When is ACP a covered service for Medicare patients?
Q. We have had several families of Medicare pateitns ask if they would need to pay for advanced care planning (ACP) for their loved ones. When is ACP a covered service for Medicare patients?
A: Beginning in calendar year 2016, the Centers for Medicare & Medicaid Services (CMS) made ACP codes separately payable under Outpatient Prospective Payment System (OPPS):
According to CMS, voluntary ACP means a discussion about the care a patient would want to receive if s/he becomes unable to speak for her/himself, including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional face-to-face with the patient, family members and/or surrogate.
ACP with and without other services
When these services are performed with another service by the same provider for the same patient on the same day, the ACP service is packaged.
When ACP is the only service furnished, payment is made separately.
ACP service with AWV
CMS issued MLN Matters Number: MM10000, with an implementation date of June 19, 2017, that reinforced the ACP as an optional element of the AWV.
CMS considers an ACP as a preventive service when furnished on the same day, by the same provider as an AWV. Therefore, the deductible and coinsurance are not applied to 99497 and 99498 when performed as part of an AWV (G0438, G0439).
The ACP is a voluntary and optional element of the AWV, so the patient needs to agree to the service. When ACP services are furnished as a part of an AWV, the coinsurance and deductible do not apply.
The deductible and coinsurance does apply when ACP is not furnished as part of a covered AWV.
The deductible and coinsurance for ACP will only be waived when billed on the same day and on the same claim as an AWV and must also be furnished by the same provider. Waiver of the deductible and coinsurance for ACP is limited to once per year. Payment for an AWV is limited to once per year.
If the AWV billed with ACP is denied for exceeding the once per year limit, the deductible and coinsurance will be applied to the ACP.