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Advance care planning discussions: Talk is no longer cheap
Clinicians outside of the surgical specialties may consider surgeons primarily providers of technical services, but those of us who provide surgical care fully appreciate that communicating with patients and families is a large component of routine surgical practice. Typical communications in surgical practice include obtaining a history of present illness, which is a key element in the ultimate decision to offer a surgical intervention, or not; discussing the risks, benefits, and alternatives of any operation being considered; and the numerous discussions held following any surgical procedure. What many surgeons may not fully appreciate, however, is how these routine communication events can fall under the general category of advance care planning (ACP).
ACP is defined as a process in which physicians (and other health care providers) discuss a patient’s goals, values, and beliefs and determine how these inform a patient’s desire for current or future medical care. Hickman et al. (Hastings Center Report Special Report 35, no. 6 (2005):S26-S30) note that ACP should focus on defining “good” care for each patient. Furthermore, changes in a patient’s medical condition represent an opportune time to revisit a patient’s hopes and goals. Consideration of surgical intervention often represents a major change in a patient’s medical condition and therefore is an excellent opportunity to engage a patient in an ACP discussion.
Given that ACP discussions are likely occurring in surgical practices on a regular basis, surgeons need to be aware of a recent change in the Physician Fee Schedule that took effect Jan. 1, 2016. Effective this date, Current Procedural Terminology (CPT) codes 99497 and 99498 now allow for billing for ACP services. CPT code 99497 includes ACP “including the explanation and discussion of advance directives such as standard forms (with the completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with patient, family member(s) and/or surrogate.” CPT code 99498 is used for each additional 30 minutes spent in such face-to-face ACP counseling.
The nuts and bolts of how these ACP CPT codes work:
How many times can these code(s) be used? There are no limits on the number of times ACP can be reported for a given beneficiary in a given time period. For example, if an ACP discussion was held with a patient and/or family member and/or surrogate prior to a major elective procedure and again in the postoperative period, the above CPT codes could be used twice. In each instance, the ACP discussion must be documented, along with any relevant change in the patient’s clinical status that prompted another ACP discussion.
Can a patient or their family member/surrogate refuse ACP services? ACP services are voluntary; therefore, a patient or their family member/surrogate can refuse ACP services. These CPT codes only can be used if a patient or family member/surrogate consents for ACP services.
What must be documented in ACP services? Physicians should consult their Medicare Administrative Contractors for documentation requirements. Examples of elements to be included in the documentation are a brief description of the discussion with the patient or family/surrogate regarding the voluntary nature of ACP services, an explanation of advance directives and documentation if an advance directive is completed, who was present during the discussion, and time spent in the face-to-face encounter.
Does an advance directive have to be completed to bill the service? No. If an advance directive is completed, this should be documented (see above), but completion of the directive is not a requirement for billing the service.
Can ACP be reported in addition to an evaluation and management (E/M) service (such as an office visit)? Yes. CPT codes 99497 and 99498 may be billed on the same day or a different day as most other E/M services. They may be billed within the global surgical period.
Is a specific diagnosis required to use the ACP CPT codes? No, a specific diagnosis is not required for the ACP codes to be billed.
According to the 2016 Medicare Physician Fee Schedule, the reimbursement is $85.99 for CPT 99497 and $74.88 for CPT 99498. For comparison, the reimbursement for E/M CPT 99203 (30-minute initial evaluation) = $108.85, CPT 99204 (45-minute initial evaluation) = $166.13, and CPT 99205 (60-minute initial evaluation) = $208.38. Far more important than the financial remuneration for these discussions, however, is the critical need for surgeons to have and document their ACP discussions with their patients and/or their family member/surrogate. As surgeons, we are often called to see patients when they are facing a significant change in their health – whether that is a new diagnosis of cancer or after a traumatic injury. Understanding a patient’s values, hopes, and concerns is an essential component to ensuring that our patients receive the best care, as defined by them.
Dr. Fahy is associate professor of surgery and internal medicine at the University of New Mexico, Albuquerque. She is a surgical oncologist who is also board certified in hospice and palliative medicine. Dr. Fahy does not have any relevant conflicts of interest to disclose.
