Advance care planning (ACP) is the cornerstone to ensuring goal-concordant care by enabling persons to state their treatment preference prior to potential mental incapacity.1 Beginning in January 2016, the Centers for Medicare & Medicaid Services (CMS) introduced Current Procedural Terminology (CPT) reimbursement codes for ACP visits (99497 and 99498). Introduction of these codes represents recognition of the value of ACP for respecting patients’ preferences.2 Early indications from physician surveys and CMS reports indicate that there may be minimal use of these new CPT codes,3,4 and their use has not been rigorously examined. The objective of this study was to expand on these reports by examining early utilization patterns in ACP billing nationally, by physician specialty, care setting, and across states, and to determine to what degree ACP billing is increasing over time.
Secondary analyses of Medicare Physician/Supplier Part B claims (Carrier File) were conducted for all Fee-for-Service (FFS) Medicare beneficiaries 65 years and older in 2016 and until the third quarter of 2017. This study was reviewed and approved by the Institutional Review Board at Brown University, and a waiver for patient written informed consent and a Health Insurance Portability and Accountability Act waiver of authorization were obtained specific to the release of data from the Centers for Medicare & Medicaid Services. Data on ACP visits were compiled by aggregating claims from the same health care professional on the same date with the CPT codes 99497 (initial 30 minutes) and 99498 (each additional 30 minutes). Advance care planning claims do not contain any information about the content or the quality of ACP conversations. Herein, we report on utilization rates for Medicare beneficiaries (overall rates and rates for decedents each year in 2016 or 2017) along with descriptive statistics about place of service and physician specialty. State-level variation in the percentage of decedents with an ACP claim in 2016 was also examined.
During 2016, the first year of implementation of the ACP CPT codes, 496 085 (1.9%) FFS Medicare beneficiaries 65 years or older had 538 275 ACP visits. During the first 3 quarters of 2017, ACP billing increased to 574 802 (2.2%) beneficiaries and 633 214 ACP visits. Advance care planning claim rates were higher among beneficiaries who died within a given year, reaching 3.3% in 2016 and 5.8% in 2017. The Figure demonstrates strong variation in the percentage of decedents with an ACP visit in 2016 across states, ranging from 4.0% to 10.9% in the top quintile to 0.1% to 1.4% in the lowest quintile. Most ACP visits in 2016 took place in physicians’ offices (71.2%), followed by hospitals (11.2%), and nursing homes (8.6%). The number of ACP visits increased at all places of service in 2017, but growth was largest in hospitals and nursing homes. Most ACP visits were billed by internists (48.0%) and family physicians (27.9%) in 2016. When considering the percentage of physicians with at least 1 ACP claim by specialty (Table), the percentage of hospice and palliative medicine (HPM) specialists using an ACP code at least once increased from 27.6% (n = 329) in 2016 to 35.9% (n = 444) in 2017, compared with a modest change from 7.5% (n = 8482) in 2016 to 9.3% (n = 10 309) in 2017 among internists.
Despite an increase in ACP claims nationally, particularly among decedents each year, the overall ACP claims rate remains low. Two-thirds of HPM specialists did not use the new CPT code in 2017 despite working with seriously ill patients and it being unlikely that they would have no ACP conversation in a given year. A portion of the HPM specialists may have a practice focused on actively dying patients, in which case ACP would no longer be appropriate. Low use of the CPT codes for ACP by HPM specialists suggests that, for now, ACP billing is a poor proxy for actual ACP practice, and that important structural and professional barriers to wider adoption of ACP billing remain. Reimbursement rates of $80 to $86 for the first 30 minutes, depending on place of service, may not be a high enough financial incentive to induce fast changes in existing billing practices.
The influence of these CPT codes on actual care delivery and goal-directed patient outcomes requires more detailed examination. At this time, it remains unclear whether variation in ACP billing across states reflects potential differences in end-of-life care or differential billing practices.
Accepted for Publication: December 14, 2018.
Corresponding Author: Emmanuelle Belanger, PhD, Center for Gerontology and Healthcare Research, Department of Health Services, Policy & Practice, Brown University, School of Public Health, 121 S Main St, 6th Floor, Providence, RI 02903 (emmanuelle_belanger@brown.edu).
Published Online: March 11, 2019. doi:10.1001/jamainternmed.2018.8615
Author Contributions: Mr Adhikari and Dr Gozalo had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Belanger, Teno, Mitchell, Gozalo.
Acquisition, analysis, or interpretation of data: Belanger, Loomer, Adhikari.
Drafting of the manuscript: Belanger, Loomer, Teno, Mitchell.
Critical revision of the manuscript for important intellectual content: Belanger, Teno, Mitchell, Adhikari, Gozalo.
Statistical analysis: Belanger, Loomer, Adhikari, Gozalo.
Obtained funding: Gozalo.
Administrative, technical, or material support: Gozalo.
Study supervision: Belanger, Mitchell, Gozalo.
Conflict of Interest Disclosures: Dr Belanger reports grants from the National Institute of Aging (NIA) outside of the submitted work during the conduct of the study. Dr Teno reports grants from NIA during the conduct of the study. Dr Mitchell reports grants from National Institutes of Health (NIH) during the conduct of the study and grants from the NIH outside the submitted work. Dr Gozalo reports grants from the NIH/NIA during the conduct of the study. No other disclosures were reported.
Data Sharing Statement: The authors report that analytical files can be accessed at https://repository.library.brown.edu/studio/item/bdr:841038/.