Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE:01|01|2018 POLICY LAST UPDATED: 07|06|2022

OVERVIEW End-of-life planning is verbal or written information that is provided to a patient regarding a patient’s ability to prepare an advance directive in the case that an illness or injury causes the patient to be unable to make healthcare decisions. PRIOR AUTHORIZATION None

POLICY STATEMENT Medicare Advantage Plans and Commercial Products Advance care planning services are covered. Reimbursement of CPT 99497 is limited to the following payment guidelines: • covered but NOT separately reimbursed when rendered on the same day as a Welcome to Medicare visit or an Annual Well visit (G0402, G0438 or G0439) or Preventive Medicine (99381-99397) Visit.
• covered and separately reimbursed when filed as the only service rendered on that date or when filed with 99202-99215
• copays and deductibles apply when 99497 is the only service on claim • deductible only applies when filed with 99202-99215

CPT 99498, which is an add on code, will continue to be covered but not separately reimbursed

Note: completion of an advance directive form is not a requirement for billing the service and documentation in the medical record must reflect the following information: • Total time in minutes spent on discussion
• Patient/surrogate/family “given opportunity to decline” • Details of discussion (e.g. Who was involved? What was discussed? Understanding of illness, spiritual factors. Why are they making the decisions they are making? Was any advance directive offered/filled out? Follow-up)

MEDICAL CRITERIA None

BACKGROUND Advance care planning is a service that supports conversations between patients and their doctors and non- physician practitioners (NPPs) to decide what type of care may be right for them in the event of life-limiting conditions or incapacitating illness. Advance care planning is not the same as an advance directive, which is a legal document that specifies what should happen if a person is no longer able to make his/her own medical decisions. Advance directives take many forms, such as living wills and durable powers of attorney for health care

During advance care planning conversations, doctors/NPPs may talk through and help the person plan for a time when he/she cannot make his/her own medical decisions. If the member has a life-threatening condition, the practitioner may discuss creating a disease specific plan, help the member explore his/ her Payment Policy | Advance Care Planning (formally Advanced Directives)

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

understanding of the illness progression, and discuss his/her own and their family’s hopes, fears, and concerns. They may also talk about care choices during a critical event, and how aggressive they would like their treatment to be (e.g., resuscitation status, antibiotics, and feeding tubes).

The person does not have to have a terminal illness. Indeed, often the best time to begin to discuss end-of- life care may be before a person is diagnosed with a life-threatening condition, when there is plenty of time to consider one’s preferences. Having these discussions early also may be useful in guiding future care and treatment decisions by family members and caregivers should the person become incapacitated and unable to make his/her choices known.

Voluntary ACP as defined by Centers for Medicare and Medicaid Services (CMS) means the face-to-face service between a physician (or other qualified health care professional) and the patient discussing advance directives, with or without completing relevant legal forms. An advance directive is a document appointing an agent and/or recording the wishes of a patient pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at that time

Examples of appropriate documentation in the members medical record would include an account of the discussion with the beneficiary (or family members and/or surrogate) regarding the voluntary nature of the encounter; documentation indicating the explanation of advance directives (along with completion of those forms, when performed); who was present; and the time spent in the face-to-face encounter.

COVERAGE Medicare Advantage Plans and Commercial Products Benefits may vary between groups/contracts. Please refer to the appropriate Member Certificate or Subscriber Agreement for applicable office visit coverage/benefits.

CODING Medicare Advantage Plans and Commercial Products The following code is covered and reimbursed when the policy guidelines are met: 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 healthcare professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate

The following code is covered but not separately reimbursed 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 healthcare professional; each additional 30 minutes (list separately in addition to code for primary procedure)

Medicare Advantage Plans and Commercial Products Claims filed with the following code will deny as use alternate. Claims should be filed with one of the above CPT codes.
S0257 Counseling and discussion regarding advance directives or end-of-life care planning and decisions, with patient and/or surrogate

RELATED POLICIES None

PUBLISHED Provider Update, September 2022 Provider Update, April 2019 Provider Update, November 2017

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

Provider Update, May 2017 Provider Update, August 2016 Provider Update, November 2013 Provider Update, May 2006 Provider Update, January 2006

REFERENCES

1. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/MM6223.pdf
2. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/preventive-services/medicare-wellness-visits.html

3. https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=58664

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   This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

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