Clinicians outside of the surgical specialties may consider surgeons primarily providers of technical services, but those of us who provide surgical care fully appreciate that communicating with patients and families is a large component of routine surgical practice. Typical communications in surgical practice include obtaining a history of present illness, which is a key element in the ultimate decision to offer a surgical intervention, or not; discussing the risks, benefits, and alternatives of any operation being considered; and the numerous discussions held following any surgical procedure. What many surgeons may not fully appreciate, however, is how these routine communication events can fall under the general category of advance care planning (ACP).
ACP is defined as a process in which physicians (and other health care providers) discuss a patient’s goals, values, and beliefs and determine how these inform a patient’s desire for current or future medical care. Hickman et al. (Hastings Center Report Special Report 35, no. 6 (2005):S26-S30) note that ACP should focus on defining “good” care for each patient. Furthermore, changes in a patient’s medical condition represent an opportune time to revisit a patient’s hopes and goals. Consideration of surgical intervention often represents a major change in a patient’s medical condition and therefore is an excellent opportunity to engage a patient in an ACP discussion.
Given that ACP discussions are likely occurring in surgical practices on a regular basis, surgeons need to be aware of a recent change in the Physician Fee Schedule that took effect Jan. 1, 2016. Effective this date, Current Procedural Terminology (CPT) codes 99497 and 99498 now allow for billing for ACP services. CPT code 99497 includes ACP “including the explanation and discussion of advance directives such as standard forms (with the completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with patient, family member(s) and/or surrogate.” CPT code 99498 is used for each additional 30 minutes spent in such face-to-face ACP counseling.
The nuts and bolts of how these ACP CPT codes work:
How many times can these code(s) be used? There are no limits on the number of times ACP can be reported for a given beneficiary in a given time period. For example, if an ACP discussion was held with a patient and/or family member and/or surrogate prior to a major elective procedure and again in the postoperative period, the above CPT codes could be used twice. In each instance, the ACP discussion must be documented, along with any relevant change in the patient’s clinical status that prompted another ACP discussion.
Can a patient or their family member/surrogate refuse ACP services? ACP services are voluntary; therefore, a patient or their family member/surrogate can refuse ACP services. These CPT codes only can be used if a patient or family member/surrogate consents for ACP services.
What must be documented in ACP services? Physicians should consult their Medicare Administrative Contractors for documentation requirements. Examples of elements to be included in the documentation are a brief description of the discussion with the patient or family/surrogate regarding the voluntary nature of ACP services, an explanation of advance directives and documentation if an advance directive is completed, who was present during the discussion, and time spent in the face-to-face encounter.
Does an advance directive have to be completed to bill the service? No. If an advance directive is completed, this should be documented (see above), but completion of the directive is not a requirement for billing the service.
Can ACP be reported in addition to an evaluation and management (E/M) service (such as an office visit)? Yes. CPT codes 99497 and 99498 may be billed on the same day or a different day as most other E/M services. They may be billed within the global surgical period.
Is a specific diagnosis required to use the ACP CPT codes? No, a specific diagnosis is not required for the ACP codes to be billed.
According to the 2016 Medicare Physician Fee Schedule, the reimbursement is $85.99 for CPT 99497 and $74.88 for CPT 99498. For comparison, the reimbursement for E/M CPT 99203 (30-minute initial evaluation) = $108.85, CPT 99204 (45-minute initial evaluation) = $166.13, and CPT 99205 (60-minute initial evaluation) = $208.38. Far more important than the financial remuneration for these discussions, however, is the critical need for surgeons to have and document their ACP discussions with their patients and/or their family member/surrogate. As surgeons, we are often called to see patients when they are facing a significant change in their health – whether that is a new diagnosis of cancer or after a traumatic injury. Understanding a patient’s values, hopes, and concerns is an essential component to ensuring that our patients receive the best care, as defined by them.
Dr. Fahy is associate professor of surgery and internal medicine at the University of New Mexico, Albuquerque. She is a surgical oncologist who is also board certified in hospice and palliative medicine. Dr. Fahy does not have any relevant conflicts of interest to disclose.
