Its use leads to better care, lower costs and greater provider satisfaction
Multiple studies have demonstrated that advance care planning (ACP) is a cost-effective way to improve patient-and family-centered care while reducing costs. Recognizing the time required for ACP discussions, in 2016 the Centers for Medicare and Medicaid Services (CMS) introduced billing codes for them. But while the use of ACP codes is increasing, absolute provider use remains low.
Increasing ACP discussions can improve care quality and help health systems achieve the Quadruple Aim of reducing costs, improving patients' and families’ experience, improving the health of populations, and increasing provider satisfaction.
What is ACP?
ACP is a conversation between a physician or other qualified health professional—nurse practitioner, physician assistant, or clinical nurse specialist—and a patient, family member, or other surrogate decision-maker about the patient’s health care wishes. ACP discussions can include identifying a surrogate decision-maker or helping a patient complete legal forms such as a living will, medical orders for life-sustaining treatment, or durable power of attorney for health care. Completion of these steps is not required for an ACP discussion, however.
These conversations can occur in facility and non-facility settings, including via telehealth, and can be initiated as part of an annual wellness visit or as a separately billed Medicare Part B medically necessary service.
Costs and benefits of ACP
The cost of end-of-life care can be significant; one meta-analysis found that 21% of all Medicare spending was on the 6.4% of enrollees in their last 12 months of life. Significant spending is expected for very sick patients and may be justified if it corresponds to patients’ preferences. However, data suggest this is not the case. In one study of Medicare enrollees, 71.7% wanted palliative drugs in the event of a terminal illness, even if those drugs might shorten their life span, and 77.4% did not want mechanical ventilation, even if it would extend their lives by a month.
Similarly, a study of adult cancer patients found that 556% would prefer to die at home. Despite these preferences, only 30.7% of patients died at home and 29% of Medicare decedents stayed in an ICU during the last month of their life. Terminally ill patients who had participated in end-of-life discussions were less likely to have ventilation or aggressive medical care and more likely to have earlier hospice admission and better quality of life.
The mismatch between patient preferences and patient care has implications beyond patient satisfaction. When terminally ill patients participated in ACP, their caregivers had a lower risk of depression and regret after patients’ deaths.
Families of patients are not the only ones who suffer from an absence of ACP. Physicians who provide ICU care for patients may experience moral distress. They raise concerns about offering potentially inappropriate treatments for the patient’s state of health, families not understanding the patients’ prognosis, and caring for patients whose course of treatment is unclear, with neither palliative care nor active treatment being offered.
Much of this suffering, guilt, and uncertainty could be avoided if patients and families are offered advanced care planning early in the course of an illness. Patients who participated in ACP discussions were more than 2.5 times as likely to have their wishes known and followed compared to controls, and families whose loved ones participated in ACP experienced less stress, anxiety, and depression.
Despite these advantages, the ACP billing codes are underutilized, which likely reflects a similarly low level of ACP discussions and documentation. Among Medicare beneficiaries aged 65 and older, only about 2.4% were part of a documented ACP discussion.
ACP claims were still extremely low for seriously ill and frail patients, with 5.2% having an ACP discussion. A study of a large national hospitalist, emergency medicine, and critical care physician practice found that acute care physicians completed an ACP conversation for only 5.4% of hospital encounters. Even when physicians answered “no” to the question “Would you be surprised if the patient died in the next year?” only 8.3% documented an ACP conversation. Furthermore, primary care physicians who cared for Medicare patients with the highest severity of illness were least likely to document ACP services.
Billing for ACP
CMS has implemented standards for ACP billing. First, ACP may only be performed by a physician or other qualified health professional. The medical provider must document the voluntary nature of the visit, an explanation of advance directives, who was present during the discussion, any change in health status or health care wishes if the patient can no longer make decisions, as well as the time spent on ACP during the face-to-face encounter.
ACP is billed under a time-based system: the first 15 minutes of ACP cannot be billed; minutes 16-30 are billed under CPT code 99497, and each additional half hour is billed under CPT code 99498 (See table). If ACP is not provided as a part of an annual wellness visit or preventative care, the patient may participate in cost-sharing.
Billing codes, their descriptions, and national reimbursements for advance care planning discussions. Reimbursements are based on national Medicare payments in 2023 from the Medicare Physician Fee Schedule. (Click on image to enlarge)
Other barriers to increasing ACP use
Implementing billing for ACP is only one challenge involved in increasing ACP discussions. Physicians and other qualified health professionals must be willing to engage in ACP discussions and agree on who should take charge of ACP discussions for patients with multiple serious conditions. Educational interventions for health care professionals and trainees can increase ACP discussions and emphasize that broaching ACP with patients can increase patient and family satisfaction.
For ACP discussions to be most effective in improving the quality of care for patients, ACP documentation must be easy to access in the patient’s medical record. Implementing standardized electronic health record (EHR) ACP forms that make it easy to document and find patient wishes may increase the number of ACP discussions and increase the probability that a patient’s wishes are easily accessible to acute care clinicians. If clinicians can easily discern whether a patient has a documented ACP discussion in the EHR, they may be more likely to engage in ACP with high-risk patients.
Physicians and other qualified health professionals must also be aware that it is possible to bill for ACP discussions that may already be occurring within an organization. One small study in a family medicine clinic found that while 52% of their patients who were over 70 years old had documented ACP conversations in visits, only 44% of those patients were formally billed for ACP. Billing for ACP rewards physicians who take the time to evoke, understand, and document their patients’ wishes.
Documented ACP discussions continue to increase since the inception of the ACP CPT codes in 2016 but remain low in absolute terms. Increasing and improving ACP discussions has the potential to increase patient and family satisfaction, decrease health care costs, and reduce moral injury in physicians and other qualified health professionals. Health systems that incorporate advanced care planning may be better able to increase the value of the care they provide, improve their staff’s well-being, and implement patient-and family-centered care.
Coffin is a professor in the department of family medicine at the Medical College of Georgia. The other authors are second-year medical students there.