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Medicare’s Proposed Payment for Advance Care Planning Doesn’t Go Far Enough

Posted in Home Healthcare, Hospitals and Institutions, Legislation and Public Policy, Medicare and Medicaid, Reimbursement Matters

In its proposed 2016 physician fee schedule rule published on July 15 (the “Rule”), the Centers for Medicare & Medicaid Services (CMS) proposed new separate Medicare payment for two CPT codes (99497 and 99498) that describe advance care planning (ACP) services. (See page 41773 of the Rule.)  However, the proposal falls short of creating a clear coverage policy.

The Rule specifically states that paying for the two new codes “does not mean that Medicare has made a national coverage determination regarding the service.” In fact, CMS reiterated that the ACP CPT codes “should be reported when the described service is reasonable and necessary for the diagnosis or treatment of illness or injury.” Additionally, the example provided in the Rule includes ACP services that are provided in conjunction with a visit for treatment of an existing medical condition; however, CMS did note that the two services could be provided on different days.

CMS requested input on when payment for ACP would be appropriate in other circumstances. While roughly one-quarter of Medicare’s annual spending is on care provided in the last year of a beneficiary’s life (see “10 FAQs: Medicare’s Role in End-of-Life Care,” recently published by the Kaiser Family Foundation), CMS continues to struggle with developing a cogent national policy on payment for end-of-life discussions. Not only would a reasonable Medicare policy reduce costs by avoiding undesired care, more importantly, it would help healthcare providers better understand the desires of patients facing end-of-life care decisions.

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