Clinicians outside of the surgical specialties may consider surgeons primarily providers of technical services, but those of us who provide surgical care fully appreciate that communicating with patients and families is a large component of routine surgical practice. Typical communications in surgical practice include obtaining a history of present illness, which is a key element in the ultimate decision to offer a surgical intervention, or not; discussing the risks, benefits, and alternatives of any operation being considered; and the numerous discussions held following any surgical procedure. What many surgeons may not fully appreciate, however, is how these routine communication events can fall under the general category of advance care planning (ACP).
ACP is defined as a process in which physicians (and other health care providers) discuss a patient’s goals, values, and beliefs and determine how these inform a patient’s desire for current or future medical care. Hickman et al. (Hastings Center Report Special Report 35, no. 6 (2005):S26-S30) note that ACP should focus on defining “good” care for each patient. Furthermore, changes in a patient’s medical condition represent an opportune time to revisit a patient’s hopes and goals. Consideration of surgical intervention often represents a major change in a patient’s medical condition and therefore is an excellent opportunity to engage a patient in an ACP discussion.
Given that ACP discussions are likely occurring in surgical practices on a regular basis, surgeons need to be aware of a recent change in the Physician Fee Schedule that took effect Jan. 1, 2016. Effective this date, Current Procedural Terminology (CPT) codes 99497 and 99498 now allow for billing for ACP services. CPT code 99497 includes ACP “including the explanation and discussion of advance directives such as standard forms (with the completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with patient, family member(s) and/or surrogate.” CPT code 99498 is used for each additional 30 minutes spent in such face-to-face ACP counseling.
The nuts and bolts of how these ACP CPT codes work:
How many times can these code(s) be used? There are no limits on the number of times ACP can be reported for a given beneficiary in a given time period. For example, if an ACP discussion was held with a patient and/or family member and/or surrogate prior to a major elective procedure and again in the postoperative period, the above CPT codes could be used twice. In each instance, the ACP discussion must be documented, along with any relevant change in the patient’s clinical status that prompted another ACP discussion.
Can a patient or their family member/surrogate refuse ACP services? ACP services are voluntary; therefore, a patient or their family member/surrogate can refuse ACP services. These CPT codes only can be used if a patient or family member/surrogate consents for ACP services.
What must be documented in ACP services? Physicians should consult their Medicare Administrative Contractors for documentation requirements. Examples of elements to be included in the documentation are a brief description of the discussion with the patient or family/surrogate regarding the voluntary nature of ACP services, an explanation of advance directives and documentation if an advance directive is completed, who was present during the discussion, and time spent in the face-to-face encounter.
Does an advance directive have to be completed to bill the service? No. If an advance directive is completed, this should be documented (see above), but completion of the directive is not a requirement for billing the service.
Can ACP be reported in addition to an evaluation and management (E/M) service (such as an office visit)? Yes. CPT codes 99497 and 99498 may be billed on the same day or a different day as most other E/M services. They may be billed within the global surgical period.
Is a specific diagnosis required to use the ACP CPT codes? No, a specific diagnosis is not required for the ACP codes to be billed.
According to the 2016 Medicare Physician Fee Schedule, the reimbursement is $85.99 for CPT 99497 and $74.88 for CPT 99498. For comparison, the reimbursement for E/M CPT 99203 (30-minute initial evaluation) = $108.85, CPT 99204 (45-minute initial evaluation) = $166.13, and CPT 99205 (60-minute initial evaluation) = $208.38. Far more important than the financial remuneration for these discussions, however, is the critical need for surgeons to have and document their ACP discussions with their patients and/or their family member/surrogate. As surgeons, we are often called to see patients when they are facing a significant change in their health – whether that is a new diagnosis of cancer or after a traumatic injury. Understanding a patient’s values, hopes, and concerns is an essential component to ensuring that our patients receive the best care, as defined by them.
Dr. Fahy is associate professor of surgery and internal medicine at the University of New Mexico, Albuquerque. She is a surgical oncologist who is also board certified in hospice and palliative medicine. Dr. Fahy does not have any relevant conflicts of interest to disclose.
Fellowship Training in Hospice and Palliative Care: New Pathways for Surgeons
Hospice and Palliative Medicine (HPM) has been a medical subspecialty recognized by the American Board of Medical Specialties since 2006. The American Board of Surgery (ABS) is one of 10 medical boards that offers board certification in HPM. Cosponsorship of HPM board certification by the ABS is significant because it signals an understanding and appreciation that patients in need of hospice and palliative care frequently require surgical services and also recognizes that many surgical patients benefit from palliative care.
