Use of Advance Care Planning Billing Codes for Hospitalized Older Adults at High Risk of Dying: A National Observational Study
We analyzed advance care planning (ACP) billing for adults aged 65 years or above and who were managed by a large national physician practice that employs acute care providers in hospital medicine, emergency medicine and critical care between January 1, 2017 and March 31, 2017. Prompting hospitalists to answer the validated “surprise question” (SQ; “Would you be surprised if the patient died in the next year?”) for inpatient admissions served to prime hospitalists and triggered an icon next to the patient’s name. Among 113,621 hospital-based encounters, only 6,146 (5.4%) involved a billed ACP conversation: 8.3% among SQ-prompted who answered “no” and 4.1% SQ-prompted who answered “yes” (for non-SQ prompted cases, the fraction was 3.5%; P < .0001). ACP conversations were associated with a comfort-focused care trajectory. Low ACP rates among even those with high hospitalist-predicted mortality risk underscore the need for quality improvement interventions to increase hospital-based ACP.
© 2019 Society of Hospital Medicine
Advance care planning (ACP) is the process wherein patients, in discussions with their healthcare providers, family members, and other loved ones, make individual decisions about their future healthcare or prepare proxies to guide future medical treatment decisions.1,2 In 2016, the Centers for Medicare and Medicaid Services (CMS) began paying providers for ACP by using billing codes 99497 (first 30 min of ACP) and 99498 (additional 30 min of ACP). According to the CMS, during the first year after the billing codes were introduced, 22,864 providers billed for ACP conversations with 574,621 patients.3 While all adults are eligible, common triggers for ACP include advanced age, serious illness, and functional status changes that confer an increased risk of dying. We explored the early uptake of the ACP billing code in a large national physician practice that provided mandatory education in use of the ACP billing code, offered a small financial incentive for ACP documentation, and primed physicians to reflect on the patient’s risk of dying in the next year at the time of hospital admission.
METHODS
We analyzed ACP billing for hospitalized adults aged 65 years or above and who were managed by a large national physician practice that employs acute care providers in hospital medicine, emergency medicine and critical care between January 1, 2017 and March 31, 2017. This practice employs approximately 2,500 hospital-based physicians in 250 community hospitals in 38 states. They collect data through handheld and desktop information technology (IT) tools to facilitate coding, billing, and compliance by hospitalists. Hospitalists receive mandatory web-based training in compliance with CMS ACP billing and templated ACP documentation. Additionally, they receive web-based training in serious illness communication skills during the first two years of employment. The training includes didactic content regarding steps for collaborative decision making, words to use during the encounter, and videos of simulated patient encounters demonstrating best practices. Hospitalists also receive a small financial incentive ($20) for each properly documented ACP conversation that meets CMS criteria for ACP code payment.
