and asks the doctor to also discuss creating an advance directive to denote his wishes if he ever lacks the capacity to make those decisions on his own. You’ll report G0438 (Annual wellness visit; includes a personalized prevention plan of service [PPPS], initial visit) for the AWV, as well as 99497 for the ACP service, together on the same claim form. You should append modifier 33 (Preventive services) to 99497 to ensure that the deductible and coinsurance are waived.

Resource: Too read more about coding and billing for ACP services, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9271.pdf.