Two specific domains of palliative care have been identified as core competencies for all surgeons: pain management and communication skills (Otolaryngology Clinics of North America 2009;42:1-13). Incorporation of these basic domains of care is considered primary palliative care for surgeons and inherent to good surgical care. For surgeons interested in obtaining subspecialty training in HPM, fellowship training is now required (the experiential pathway is no longer available).
Surgeons most likely to benefit from this additional training are those involved in the interdisciplinary care of chronically disease, critically ill, or terminally ill patients. Apparent in this description is the need for surgical palliative care providers across the full range of surgical subspecialties: pediatric to adult providers, trauma/critical care to oncology, cardiovascular surgery to transplant surgery. Currently, there are fewer than 100 surgeons with subspecialty board certification in HPM, constituting <1% of all physicians board certified in HPM.
The nascent field of HPM and needs surgeons as do the growing number of patients who require hospice and palliative medicine services. There currently exists a critical shortage of HPM physicians. A 2010 report by a task force appointed by the American Academy of Hospice and Palliative Medicine to study HPM physician workforce found that an estimated 6,000-18,000 additional physicians were needed to staff the then existing hospice and hospital-based palliative care programs (J. Pain Symptom Manage. 2010;40:899-91). The authors concluded that the capacity of fellowship programs at that time was insufficient to fill the shortage and changes in graduate medical education funding and structures were needed to increase the capacity to train sufficient numbers of HPM physicians. There are currently 108 Accreditation Council for Graduate Medical Education–accredited fellowships, up from 63 in 2009.
Surgeons interested in pursuing subspecialty training in HPM must complete a 1-year ACGME-accredited fellowship. Surgeons currently board-certified in surgery are eligible to apply. Many fellowship training programs have trained, or are willing to consider applications from, mid-career physicians, including surgeons (personal communication via HPM fellowship program directors listserv). Beginning July 1, 2015, an important change in eligibility for HPM fellowships goes into effect: Surgical residents with 3 years of training are now eligible to apply for ACGME-accredited HPM fellowships. This change in eligibility opens up an important pathway to HPM board certification, similar to that currently available for Surgical Critical Care. Trainees who complete HPM fellowship training through this pathway will not be eligible to obtain board certification in HPM until they have successfully achieved their primary board certification through the ABS.
Surgeons currently board certified in HPM incorporate their HPM training in a variety of ways: Some practice HPM full-time as members of a multidisciplinary in-patient palliative medicine consultation service while others integrate their training into their daily surgical practice, often serving as a resource on issues of surgical palliative care for their surgical colleagues. In my practice, I spend 1 day a week as a consultant on our in-patient palliative medicine consultation service in addition to providing faculty supervision to our palliative medicine fellows in our weekly outpatient clinic. For the remainder of the week, I am a practicing surgical oncologist and have found my training in palliative medicine invaluable in my daily care of patients with a variety of malignancies.
Like many of my surgical colleagues with HPM board certification, I am also actively engaged in teaching medical students, residents, and fellows about a variety of topics in palliative medicine, from evidence-based management of malignant bowel obstruction to communication skills for breaking bad news. Incorporating palliative medicine into my surgical practice has been incredibly rewarding, both personally and professionally.
In summary, HPM is in critical need of specialty trained physicians, including surgeons. Fellowship training is currently available to mid-career surgeons and, beginning July 1, 2015, surgical residents with 3 years of clinical training. Surgeons with subspecialty training in HPM are certain to find a wealth of clinical and academic opportunities as well as a path to a personally and professionally rewarding career.
For surgeons interested in obtaining more information about HPM fellowship training, go to the for a full list of programs and other training information.
Dr. Fahy is an associate professor of surgery at the University of New Mexico, Albuquerque. She is a surgical oncologist who is also board certified in hospice and palliative medicine. Dr. Fahy does not have any relevant conflicts of interest to disclose.
