Advance Care Planning Services

AAFP to CMS: Now, Make a National Coverage Determination

July 28, 2015 04:15 pm News Staff

CMS made the right move when it included advance care planning (ACP) services in the proposed 2016 Medicare physician fee schedule, and now the agency needs to ensure that this coverage determination is applied nationwide.

[Physician talking with elderly woman at desk]

That was the AAFP's message to CMS in July 23 letter(2 page PDF) about ACP services in the proposed fee schedule as published( in the Federal Register on July 15.

AAFP Board Chair Reid Blackwelder, M.D., of Kingsport, Tenn., told CMS Acting Administrator Andy Slavitt that the AAFP fully supported the establishment of separate payment for CPT codes 99497 and 99498. But CMS proposes giving the codes status indicator "A," which indicates that Medicare has not made a national coverage determination regarding advance care planning services. Without a national policy, Medicare contractors can make local coverage decisions.

"The AAFP strongly encourages CMS to prevent what will quickly become inconsistent local interpretations, which will be particularly confusing for physician practices that serve patients in two or more local coverage areas," Blackwelder said.

He told CMS to "promptly begin the process of making a national coverage determination for ACP services."

Story Highlights
  • CMS included advance care planning services in the proposed 2016 Medicare physician fee schedule.
  • AAFP sent CMS a letter pointing out that the coverage determination should apply nationwide.
  • The proposal includes flexibility in how physicians schedule the services.

The AAFP also urged CMS and agency contractors to consider including the codes in the final 2016 rule "as a national policy applicable to all Medicare beneficiaries regardless of their locality."

For those unfamiliar with ACP services, CPT's editorial panel created the two new codes earlier this year and established that 99497 would cover the first 30 minutes of advance care planning and 99498 each additional 30 minutes of such planning.

In the 2016 proposed fee schedule, CMS included an example of how advance care planning could take place in conjunction with the management or treatment of a patient's presenting condition. For instance, consider a patient who is receiving treatment for heart failure and diabetes, and sees his physician for evaluation and management (E/M) of these two diseases.

In addition to discussing short-term treatment options, the patient might ask to discuss long-term treatment options such as a heart transplant. According to CMS in the proposed rule, "In this case the physician would report a standard E/M code for the E/M service and one or both of the ACP codes depending upon the duration of the ACP service.

"However, the ACP services as described in this example would not necessarily have to occur on the same day as the E/M service"

Blackwelder said the AAFP supported flexibility in allowing E/M services to be provided on the same day as ACP services or during separate visits.

Ditto for a patient's desire to work on advance care planning during his or her Medicare annual wellness visit or during other appropriate times and circumstances.

"The AAFP supports giving Medicare patients flexibility in how they seek their care," said Blackwelder. "We equally support providing that same flexibility for medical practices offering these services."

"The AAFP strongly urges CMS to include ACP codes in the final rule since advance care plans help patients receive the care they want. Knowing a person's wishes regarding medical care in advance eases patients' and families' burden as they grapple with difficult decisions in the face of life-limiting illness or injury," said Blackwelder.

Furthermore, "Helping families understand the medical underpinnings for such decisions requires deliberate conversations based on the family physician's expertise," he added.

The AAFP is studying CMS' full proposed 2016 Medicare physician fee schedule and will weigh in with more recommendations before the public comment deadline of Sept. 8.

Related AAFP News Coverage
2016 Proposed Medicare Physician Fee Schedule
AAFP Lauds Payment Stability, Action on Advance Care Planning Codes


'Care Planning Act' Gets Big Thumbs Up From AAFP
Bill Would Safeguard Medicare Beneficiaries' End-of-Life Wishes


Getting Paid for Advance Care Panning
Organizations Prod HHS to Recognize Existing CPT Codes