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Avoid These Advance Care Planning Errors to Keep Pay Flowing

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Avoid These Advance Care Planning Errors to Keep Pay Flowing

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Advance care planning

Is your practice reporting advance care planning (ACP) properly? If you’re like the majority of practices that the OIG recently audited, you’re probably documenting these incorrectly, which could mean you’ll need to pay money back to Medicare.

Here’s why: A recent OIG audit revealed that out of 691 ACP services they reviewed, 466 didn’t comply with government requirements, which means that a startling 67 percent of ACP claims were documented incorrectly.

Check out a few of the most common advance care planning errors that the OIG identified to find out how you can stay on the right side of the rules.

Error 1: Providers Didn’t Differentiate Face-to-Face Time

When your physician spends time with Medicare patients or their caregivers to discuss their health care wishes if they can’t make their own medical decisions, you can typically bill for advance care planning — but only for face-to-face (F2F) services. And many providers aren’t distinguishing their F2F services from time spent on other care, and they will have to pay Medicare back.

According to the OIG, 268 of the 691 claims they reviewed were flawed due to failure to differentiate F2F time from non-F2F time.

For example: One note that the auditors reviewed said, “We have spent 35 minutes in obtaining interval history and performing clinical exam. We have reviewed her medications, allergies, and ROS.We have reviewed her medications and she continues her current meds. Her recent eye exam was good and her xeropthalmia has been controlled. We have reviewed her advanced directives and performed medication reconciliation.”

Here’s the problem: The provider noted that the entire visit took 35 minutes, but included other activities in addition to advance care planning. Without differentiation by the provider about how much time was spent on each activity, it’s impossible to tell which portion of the 35 minutes was spent discussing ACP. Because the following ACP codes are time-based, this note won’t support reporting advance care planning:

  • 99497 (Advance care planning 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 care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate)
  • +99498 ( … each additional 30 minutes (List separately in addition to code for primary procedure)).

Error 2: Providers Didn’t Document the ACP Itself

If your providers document the time spent during the visit and what they did during each portion, you should pat yourself on the back—but not too hard. In some cases, even though the time is documented and broken down by activity, the physician will fail to document that any ACP discussion occurred at all.

The OIG report indicates that 174 of the 691 claims they audited were flawed due to missing documentation that an advance care planning discussion occurred.

For example: Suppose the note said, “I spent 30 minutes with Mrs. Jones today going over her labs and ECG findings. For 10 minutes, we discussed the potential need for a stent, along with her daughter, who was present. For 10 minutes, we talked about the possibility of mild heart failure and the ensuing implications for quality of life. For 10 minutes, we discussed her options for discontinuing her cigarette smoking habit.”

Here’s the problem: The provider broke down each activity appropriately, but never mentioned anything related to advance care planning, which means reporting 99487-99498 would not be justified.

Error 3: Providers Didn’t Send OIG Their Records

When the OIG asks for medical records, it’s your responsibility to submit them by the deadline or ask for more time. If you don’t, the auditors will ask you to return the money you got for those services since you haven’t shared documentation to justify the fact that your claims were supported.

Such was the case with 24 of the 691 services that the OIG audited. Providers did not submit any medical records in response to the auditors’ requests, which meant the providers had to return the payments for those claims. Because 99497 reimburses about $85 and 99498 pays about $75, you could be losing significant cash if you fail to document these services properly.

Best Practice: Document What You Discussed, and for How Long

To ensure that your ACP services are justified in the documentation, always record what you talked about with the patient, and for how long. Be sure to include detail about the specific ACP services performed.

For example: A solid ACP note might say, “Today I met with Mrs. Smith to discuss advance care planning. We spent 10 minutes discussing why advance care planning is important and she shared with me that she wants to move forward with an advance directive because she felt pressure to make decisions on her husband’s behalf when he was sick several years ago. For 10 minutes, we talked about which decisions she can plan in advance, including whether she would want intubation or blood transfusion. I asked if she has a healthcare agent in her life who she trusts and she said she trusts her daughter to do it. For 10 minutes, we looked over the sample advance directive she brought and I answered her questions about what each part meant. For next steps, she is going to talk to her daughter about her options and meet with an attorney. In total, we spent 30 minutes discussing her advance care planning.

If you want to ensure you don’t run afoul of the OIG, it’s a good idea to master your compliance know-how. Consider an online training with experts who can provide you with plain-English, actionable tips that will help you stay on the right side of the coding and billing regulations.


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