Hospice and Palliative Medicine (HPM) has been a medical subspecialty recognized by the American Board of Medical Specialties since 2006. The American Board of Surgery (ABS) is one of 10 medical boards that offers board certification in HPM. Cosponsorship of HPM board certification by the ABS is significant because it signals an understanding and appreciation that patients in need of hospice and palliative care frequently require surgical services and also recognizes that many surgical patients benefit from palliative care.
Two specific domains of palliative care have been identified as core competencies for all surgeons: pain management and communication skills (Otolaryngology Clinics of North America 2009;42:1-13). Incorporation of these basic domains of care is considered primary palliative care for surgeons and inherent to good surgical care. For surgeons interested in obtaining subspecialty training in HPM, fellowship training is now required (the experiential pathway is no longer available).
Surgeons most likely to benefit from this additional training are those involved in the interdisciplinary care of chronically disease, critically ill, or terminally ill patients. Apparent in this description is the need for surgical palliative care providers across the full range of surgical subspecialties: pediatric to adult providers, trauma/critical care to oncology, cardiovascular surgery to transplant surgery. Currently, there are fewer than 100 surgeons with subspecialty board certification in HPM, constituting <1% of all physicians board certified in HPM.
The nascent field of HPM and needs surgeons as do the growing number of patients who require hospice and palliative medicine services. There currently exists a critical shortage of HPM physicians. A 2010 report by a task force appointed by the American Academy of Hospice and Palliative Medicine to study HPM physician workforce found that an estimated 6,000-18,000 additional physicians were needed to staff the then existing hospice and hospital-based palliative care programs (J. Pain Symptom Manage. 2010;40:899-91). The authors concluded that the capacity of fellowship programs at that time was insufficient to fill the shortage and changes in graduate medical education funding and structures were needed to increase the capacity to train sufficient numbers of HPM physicians. There are currently 108 Accreditation Council for Graduate Medical Education–accredited fellowships, up from 63 in 2009.
Surgeons interested in pursuing subspecialty training in HPM must complete a 1-year ACGME-accredited fellowship. Surgeons currently board-certified in surgery are eligible to apply. Many fellowship training programs have trained, or are willing to consider applications from, mid-career physicians, including surgeons (personal communication via HPM fellowship program directors listserv). Beginning July 1, 2015, an important change in eligibility for HPM fellowships goes into effect: Surgical residents with 3 years of training are now eligible to apply for ACGME-accredited HPM fellowships. This change in eligibility opens up an important pathway to HPM board certification, similar to that currently available for Surgical Critical Care. Trainees who complete HPM fellowship training through this pathway will not be eligible to obtain board certification in HPM until they have successfully achieved their primary board certification through the ABS.
Surgeons currently board certified in HPM incorporate their HPM training in a variety of ways: Some practice HPM full-time as members of a multidisciplinary in-patient palliative medicine consultation service while others integrate their training into their daily surgical practice, often serving as a resource on issues of surgical palliative care for their surgical colleagues. In my practice, I spend 1 day a week as a consultant on our in-patient palliative medicine consultation service in addition to providing faculty supervision to our palliative medicine fellows in our weekly outpatient clinic. For the remainder of the week, I am a practicing surgical oncologist and have found my training in palliative medicine invaluable in my daily care of patients with a variety of malignancies.
Like many of my surgical colleagues with HPM board certification, I am also actively engaged in teaching medical students, residents, and fellows about a variety of topics in palliative medicine, from evidence-based management of malignant bowel obstruction to communication skills for breaking bad news. Incorporating palliative medicine into my surgical practice has been incredibly rewarding, both personally and professionally.
In summary, HPM is in critical need of specialty trained physicians, including surgeons. Fellowship training is currently available to mid-career surgeons and, beginning July 1, 2015, surgical residents with 3 years of clinical training. Surgeons with subspecialty training in HPM are certain to find a wealth of clinical and academic opportunities as well as a path to a personally and professionally rewarding career.
For surgeons interested in obtaining more information about HPM fellowship training, go to the for a full list of programs and other training information.
Dr. Fahy is an associate professor of surgery at the University of New Mexico, Albuquerque. She is a surgical oncologist who is also board certified in hospice and palliative medicine. Dr. Fahy does not have any relevant conflicts of interest to disclose.
