Advance care planning (ACP) services were meant to give patients the opportunity to choose the care that is right for them at the end of their lives or during medical crises that could render them unable to make personal health decisions.
However, in a recently released report, the U.S. Department of Health and Human Services’ (HHS) Office of Inspector General (OIG) found that physicians and other qualified health care professionals that billed for ACP services did not always comply with federal requirements to the tune of an estimated $42 million in improper payments.
CMS highlighted improper documentation as a top reason for noncompliance, namely for billing codes 99497 and 99498. A large number of other “questionable claims” did not meet CMS’ guidance, but were not deemed erroneous, the report states.
Of those ACP services in OIG’s audit sample that physicians and others billed for, the agency found 67% were documented incorrectly, causing Medicare to pay $33,332 for those services in error. OIG recommended the Centers for Medicare & Medicaid Services (CMS) instruct Medicare administrative contractors (Novitas in Texas) to recoup that amount.
CMS confirmed to Texas Medicine Today the agency concurred with OIG’s recommendation and will proceed with steps to collect overpayments, but did not specify a timeline.
As a reminder from Texas Medical Association experts, Medicare pays for ACP services under the “Welcome to Medicare” visit, and there are no limits to the frequency of these services in a given time period. Medicare covers these two Current Procedural Terminology (CPT)codes separately:
CPT code 99497: ACP services that include a 30-minute (minimum of 16 minutes) face-to-face discussion with the patient, family member(s) and/or surrogate on advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional.
Add-on CPT code 99498: Supplemental ACP services for each additional 30-minute (minimum of 16 minutes past the first 30 minutes documented) discussions on the explanation of advance directives by the physician or other qualified health professional; each additional 30 minutes must be listed separately in addition to the code for the primary procedure.
For more information on documentation and coding, CMS offers various resources.
For additional help, contact TMA’s payment specialists for help or submit a request for information.
Last Updated On
January 05, 2023
Originally Published On
December 22, 2022