CLIENT ADVISORY: A Death Preference Not a Panel: Medicare to Pay for Advance Care Planning at the Beneficiaries’ Discretion

On October 30th, 2015, the Centers for Medicaid and Medicare Services (“CMS”) issued its final rules for physician payment for CY 2016. As part of this rule, physicians will now be paid for providing Advance Care Planning consultation to Medicare beneficiaries. While Medicare currently covers this service as part of the “Welcome to Medicare” visit, this update expands coverage to allow beneficiaries to have end-of-life planning discussions at the time of their choosing.

Two CPT codes, 99497 and 99498, have been designated for physicians to use for advance care planning consultations with patients and their families. Advance care planning may be covered at an annual wellness visit, during palliative care, regular office visits, or after the occurrence of a major health event. Requirements for payment include documented face-to-face explanation and discussion of advance directives and completion of advance directive forms.

The rule establishes Medicare standard rates (subject to geographic adjustment) for coverage at $86 (in a physician office) or $80 (in a hospital settling) for the first 30 minutes of advance care planning, and up to $75 for an additional 30 minutes of consultation. CMS has not placed a limit on the number of times this service may be covered for a Medicare beneficiary. When asked during the comment period about overutilization and potential abuse by practitioners, CMS responded that it planned to monitor utilization over time to ensure the service was appropriately used but it declined to put frequency limits on the service. CMS suggested that to combat overuse by beneficiaries, providers should remind beneficiaries that Part B cost sharing would apply every time advance care planning was discussed except when advance care planning is provided as part of an annual wellness visit.

CMS’s stated intention in this final rule is to provide better flexibility and opportunity for both doctors and patients to have these vital conversations when patients are medically ready but still competent. The rule emphasizes patient freedom of choice to initiate end-of-life discussions. Payment for this service will begin on January 1, 2016.

Should you or your organization have any questions regarding practitioner advance care planning and reimbursement, please contact Peter Mellette (Peter@mellettepc.com), Harrison Gibbs (Harrison@mellettepc.com), Nathan Mortier (Nathan@mellettepc.com), or Elizabeth Dahl (Elizabeth@mellettepc.com), or call Mellette PC at (757) 259-9200.

This Client Advisory is for general educational purposes only. It is not intended to provide legal advice specific to any situation you may have. Individuals desiring legal advice should consult legal counsel for up to date and fact specific advice.

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