Wiki Advanced Care Planning Diagnosis - claims denied for medical necessity

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lcohen4

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Claims are being denied as not being medically necessary. Can any one confirm that when performing ACP with AWV that one of the diagnosis submitted with the Z00.00 should be supporting that the patient has a end-stage chronic illness such as heart failure, or COPD, or AID, etc. If claim is submitted with cpt G0438 and 99497 and diagnosis Z00.00 for example, is that sufficient? In reading thru the guidelines of ACP i'm interpreting that there has to be an additional more identifiable life threatening condition the patient has in order to support the medical necessity of the ACP and AWV.
Thank you. Any and all inoput is appreciated
 
lcohen4 said:
Claims are being denied as not being medically necessary. Can any one confirm that when performing ACP with AWV that one of the diagnosis submitted with the Z00.00 should be supporting that the patient has a end-stage chronic illness such as heart failure, or COPD, or AID, etc. If claim is submitted with cpt G0438 and 99497 and diagnosis Z00.00 for example, is that sufficient? In reading thru the guidelines of ACP i'm interpreting that there has to be an additional more identifiable life threatening condition the patient has in order to support the medical necessity of the ACP and AWV.
Thank you. Any and all inoput is appreciated
Click to expand...


I am very curious about this also. I have read everything I can get my hands on. My understanding upon reading the CMS ruling approving payment is that this was not intended as a medical necessity for those with chronic diseases. Instead, it was intended for all Medicare beneficiaries so they can get an Advance Directive on file in case of incapacitation, no matter the health status. It is possible that one of two things are occurring. One would be that this is so new that the computer systems have not been properly updated and therefore it is getting kicked back. Or, and this would be very disappointing and counter to CMS, it may be possible that since CMS left the payment determination of this up to the MACs that they have decided not to pay. This, I hope, is not the case since it has taken years, thousands of doctors, and hundreds of companies to get payment for this put through.
 
Advanced Care Planning - CMS

i agree.. i thought it to be intended for all Medicare beneficiaries so they can get an Advance Directive on file in case of incapacitation. however, I'm not sure that is how the MACs are applying it.
Please share any thoughts, experience or other interpretation you have on this matter.
Best Regards..
 
I agree with both of you, I thought it to be for all Medicare beneficiaries. I will continue to look into. If you or anyone comes across any new information, please share. thank you
 
Information that might be helpful.

Annual Wellness Visit

In the final rule, CMS is allowing ACP as a voluntary, separately payable element of the Medicare
patient’s Annual Wellness Visit (AWV), at the beneficiary’s discretion. When ACP is furnished as an
optional element of the AWV as a part of the same visit with the same date of service, the CPT codes
99497 and 99498 “should be reported and will be payable in full in addition to the payment that is
made for the AWV.” ACP services provided in conjunction with the AWV should be reported with
modifier -33. There will be no Part B coinsurance or deductible since it is connected to the AWV,
which requires no cost sharing.
CMS states that the “current regulations for the AWV allow the AWV to be furnished under a team
approach by physicians or other health professionals under the physician’s direct supervision.”

https://www.caredimensions.org/userfiles/files/Physician_Fee_Schedule_Final_Rule_110215.pdf

CMS has not developed a national coverage determination. Individual Medicare Administrative Contractors will develop their own policies. CMS hasn’t placed frequency limits on the service, realizing that as a patient’s condition changes, the physician and patient and family may need to re-discuss these critical issues. There is not a limit on the specialty designation of the physician or NPP who provides the service. The service may be performed in an RHC or an FQHC, but those centers will be paid their all-inclusive rate for a visit, and won’t receive any additional payment. A Medicare patient will be responsible for a co-pay and deductible for the service, unless it is performed on the same day as a wellness visit, (G0438 or G0439). In that case, append modifier 33 to the ACP code and the patient will not be charged a co-pay or deductible. Document the time spent in the discussion (exclusive of other E/M services that day) in the medical record.

http://nicolettinotes.com/2015/12/02/advance-care-planning-99497-99498/

Every article I found states that CMS is currently working on NCD for 99497 and 99498.

http://www.aafp.org/news/government-medicine/20150728advancecare.html

http://www.nahc.org/NAHCReport/nr151113_1/
 
Thank you Valerie. I had read those same postings. I did also read on AAPC webiste: CPT Assistant (December 2014) specifies:
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 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.
so do you interpret this to mean that the patient needs to faill into the above definition of who needs the ACP?
 
ACP services furnished w/ AWV are considered preventative

In addition, CMS is also including voluntary ACP as an optional element of the AWV. ACP services furnished on the same day and by the same provider as an AWV are considered a preventive service. Therefore, the deductible and coinsurance are not applied to the codes used to report ACP services when performed as part of an AWV.

In order to have the deductible and coinsurance waived for ACP when performed with an AWV, the ACP code(s) must be billed with modifier 33 (Preventive services).

https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/Downloads/MM9271.pdf

When I read through the information because CMS has used the word optional/voluntary and when performed w/a AWV is considered preventative. It appears to me that it should be treated as a preventative service. Did you include modifier 33 (Preventive services) when submitting this claim?

If the ACP was performed separate from the AWV then I would say yes. We would need to identify the reason and assign an appropriate diagnosis to support medical necessity and omit the modifier 33.
 
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Advance Care Planning

I contacted Novitas who does not, at this time, have an LCD for the ACP codes. there is no list of allowable ICD-10 codes for the CPT codes.
 
Update on ACP DX?

ValerieBatesHoffCPCCPMA said:
In addition, CMS is also including voluntary ACP as an optional element of the AWV. ACP services furnished on the same day and by the same provider as an AWV are considered a preventive service. Therefore, the deductible and coinsurance are not applied to the codes used to report ACP services when performed as part of an AWV.

In order to have the deductible and coinsurance waived for ACP when performed with an AWV, the ACP code(s) must be billed with modifier 33 (Preventive services).

https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/Downloads/MM9271.pdf

When I read through the information because CMS has used the word optional/voluntary and when performed w/a AWV is considered preventative. It appears to me that it should be treated as a preventative service. Did you include modifier 33 (Preventive services) when submitting this claim?

If the ACP was performed separate from the AWV then I would say yes. We would need to identify the reason and assign an appropriate diagnosis to support medical necessity and omit the modifier 33.
Click to expand...

Are there any updates if anyone is now receiving payment and with using which DX?
 
We have started billing the advanced care planning code. This is a sample of what is dictated

Advance Directive Planning
Advance Care Planning: was provided opportunity to discuss, verbal explanation given
Present during discussion: patient
Advance care directives: has been discussed
The directives include: Full Code
Time (minutes) discussing advance directives: 3

I don't think this would qualify as I don't think that is enough time based on Medicare guidelines that state over half the amount of time, which would be 16 minutes based on the 30 minutes for the code.
What are some other coders thoughts. Also is there any documentation on this.

Also we are using the Z71.89 code. I have not heard anything on denials and we have been using it for a couple of months.

Thanks
 
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