"finding Wisdom in the Dynamic Equilibrium between Living and Dying"
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Living in the Dynamic Equilibrium between Autonomy & Dependence
"How to Approach End-of-Life Discussions," Wall Street Journal, Sept 28, 2015, R5.
Today, CMS released the first proposed update to the physician payment schedule since the repeal of the Sustainable Growth Rate through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The proposal includes a number of provisions focused on person-centered care, and continues the Administration’s commitment to transform the Medicare program to a system based on quality and healthy outcomes. . .
ADVANCE CARE PLANNING
The proposed rule also seeks comment on a proposal that would better enable seniors and other Medicare beneficiaries to make important decisions that give them control over the type of care they receive and when they receive it.
Consistent with recommendations from the American Medical Association (AMA) and a wide array of stakeholders, CMS proposes to establish separate payment and a payment rate for two advance care planning services provided to Medicare beneficiaries by physicians and other practitioners. The Medicare statute currently provides coverage for advance care planning under the “Welcome to Medicare” visit available to all Medicare beneficiaries, but they may not need these services when they first enroll. Establishing separate payment for advance care planning codes provides beneficiaries and practicioners greater opportunity and flexibility to utilize these planning sessions at the most appropriate time for patients and their families.
The AMA Current Procedural Terminology (CPT) Editorial Panel and the AMA Relative Value Update Committee (RUC) recommended new CPT codes and associated payment amounts for calendar year 2015. CMS did not make the new codes payable for 2015 in order to allow the public full opportunity to comment on whether Medicare should pay separately for these services and, if so, how much beginning January 1, 2016.
For Medicare beneficiaries who choose to pursue it, advance care planning is a service that includes early conversations between patients and their practitioners, both before an illness progresses and during the course of treatment, to decide on the type of care that is right for them.
CMS is accepting public comments on this proposal, as part of the CY 2016 PFS proposed rule, until September 8, 2015.
Federal Register /Vol. 80, No. 135/Wednesday, July 15, 2015/Proposed Rules Page 41773
c. Advance Care Planning Services For CY 2015, the CPT Editorial Panel created two new codes describing advance care planning (ACP) services: CPT code 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 professional; first 30 minutes, face-to- face with the patient, family member(s) and/or surrogate); and an add-on CPT code 99498 (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 professional; each additional 30 minutes (List separately in addition to code for primary procedure)). In the CY 2015 PFS final rule with comment period (79 FR 67670–71), we assigned a PFS interim final status indicator of ‘‘I’’ (Not valid for Medicare purposes. Medicare uses another code for the reporting and payment of these services) to CPT codes 99497 and 99498 for CY 2015. We said that we would consider whether to pay for CPT codes 99497 and 99498 after we had the opportunity to go through notice and comment rulemaking.
We received many public comments to the final rule recommending that we recognize these two CPT codes and make separate payment for ACP services, in view of the time required to furnish the services and their importance for the quality of care and treatment of the patient. For CY 2016, we are proposing to assign CPT codes 99497 and 99498 PFS status indicator ‘‘A,’’ which is defined as: ‘‘Active code. These codes are separately payable under the PFS. There will be RVUs for codes with this status.’’ The presence of an ‘‘A’’ indicator does not mean that Medicare has made a national coverage determination regarding the service. Contractors remain responsible for local coverage decisions in the absence of a national Medicare policy. We are proposing to adopt the RUC- recommended values (work RVUs, time, and direct PE inputs) for CPT codes 99497 and 99498 beginning in CY 2016 and will consider all public comments that we receive on this proposal. Physicians’ services are covered and paid by Medicare in accordance with section 1862(a)(1)(A) of the Act. Therefore, CPT code 99497 (and CPT code 99498 when applicable) should be reported when the described service is reasonable and necessary for the diagnosis or treatment of illness or injury. For example, this could occur in conjunction with the management or treatment of a patient’s current condition, such as a 68 year old male with heart failure and diabetes on multiple medications seen by his physician for the evaluation and management of these two diseases, including adjusting medications as appropriate. In addition to discussing the patient’s short-term treatment options, the patient expresses interest in discussing long-term treatment options and planning, such as the possibility of a heart transplant if his congestive heart failure worsens and advance care planning including the patient’s desire for care and treatment if he suffers a health event that adversely affects his decision-making capacity. In this case the physician would report a standard E/M code for the E/M service and one or both of the ACP codes depending upon the duration of the ACP service. However, the ACP service as described in this example would not necessarily have to occur on the same day as the E/ M service. We seek comment on this proposal, including whether payment is needed and what type of incentives this proposal creates. In addition, we seek comment on whether payment for advance care planning is appropriate in other circumstances such as an optional
element, at the beneficiary’s discretion, of the annual wellness visit (AWV) under section 1861(hhh)(2)(G) of the Act.
Although, the definition of “other qualified healthcare professional,” has not made a place in CPT 2012 manual, the AMA lists it as part of the “CPT 2012 Errata” on its Web site (www.ama-assn.org/resources/doc/cpt/cpt-2011-corrections.pdf) and the definition is as follows:
“A ‘physician or other qualified health care professional’ is an individual who by education, training, licensure/regulation, and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports a professional service. These professionals are distinct from ‘clinical staff.’ A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service. Other policies may also affect who may report specified services.”
Part B practices may be disappointed that RNs and LPNs aren’t included in the definition, because it means that CPT will now prevent RNs and LPNs from reporting certain codes that are meant for physicians and “other qualified healthcare professionals” — for instance, immunization administration codes 90460-90461, neuropsychological testing code 96120, cognitive testing code 96125, and prolonged E/M codes 99358-99359.
However, if your payer does not follow CPT rules on this issue, you may still be able to allow an RN or LPN to perform the service, depending on what your insurer states in writing. And remember that state and local laws may specifically dictate who can perform each type of service, so look to your state medical society for information on that as well.
"We have broadened the concept of 'medical staff' and have allowed hospitals the flexibility to include other practitioners as eligible candidates for the medical staff with hospital privileges to practice in accordance with state law," CMS said in the final rule. The explicit change now allows hospitals to give nonphysician practitioners, such as advanced practice nurses, physician assistants and pharmacists, the power to perform duties that they are trained for and allowed to do within their scope of practice and state law. If hospitals choose to do so, nonphysician practitioners could free up physicians to work on more medically complex patients, CMS said.
Scripts for End-of-Life Conversations
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