Billing for POLST Consultation

Effective January 1, 2016 Medicare reimburses physicians, APRNs and PAs for Advance Care Planning (ACP).

Code 99497 provides for a 30 minute conversation with a patient, their family or their surrogate decision-maker.

Code 99498 is an add-on code providing for an additional 30 minute conversation.

Advance Care Planning as described by CPT codes is primarily the provenance of patients and physicians, APRNs and PAs. Accordingly, CMS “expects the billing physician or NPP [APRN or PA] to manage, participate and meaningfully contribute to the provision of the services, in addition to providing a minimum of direct supervision”. Also noted is that “the usual PFS [Physician Fee Schedule] payment rules regarding ‘incident to’ services apply, so that all applicable state law and scope of practice requirements must be met in order to bill ACP services”. In addition, because patients may be in various settings, “these codes will be separately payable to the billing physician or practitioner in both facility and non-facility settings and are not limited to particular physician specialties”. ACP may be added as a voluntary, separately payable element of the AWV [Annual Wellness Visit]. CMS instructs that “when ACP is furnished as an optional element of AWV as part of the same visit with the same date of service, CPT codes 99497 and 99498 should be reported and will be payable in full in addition to payment that is made for the AWV under HCPCS code G0438 or G0439, when the parameters for billing those CPT codes are separately met, including requirements for the duration of the ACP services. Under these circumstances, ACP should be reported with modifier -33 and there will be no Part B coinsurance or deductible, consistent with the AWV”. ACP services were not added to the list of Medicare telehealth services, so the face-to-face services described by the codes need to be furnished in-person in order to be reported to Medicare.

For the purposes of the Nevada POLST, billing for a POLST discussion would include a discussion with the patient, their representative or surrogate.

For more information on these new CMS provisions, click here.