Making sure that each patient’s goals are incorporated into their treatment plan is a must for providers that hope to maintain high patient satisfaction rates. One way to help maintain and document these goals for alignment is by having patients complete and Advance Care Plan. CMS has determined that this particular document is important enough to include in its different quality payment programs so we felt a bit more detail on completing this service might be warranted. Below you will find a roadmap to successfully implementing the Advance Care Planning process the clinical workflow with minimal disruption.

What is it?

First off, what exactly is an Advance Care Plan (ACP)? Simply put, the ACP is a documented course of action to be taken for a patient who’s current medical status prevents them from making decision for themselves. The ACP will include an identified surrogate decision maker to speak on behalf of the patient and/or a predefined list of treatment decisions with respect to the following items: resuscitation procedures, mechanical respiration, chemotherapy, radiation therapy, dialysis, simple diagnostic tests, pain control, blood products, transfusions, and intentional deep sedation.

Criteria

Advance directives are designed to respect patient’s autonomy and determine his/her wishes about future life- sustaining medical treatment if unable to indicate wishes. In order to satisfy the needs of the quality measure as it pertains to the CMS QPP criteria a patient must complete the ACP and a provider must have the responses documented in their chart. There is a reimbursement for completing the ACP and it can be added to a patients Annual Wellness Visit without any additional copay.

Advance Care Plan Economics:

• Average Reimbursement: $86
• Procedure Code Used on Claim: 99497

Measure Details

For providers participating in Primary Care First or other CMS alternative payment models which specify the need for collecting an Advance Care Plan, the financial benefits can be even greater. Patient eligibility for this measure is outlined below:

Denominator (patients that should have an ACP according to CMS)

DENOMINATOR:

All patients aged 65 years and older

DENOMINATOR NOTE: MIPS eligible clinicians indicating the Place of Service as the emergency department will not be included in this measure.

Denominator Criteria (Eligible Cases):

Patients aged ≥ 65 years on date of encounter

AND Patient encounter during the performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99291, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439 AND NOT DENOMINATOR EXCLUSION: **Hospice services received by patient any time during the measurement period: **G9692

Numerator (Patients that have completed the ACP according to CMS criteria guidelines)

NUMERATOR:

Patients who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan

Definition:

Documentation that Patient did not Wish or was not able to Name a Surrogate Decision Maker or Provide an Advance Care Plan – May also include, as appropriate, the following:

• That the patient’s cultural and/or spiritual beliefs preclude a discussion of advance care planning, as it would be viewed as harmful to the patient’s beliefs and thus harmful to the physician-patient relationship.

Numerator Instruction: If patient’s cultural and/or spiritual beliefs preclude a discussion of advance care planning, submit 1124F.

NUMERATOR NOTE: The CPT Category II codes used for this measure indicate: Advance Care Planning was discussed and documented. The act of using the Category II codes on a claim indicates the provider confirmed that the Advance Care Plan was in the medical record (that is, at the point in time the code was assigned, the Advance Care Plan in the medical record was valid) or that advance care planning was discussed. The codes are required annually to ensure that the provider either confirms annually that the plan in the medical record is still appropriate or starts a new discussion.

The provider does not need to review the Advance Care Plan annually with the patient to meet the numerator criteria; documentation of a previously developed advanced care plan that is still valid in the medical record meets numerator criteria.

Services typically provided under CPT codes 99497 and 99498 satisfy the requirement of Advance Care Planning discussed and documented, minutes. If a patient received these types of services, submit CPT II 1123F or 1124F.

Summary

It is important for providers and clinical staff to document properly in order to receive payment or credit for completion of the ACP Measure 47. This includes confirming performance has been met by adding the necessary CPT II codes to the outgoing claim. Medical Organizations are required to partner with a Qualified Registry to submit performance data to CMS, Quantician can help track, monitor and design a workflow that satisfies the requirements for successful ACP documentation.