News & Events

Medical Billing Clearinghouse: Understanding Medicare’s Role – Five Questions Medical Billing Companies Need to Know.

Understanding Medicare’s Role in Advance Care Planning.

As a follow-up to our recent article on the 2016 Medicare regulation change that allows physicians to bill for advance care discussions, we thought we’d share a few pertinent details on what “advance care” really means. Though doctors have some leeway to cover what they think is best, the more medical billing companies know, the better they can protect their clients.

Everything from updating patient management software to health insurance claims processing can be affected by the change – here’s a primer on advanced care terms and technicalities.

As a Matter of Fact…

  • ¾ of the 2.5 million Americans who pass away each year are 65 and older.
  • Medicare is the largest health insurance provider for Americans in their last year of life.
  • ¼ of all Medicare health care coverage is spent on beneficiaries in their last 12 months of life.
  • 90 percent of aging adults report that they’d prefer to die at home, though historically only 1/3 actually do.

What is “end-of-life care” exactly?

In simple terms, end-of-life care includes all the services provided for patients in the days (or even years) prior to their death. Medicare covers a comprehensive list of end-of-life health care services, including hospital stays, diagnostic testing, physician visits, home health care, prescriptions, and so forth. Though a patient’s prognosis may be “terminal”, end-of-life services can be intended to either cure conditions or simply provide symptom relief.

What does “advance care planning” entail?

The goal of advance care planning is to help patients and their family members/caregivers better understand all the care options available for them at the end of their lives. Typically, physicians will discuss the various options available (curative treatments, pain management options, at-home care or in-hospital stays for example), make recommendations on a treatment plan, then help the patient to determine which options best align with their individual desires. (In terms of billing for claims processing software, there are two codes to cover these conversations. The first covers the first 30 minutes of discussion – which may be all a patient needs. There is an additional code that covers additional 30 minute conversations as necessary.)

Are physicians the only Medicare-approved resources for advance care discussions?

No. Under the new regulation, Medicare covers advance care planning discussions provided by physicians and other health professionals, such as nurse practitioners, who bill Medicare according to the official physician fee schedule. Discussions should take place in medical offices and approved facilities and hospitals, and can be part of an annual check-ups or wellness visit. (Note for health insurance claims processing: Medicare should be billed separately for advance care.)

What are “advance directives” and in terms of patient management software, are facilities required to keep records of them?

In essence, advance directives are written instructions that define a patient’s wishes for end-of-life care. They become invaluable in instances where a patient is incapacitated or is no longer able to speak for themselves. They are often referred to as a “living will” and typically result from advance care planning discussions. Advance directives define specifically the medical treatments and types of treatments each patient prefers as they are nearing dying.

Advance directives fall under state regulations. Official forms for directives vary from state to state as do the requirements for documentation. Though patients are not required to have one, the Patient Self-Determination Act of 1991 requires that hospitals, skilled nursing facilities, etc. ask each patient if they have an advance directive at the time of admission.

What is “palliative care” and is it covered by Medicare?

As opposed to services intended to cure or treat a specific illness, palliative care generally focuses on managing symptoms and providing comfort to patients nearing the end of life. (Although palliative care is most common for patients receiving end-of-life care, it is not restricted to those with terminal illnesses. It’s also very common for people living with serious chronic illnesses including cancer, heart disease and depression.) In terms of health insurance claims processing, Medicare beneficiaries can claim coverage for palliative care services whether they are offered in combination with curative treatments or not.

Posted in: Medical Billing Clearinghouse

Leave a Comment (0) →

Leave a Comment