ACP as an Optional Element of an AWV
MLN Matters® Number: MM9271
Related Change Request (CR) #: CR 9271
Related CR Release Date: December 22, 2015
Effective Date: January 1, 2016
Related CR Transmittal #: R216BP and R3428CP
Implementation Date: January 4, 2016
Provider Types Affected
This MLN Matters® Article is intended for providers who submit claims to Medicare Administrative Contractors (MACs) for Advance Care Planning (ACP) services provided as an optional element of the Annual Wellness Visit (AWV) to Medicare beneficiaries.
Provider Action Needed
Change Request (CR) 9271 informs providers to waive the deductible and the coinsurance for ACP when furnished as an optional element of an AWV. Make sure your billing staffs are aware of these changes.
The Centers for Medicare & Medicaid Services (CMS) made the Current Procedural Terminology (CPT) codes for ACP separately payable for Medicare. The change in policy will be implemented through the annual Medicare Physician Fee Schedule Database (MPFSDB) update.
In addition, CMS is also including voluntary ACP as an optional element of the AWV. ACP services furnished on the same day and by the same provider as an AWV are considered a preventive service. Therefore, the deductible and coinsurance are not applied to the codes used to report ACP services when performed as part of an AWV.
Voluntary ACP means the face-to-face service between a physician (or other qualified health care professional) and the patient discussing advance directives, with or without completing relevant legal forms. An advance directive is a document appointing an agent and/or recording the wishes of a patient pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at that time.
Voluntary ACP, upon agreement with the patient, would be an optional element of the AWV. Effective January 1, 2016, when ACP services are provided as a part of an AWV, practitioners would report CPT code 99497 (plus add-on code 99498 for each additional 30 minutes, if applicable) for the ACP services in addition to either of the AWV codes G0438 and G0439. CPT codes 99497 and 99498 used to describe ACP are separately payable under the Medicare Physician Fee Schedule (MPFS). When voluntary ACP services are furnished as a part of an AWV, the coinsurance and deductible would not be applied for ACP. Under that circumstance, both the ACP and AWV must also be billed together on the same claim. In order to have the deductible and coinsurance waived for ACP when performed with an AWV, the ACP code(s) must be billed with modifier 33 (Preventive services). Since payment for an AWV is limited to only once a year, the deductible and coinsurance for ACP billed with an AWV can only be waived once a year.
Critical Access Hospitals (CAHs) may also bill for these professional services provided on or after January 1, 2016, using type of bill 85X with revenue codes 96X, 97X, and 98X. The CAH Method II payment will be based on the lesser of the actual charge or the facility-specific MPFS.
However, the deductible and coinsurance does apply when ACP is not furnished as part of a covered AWV.
The official instruction, CR9271, was issued to your MAC regarding this change via two transmittals. The first updates the "Medicare Benefit Policy Manual" and it is available at http://www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R216BP.pdf on the CMS website. The second transmittal updates the "Medicare Claims Processing Manual" and it is available at http://www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3428CP.pdf on the CMS website.
Last Updated Dec 30, 2015