New End-of-Life Discussion Codes a Step Toward Reimbursement?

Lara C. Pullen, PhD

September 19, 2014

The American Medical Association (AMA) has released current procedural terminology (CPT) codes for advance care planning services, a necessary step for Medicare to begin considering reimbursement for end-of-life discussions between physicians and patients.

The new codes will also help streamline reimbursement from private payers.

One billing code is for the first 30 minutes of face-to-face time with the patient, family member, and/or surrogate to explain and discuss advance directives. An additional code is provided for each additional 30 minutes of planning.

The new billing codes were released at the end of August and will be incorporated in January 2015.

"We're acknowledging that this is an important thing. That's a huge message," stated Michael Fleming, MD, former president of the American Academy of Family Physicians and chief medical officer of Amedisys Home Health and Hospice in Baton Rouge, Louisiana. He explained that end-of-life conversations are not only patient-centered, they are person-centered.

Although patients have diagnoses, persons have emotions, fears, and spiritual needs. Physicians can treat both the patient and the person by having discussions to determine the individual's needs and goals, he said.

Sarah Shannon, PhD, RN, associate professor of biobehavioral nursing and health systems at the University of Washington School of Nursing in Seattle, went even further, explaining to Medscape Medical News that "we know from research that patients and families want us to start these conversations." She also acknowledged that the conversations take time and should include opportunities for patient to think about what they would want, particularly in different scenarios.

"If a patient were able to think about what he would want for himself should/when this time comes, the medical team could better respect his autonomy and focus care entirely on fulfilling those wishes as fully as possible. Family members could focus on giving love, and on grieving, instead of trying to stand beneath the incredible burden of making decisions," elaborated Jennifer Ramsey, MD, critical care specialist at Cleveland Clinic in Ohio, in an email to Medscape Medical News.


Although physicians generally agree about the need for end-of-life discussions, the decision to reimburse for the conversations has not yet been made by Medicare.

The existence of a CPT code does not automatically mean that Medicare will reimburse for it. The Centers for Medicare & Medicaid Services is currently determining whether Medicare will reimburse for the CPT codes. The agency is expected to release its decision in November.

"When formulated properly, Medicare payment policies should be made based on full understanding of time and resources a physician utilizes when caring for patients," explained Robert M. Wah, MD, president of the AMA, in a statement to Medscape Medical News. "That's why the AMA and the medical specialty societies convene the Relative Value Scale Update Committee (RUC) as an important source of input to Medicare on the time, work, and resources needed to provide the highest and safest quality of care for their patients."

David Stevens, MD, chief executive officer of Christian Medical & Dental Associations, agrees it is a good idea for physicians to have these conversations with their patients. Unfortunately, he explained to Medscape Medical News, a physician's time is limited, and therefore reimbursement becomes an issue: "What's paid for is most likely to get done."

Creating the Code

At this time, Medicare has a Healthcare Common Procedure Coding System code that can be used if there is not a CPT code available. The code does not, however, have a payment policy associated with it; hence the need for a CPT code that is associated with reimbursement.

The Illinois State Medical Society submitted an editorial proposal to the AMA's CPT Editorial Panel requesting that a code be added for advance care planning services. The CPT Editorial Panel responded by creating the code.

The creation of the new code triggered an evaluation of the time and resources required to perform the services detailed in the code. RUC is the committee that evaluates time resources and raw materials, and it reports that information to Medicare. RUC has already met to discuss advance care planning services and has submitted its reimbursement recommendation to Medicare.

At this time, many private payers, however, do reimburse for advance care planning service. In the absence of a CPT code, many private organizations have created their own code that allows for physicians to conduct, and bill for, end-of-life conversations.

Dr. Fleming believes these new codes are steps in the right direction: "The code indicates that there is approval out there for the concept.... We have acknowledged that it's got to happen."


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