Hospice and Palliative Medicine (HPM) has been a medical subspecialty recognized by the American Board of Medical Specialties since 2006. The American Board of Surgery (ABS) is one of 10 medical boards that offers board certification in HPM. Cosponsorship of HPM board certification by the ABS is significant because it signals an understanding and appreciation that patients in need of hospice and palliative care frequently require surgical services and also recognizes that many surgical patients benefit from palliative care.
Two specific domains of palliative care have been identified as core competencies for all surgeons: pain management and communication skills (Otolaryngology Clinics of North America 2009;42:1-13). Incorporation of these basic domains of care is considered primary palliative care for surgeons and inherent to good surgical care. For surgeons interested in obtaining subspecialty training in HPM, fellowship training is now required (the experiential pathway is no longer available).
Surgeons most likely to benefit from this additional training are those involved in the interdisciplinary care of chronically disease, critically ill, or terminally ill patients. Apparent in this description is the need for surgical palliative care providers across the full range of surgical subspecialties: pediatric to adult providers, trauma/critical care to oncology, cardiovascular surgery to transplant surgery. Currently, there are fewer than 100 surgeons with subspecialty board certification in HPM, constituting <1% of all physicians board certified in HPM.
The nascent field of HPM and needs surgeons as do the growing number of patients who require hospice and palliative medicine services. There currently exists a critical shortage of HPM physicians. A 2010 report by a task force appointed by the American Academy of Hospice and Palliative Medicine to study HPM physician workforce found that an estimated 6,000-18,000 additional physicians were needed to staff the then existing hospice and hospital-based palliative care programs (J. Pain Symptom Manage. 2010;40:899-91). The authors concluded that the capacity of fellowship programs at that time was insufficient to fill the shortage and changes in graduate medical education funding and structures were needed to increase the capacity to train sufficient numbers of HPM physicians. There are currently 108 Accreditation Council for Graduate Medical Education–accredited fellowships, up from 63 in 2009.
Surgeons interested in pursuing subspecialty training in HPM must complete a 1-year ACGME-accredited fellowship. Surgeons currently board-certified in surgery are eligible to apply. Many fellowship training programs have trained, or are willing to consider applications from, mid-career physicians, including surgeons (personal communication via HPM fellowship program directors listserv). Beginning July 1, 2015, an important change in eligibility for HPM fellowships goes into effect: Surgical residents with 3 years of training are now eligible to apply for ACGME-accredited HPM fellowships. This change in eligibility opens up an important pathway to HPM board certification, similar to that currently available for Surgical Critical Care. Trainees who complete HPM fellowship training through this pathway will not be eligible to obtain board certification in HPM until they have successfully achieved their primary board certification through the ABS.
Surgeons currently board certified in HPM incorporate their HPM training in a variety of ways: Some practice HPM full-time as members of a multidisciplinary in-patient palliative medicine consultation service while others integrate their training into their daily surgical practice, often serving as a resource on issues of surgical palliative care for their surgical colleagues. In my practice, I spend 1 day a week as a consultant on our in-patient palliative medicine consultation service in addition to providing faculty supervision to our palliative medicine fellows in our weekly outpatient clinic. For the remainder of the week, I am a practicing surgical oncologist and have found my training in palliative medicine invaluable in my daily care of patients with a variety of malignancies.
Like many of my surgical colleagues with HPM board certification, I am also actively engaged in teaching medical students, residents, and fellows about a variety of topics in palliative medicine, from evidence-based management of malignant bowel obstruction to communication skills for breaking bad news. Incorporating palliative medicine into my surgical practice has been incredibly rewarding, both personally and professionally.
In summary, HPM is in critical need of specialty trained physicians, including surgeons. Fellowship training is currently available to mid-career surgeons and, beginning July 1, 2015, surgical residents with 3 years of clinical training. Surgeons with subspecialty training in HPM are certain to find a wealth of clinical and academic opportunities as well as a path to a personally and professionally rewarding career.
For surgeons interested in obtaining more information about HPM fellowship training, go to the for a full list of programs and other training information.
Dr. Fahy is an associate professor of surgery at the University of New Mexico, Albuquerque. She is a surgical oncologist who is also board certified in hospice and palliative medicine. Dr. Fahy does not have any relevant conflicts of interest to disclose.
