Linda V. DeCherrie, MD Director, Mount Sinai Visiting Doctors Program ©AAHCM

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 Medicare Fee Schedule – fee for service payments  SGR (“MACRA”) – supported permanent repeal (offered IAH to help “pay for”)  Coverage and Payment – advocate for value, coverage and payment of home care medicine services that benefit patients, the program and your practice ◦ Evaluation and Management Services - Relative values and rules – ongoing ◦ Coverage and payment for new services – Relative values and rules  Annual Wellness Visit (G $117)  Transitional Care Management – 2013 (CPT $162, CPT $232)  Chronic Care Management – 2015 (CPT $43)  Advanced Care Planning – 2016?

 at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with the following required elements:  Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient;  Chronic conditions place the patient at significant risk of death, acute exacerbation/de-compensation, or functional decline  Comprehensive care plan established, implemented, revised, or monitored.  Certified EMR  Beneficiary informed consent obtained at onset of service and if re-started

 Physician, NP, PA, CNS or CNM, subject to state licensure and scope of practice; Also “other clinical Staff”  Qualifying “clinical staff” defined by PFS incident to rules and CPT ◦ Accredited/certified/registered professionals/paraprofessionals e.g., RN, SW, MA, CNA, Techs, etc. ◦ General supervision of clinical staff ◦ PFS incident to rules apply regarding employment/contractual arrangements (42 CFR )  Only one practitioner can bill per month  CPO, TCM and other overlapping care management services cannot be billed during the same service period

 The CPT and RUC processes have developed and valued two codes for these ACP services:  first 30 minutes, valued at 1.50 RVUs  each additional 30 minutes, valued at 1.40 RVUs ©AAHCM

 99497: Advance care planning including the explanation and discussion of advance directive such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; first 30 minutes, face‐to‐face with the patient, family member(s) and/or surrogate)  99498: Advanced care planning including the explanation and discussion of advance directive such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; each additional 30 minutes.

 Evidence base - Published, peer-reviewed research shows that ACP leads to better care, higher patient and family satisfaction, fewer unwanted hospitalizations, and lower rates of caregiver distress, depression and lost productivity. Important for Medicare beneficiaries who have multiple chronic illnesses; receive care at home from family and other caregivers; and whose children and other family members are often involved in making medical decisions.  Standard of care - ACP has become a standard of care and consensus regarding its value is widespread. The 2014 Institute of Medicine (IOM) report “Dying in America” cited payment for ACP as one of its five key recommendations. The Centers for Disease Control and Prevention (CDC) has also advocated for increased use of ACP.  Coverage and payment provides for tracking and analysis – Coverage and payment for ACP will not only promote these services for beneficiaries, but will also allow Medicare to track how these services are being furnished and to assess their impact on the quality of life and effectiveness of care. Evolving payment and measures programs require ACP – PQRS already asks physicians whether they did advance care planning with patients. IAH is an example of a shared savings program that includes ACP (patient preferences) in its quality measures related to payment. Such examples will grow.