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Oncology Practice Management - December 2015, Vol 5, No 9 - Reimbursement
Rosemary Frei, MSc

The Centers for Medicare & Medicaid Services (CMS)’s planned reimbursement of advance care planning services in 2016 is being greeted with enthusiasm by the oncology community. Advance care planning comprises the discussion of options for palliative care, end-of-life care, and advance directives.

The October 30, 2015, final rule issued by CMS for 2016 introduces reimbursement for advance care planning, which is particularly relevant to providers in the oncology team. CMS will now pay for advance care planning services at each “Annual Wellness Visit,” in addition to other times when it is deemed necessary.1

“In [these] other contexts, Medicare will only pay for advance care planning when the services are medically reasonable and necessary,” a CMS spokesperson told Oncology Practice Management. “CMS believes that beneficiaries who have had advance care planning and are satisfied with their advance directives are unlikely to engage physicians to provide this service repeatedly. Beneficiaries are always free to alter their care preferences, including any decisions they have made regarding advance directives.”

Advance Care Planning in Oncology

The changes also include reimbursement for more than 1 provider for advance care planning services.

Robin T. Zon, MD, Immediate Past Chair, American Society of Clinical Oncology Clinical Practice Committee, and Chair, Finance and Quality Committees, Michiana Hematology-Oncology, IN, conveyed her enthusiasm for the changes. Dr Zon said that the multiple-provider reimbursement will mean that beneficiaries can get more information before making decisions about complex clinical issues, such as cancer treatment and end-of-life care. She also said that adding reimbursement for more than 1 advance care planning discussion will pay significant dividends to patients.

“If physicians are encouraged to deliver ACP [advance care planning] earlier in the disease process of cancer, for example, and they define the goals of treatment very early on—including the expectations and the options—then we may be able to avoid unwanted or undesired treatments up front rather than later in the game, and better comply with the wishes of the patient,” said Dr Zon.

She said the options can and should be explored, particularly now that advance care planning services will be provided more routinely. These discussions will now be reimbursed and include services such as symptom-directed treatment with hospice or palliative care, and the avoidance of futile cancer treatment at end of life.

“Sometimes patients don’t realize they have the option of hospice, or are fearful of it, as they believe hospice means an immediate death sentence when offered as an intervention,” said Dr Zon. “But there are many of my patients who receive hospice care for months at a time. As a result, they experience better symptom control and quality of life with hospice care, which is often an outpatient service based in the home.”

The new Medicare reimbursement rule for advance care planning means that advance care planning services can also be billed for nonphysician providers, including physician assistants and nurse practitioners, and for providers’ staff when they are incident to the physician services but directly supervised by the physician.

Many groups and individuals who commented before the finalization of the rule asked that CMS issue a national coverage decision, but the organization demurred. In the interim, Medicare Administrative Contractors will be responsible for local coverage decisions.

“We believe it may be advantageous to allow time for implementation and experience with ACP services, including identification of any variation in utilization, prior to considering a controlling national coverage policy through the National Coverage Determination process,” the final rule states.2

The Current Procedural Terminology billing codes for advance care planning services are 99497 for the first 30 minutes and 99498 for each additional 30 minutes.2




References

  1. Centers for Medicare & Medicaid Services. Proposed policy, payment, and quality provisions changes to the Medicare Physician Fee Schedule for calendar year 2016. Fact sheet. October 30, 2015. www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-10-30-2.html. Accessed November 11, 2015.
  2. Centers for Medicare & Medicaid Services (CMS), HHS. Medicare program; revisions to payment policies under the Physician Fee Schedule and other revisions to Part B for CY 2016. Final rule with comment period. Fed Regist. 2015;80:70885-71386.
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Last modified: January 7, 2016
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