CPT Code Updates in Emergency Medicine, Critical Care and Urgent Care

The Centers for Medicare and Medicaid Services (CMS) recently released at set of Frequently Asked Questions about billing the Advance Care Planning Services under the Physician Fee Schedule. This helpful article provides guidance on some of the intricate details of CPT codes in the ED Setting. CMS has offered helpful additional information to supplement what appears in the CPT® book describing advance care planning service, read on to know more.

Can you report ACP Codes in the ED setting?

CPT® rules set no limits on the number of times ACP you can report for a given beneficiary in a given time period and CMS has not established any frequency limits of its own. Importantly, when the service is billed multiple times for a given beneficiary, CMS will expect to see a documented change in the beneficiary’s health status and/or wishes regarding his or her end-of-life care.

What Documentation Is Required to Report the service?

CMS directs practitioners to consult their Medicare Administrative Contractors (MACs) regarding documentation requirements. Examples of appropriate documentation 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.

No specific diagnosis is required to bill the ACP codes.

Can ACP be reported in addition to an ED E/M visit?

CMS adopted the CPT® codes and provisions for reporting 99497 and 99498. This includes the instructions that these codes may be billed on the same day or a different day as most other E/M services, including the ED E/M codes.

Remember that these are time based codes so CMS says you should consult CPT® provisions regarding minimum time required to report timed services which typically include exceeding the midpoint of the time requirements.

If the required minimum time is not spent with the beneficiary, family member(s) and/ or surrogate to bill codes 99497 or 99498, you may consider billing only the ED visit, provided the requirements for billing that E/M service are met. CMS also adopted the CPT® guidance prohibiting reporting codes 99497 and 99498 on the same date of service as certain critical care services including neonatal and pediatric critical care, because those are also time based codes.

For a thorough analysis of all deleted, revised and new CPT® codes in Emergency Medicine, Urgent Care and Critical Care join coding expert Caral Edelberg in a Live Webinar on Tue, Dec 13, 2016. This session is designed to provide expert tips and tools on the appropriate use of the codes and any guideline changes that may be coming your way.

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