Capture Advance Care Planning Revenue with Expert Oncology Billing Services

 

Advance care planning is a routine service provided by an oncology practice. Simply put after a patient's disease progresses, oncologists are forced to converse about the steps the patient, and his/her family would like to consider if treatment stops responding; like palliative care.  

Now these discussions could last for minutes, if not hours. But most of the time claims are submitted with a standard E/M code and all the minutes oncologists spend on such conversations go unreimbursed. Expert oncology billing services are built to reduce such revenue losses.  

What CPT 99497 and 99498 Actually Cover  

For such conversations on advance care planning or ACP, oncologists can seek reimbursement and the applicable codes will be CPT 99497 and 99498. 

• The prior describes the first 30 minutes of face-to-face conversation practitioners have on ACP with a patient, their family or even a surrogate.   
• The conversation can include aspects like living will, health care proxy and so on.  
• The latter, acts as an add-on code for every additional 30 minutes of discussion.   

The most asked question here is when CPT 99497 and 99498 are reportable. The first becomes reportable at 16 minutes of discussion, and gradually the latter applies once the conversation reaches 46 minutes or longer.  

Why These Services Are Often Not Reported  

Oncology care workflows are built around major treatment related discussions and decision making. Naturally any discussions on ACP tend to get blended into regular discussions. Simply put, most of the time the minutes go unrecorded, and the note vaguely mentions discussions on goals of care. And coders are then left with nothing to support such time-based codes.   

Furthermore, some practices believe hospice and palliative care are the same thing, and then lose on potential revenue. This is frustrating given ACP can be reported even when a patient is receiving active cancer care.  

Things become more complicated with confusion between terminologies. For example, palliative care deals with improving quality of life during serious illness. But ACP is a specific, time-based service. Now practices that have an embedded palliative care team, often offer both the services under the same visit and fail to bill them separately. Lastly, given the time-based nature of these codes some practices even worry about increased scrutiny from payers. An expert oncology billing services team has proper understanding of all these potential leaks and develops personalized workflows to manage them.   

Documentation That Supports the Claim 

Now the question might be how to get reimbursed for ACP conversations and at the center of that answer sits proper clinical documentation. For coders to assign the relevant codes and for oncologists to get reimbursed for it, documentation must show: 

• Discussion was voluntary, information on the participants and the contents of the discussion and the total minutes spent.  
• It should also explain why the conversation was necessary like disease progression, a new line of therapy, or a decline in functional status. 
• The time must also be separate from any other management of the patient's problems.  

An expert oncology billing services team understands these requirements, and helps manage the same. 

Claim-Level Details That Trip Up Payment  

Practices can bill ACP on the same date as the E/M visit. However, there are some exceptions in the case of critical care services. In case the ACP is getting billed with the E/M service, then some payers may require the modifier 25 to be used along with the relevant E/M code.  

Additionally, if the ACP is taking place during a Medicare Annual Wellness Visit, modifier 33 may need to be used along with the CPT 99497 to remove patient cost sharing. Otherwise, deductible and coinsurance apply. 

It is noteworthy to mention here that requirements vary significantly from one payer to another. Most commercial insurance plans have distinct pre-requisites for how often a service can be provided, where it can take place, and so on. 

What the CY 2027 Proposed Rule Could Change  

CMS’s proposed 2027 rule would create two new codes, GACP1 and GACP2, for advance care planning provided by clinical staff under a practitioner’s direct supervision. 

• CPT codes 99497 and 99498 would cover only the time spent by the practitioner. 
• Both staff and practitioner codes could be billed together if each meets the required time limit. 
• CMS also proposes allowing the new codes for Medicare telehealth services.

However, the rule is not final. Practices should start recording staff time and practitioner time separately while waiting for the final decision. 

How Expert Oncology Billing Services Close the Gap 

This kind of complexity is what an expert oncology billing services provider was built to manage. They start by reviewing the charge captured and compare the visit timelines and clinical documentation against what was billed. This enables them to identify where ACP is going unreported. Accordingly, they work with oncologists to capture accurate start and stop times of ACP discussions, and participating parties and the clinical rationale behind it.  

After that, their in-house coders help review each claim against payer-specific guidelines on modifiers, frequency limits, place of service and so on. Such pre-submission review helps keep denials at bay. Even if any denial occurs, an expert oncology billing services team will be able to identify the problem like time documentation, a hospice conflict, promptly through a deep root-cause analysis. 

These expert teams also track policy changes and help keep practices compliant with recent updates, and thus create an oncology revenue cycle that is audit proof. 

Advance care planning is a crucial part of cancer care and expert oncology billing services teams make sure practitioners get paid for their services fairly.