Adding Value to Advance Care Plan

by Timothy Gieseke, MD, CMD                                                             

As of January 1, 2016, CMS is paying for advance care planning discussions.  As a post-acute care specialist with a strong interest in palliative care, I’m pleased that CMS will finally pay for what I have previously done for free (because it was the right thing to do).

This came home to me today as I was seeing a frail quite cognitively impaired 91-year-old man admitted to our facility yesterday.  As I reviewed his digital referring hospital EHR, I was surprised to only find a file indicating DNAR (do not attempt resuscitation), but not a discussion of advance care planning.  Our admitting RN did initiate a POLST conversation yesterday with his DPOA (son), which indicated “attempt CPR.”  As I talked with the son to better understand his dad’s goals and values, it became apparent the son knew his dad had a very limited life expectancy and was OK with DNAR status while at living at his assisted living facility.  However, if his dad were in the acute hospital and had a witnessed cardiac arrest, he believed his father would still want an attempt at CPR.  With this clarification, we completed a POLST indicating DNAR in section A with the son knowing this didn’t apply to the acute hospital setting.  The key issue here is that the POLST was designed for outpatient use and needs to be translated into an acute hospital care plan.  In situations like this,  the blank space in Section B of the POLST can be used to clarify such nuances; for example, “CPR and defibrillation permissible in acute hospital witnessed arrest situation.”

To capture the work I just completed, in addition to my 99306 billing code for my admission, CMS now permits the use of additional advance care planning codes.  The one I chose was 99497 which covers up to the first 30 minutes of advance care planning work.  In our area the value is about $86.  99498 is used for each additional 30 minutes of time. Both codes require documentation of the minutes of face-to-face time with minimum of 15 minutes required. The Kaiser family foundation has a nice handout on “10 FAQs: Medicare’s Role in EOLC” that addresses this new benefit at:http://kff.org/medicare/fact-sheet/10-faqs-medicares-role-in-end-of-life-care .

For those of you working with NPs and PAs, this billing code is now an option in 2016 for them as long as they have the training and skill set to perform this service.  If your facilities aren’t yet using the new 2016 POLST form, I would encourage them to do so.  The forms are available atwww.coalitionccc.org or throughwww.Med_Pass.com .  

As health professionals, let’s continue doing what’s right for our patients and families even when we aren’t directly paid to do so.  As our payers and the public see the value of what we are doing, hopefully payment will follow as we have now seen, in the area of advance health care planning.

At CALTCM, we desire to work with you to improve the value of all your “caring”— we feel that proper advance care planning, with discussion of individual goals of care, goes a long way toward ensuring that our patients get treatments in line with their own wishes and beliefs.  And what can be more important than that?