Many of us have heard the reference to this portion of a Benjamin Franklin quotation: “…but in this world nothing can be said to be certain, except death and taxes.” Each year we come face to face with taxes, they cannot be avoided. Unfortunately when patients have become seriously ill many are unaware of the benefit of advance-care planning. Studies have shown it leads to better care, higher patient and family satisfaction, fewer unwanted hospitalizations, lower rates of caregiver distress/depression, etc.
CMS is fully aware of these benefits and in 2016 will be joining commercial payers in reimbursing providers for visits used to counsel patients, family, or health surrogate about the appropriateness of advance directives and other end-of life decisions.
In 2015, CMS introduced two CPT billing codes for advance-care planning, but did not activate them for payment:
CPT code 99497 covers a discussion of advance directives with the patient, a family member, or surrogate up to 30 minutes.
CPT code 99498 is an add-on code that covers an additional 30 minutes of discussion.
The 2016 proposed fee schedule was recently released and indicates these two CPT codes could be payable.
PROPOSED CY 2016 PROPOSED CY 2016
CPT CODE FACILITY PAYMENT RATE NON-FACILITY PAYMENT RATE
99497 $80.16 $86.66
99498 $75.11 $75.11
To date, Medicare has not made a National Coverage Determination regarding the service. Without the NCD, the reimbursement decision is set by the Medicare administrative contractors (MACs). Any or all of the MACs could issue a Local Coverage Determination that would contest reimbursement for the codes.
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Providers should get more information on the reimbursement for advance-care planning by going to both the CMS.gov website as well as their MAC website.
Beyond understanding the reimbursement for end-of life discussions, providers may need help in how to proceed with their patients.
A Canadian Medical Association Journal published an end-of-life "conversation guide" containing recommendations to assist with these sensitive situations.
Specific Recommendations
To identify high-risk patients for whom end-of-life planning is needed, clinicians can use the "surprise" question ("Would I be surprised if this patient died in the next year?") or more detailed clinical criteria. These include age 55 years and older and 1 or more advanced chronic illnesses or age 80 years and older and hospital admission for an acute medical or surgical condition.
Clinicians should ask patients which family members they would like to have participate in goals-of-care discussions and should include them whenever feasible.
During such discussions, key topics should include prognosis, the patient's values, and the risks and expected outcomes of life-sustaining interventions.
Meetings to discuss prognosis require arranging a private interview, informing the patient to the extent they desire, offering empathic support, summarizing clearly, and discussing strategies to achieve goals of care.
Patients and their families should be advised that most patients who have an in-hospital cardiac arrest will not survive to discharge, and that many of those who do will have significantly decreased function.
The medical record should include clear documentation of goals-of-care discussions and decisions.
CMAJ. Published online July 15, 2013.
