​Physicians who treat Medicare patients started getting compensation for advance care planning work this year—a development that some anticipate will cast a new spotlight on these conversations.
The Centers for Medicare & Medicaid Services (CMS) in the 2016 final physician fee schedule rule added two payment codes that recognize the time associated with discussing advance care planning with patients and their families. Doctors may also get paid for these conversations in the event they’re included as part of Medicare’s annual wellness visit as an optional item. The wellness visit is an Affordable Care Act (ACA) provision that physicians can bill.
Given the rocky history associated with making counseling payments a reality, the CMS provision is a huge leap forward, says Nathan Kottkamp, a partner of health law at McGuireWoods in Richmond, Va. “These conversations take time, and not paying doctors for them is crazy.” The provision is far from a new concept; it’s just taken some time and effort to make it official.

Second Time Around

Drafts of the ACA had included provisions to reimburse doctors for conversations about advance care planning. While the language didn’t encourage people to make particular choices, it was eventually taken out of the health reform legislation due to the political flare-up that resulted from the “death panel” debate, he says.

The irony is, well before the ACA, “the Welcome to Medicare guide had encouraged people to have these conversations,” Kottkamp says. Doctors are trusted advisors in these conversations—and part of the reason why advance care planning hasn’t made much progress “is because we haven’t been reimbursing them,” he says.

Time will tell if physicians will ultimately take advantage of the new reimbursement opportunities. The pay they receive to have these conversations “is not a whole lot, but it’s something,” Kottkamp says.

Jay Galeski, MD, an internist with Virginia Physicians in Richmond, Va., says his practice has been billing under the new codes since they first went into effect in January. “CMS does not reimburse for each visit for these discussions, but rather for the duration of the conversations, as the conversation and completion of the forms may take an hour or longer, and may involve several visits,” he says.

So far, Galeski has reported success in collecting for the service. For an initial 30-minute visit, payment for the doctor amounts to $52.55, with the patient responsibility totaling $16.96.

To his knowledge, not many doctors have been using the codes, “as the advance care plan discussion has not been part of the standard wellness checkup for most practices,” Galeski says. The ACA’s Medicare wellness visit might go a long way toward encouraging dialogue, he suggests.

Galeski says he’s always made talking about advance directives a standard part of his practice.
“I have been having these discussions with my patients for many years—and most of my patients have been with me for over 25 years. Thus, there is a long time to establish comfort with them in these discussions.”