Advanced Illness / Advance Directives

Description

Advance care planning affords patients the opportunity to exercise their right to make determinations regarding their medical care, prior to becoming incapable of active participation in health care decisions. Advanced illness care planning involves discussions between patients, caregivers, and providers regarding medical care decisions associated with end-of-life care.

Advance care planning is especially appropriate prior to cases wherein an illness or injury causes the patient to be unable to make proper decisions regarding treatment. In some cases where doctors believe recuperation of injury or cure of disease is no longer possible, decisions should be made on the use of emergency treatment to keep a patient alive. Generally, these decisions are centered around the utilization of interventions such as: 

• Cardiopulmonary resuscitation (CPR)
• Artificial hydration or nutrition
• Ventilator use
• Palliative care

A patient’s wishes on the utilization of such interventions are influenced by the verbal and written information provided, personal values, medical history, and conversations with trusted healthcare providers. Through careful consideration of treatment options, patients often prepare an advance directive document, such as a living will or a health care power of attorney. Advance directives, in particular, are legal documents that go into effect only if a patient is incapacitated and unable to speak for him or herself. This could be the result of illness or severe injury, irrespective of age. Advance directives allow patients to express their values and guide providers to administer the preferred end-of-life medical care. An advance directive is a legal document that can be altered as information or health status changes.

Portable medical orders such as the Medical Orders for Scope of Treatment (MOST) or Portable Do Not Resuscitate Order, are issued by physicians (and if applicable by PAs or NPs), with the consent of the patient or the patient’s personal representative. Unlike advance directives, which guide end-of-life-care decisions, portable medical orders direct care.

According to the National Institute on Aging, one of the 27 institutes if the National Institutes of Health (NIH), people who document their preferences for end-of-life treatment using advance directives are more likely to get the care they prefer at the end of life than people who do not.

The North Carolina Department of the Secretary of State maintains the North Carolina Advance Health Care Directive Registry. It is the state’s official legal voluntary knowledgebase for any advance health care directive; however, an advance directive is not required to be filed with the North Carolina Advance Health Care Directive Registry to be effective. 

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) will reimburse advance illness care planning when the criteria outlined in this policy are met.

Reimbursement Guidelines

Counseling patients and their caregivers on advance care planning for end-of-life is an important part of their care. BCBSNC will reimburse qualified health professionals who submit claims for advance care planning for end-of-life counseling services with their patients. Payment consideration may be made for the Evaluation and Management (E&M) service if all of the following conditions are met:

• The face-to-face visit that should consist of an informative discussion between qualified health professionals, patient, and/or the patient’s family regarding end-of-life treatment options.
• The discussion must be clearly documented in the medical record.

Modifier 25 must be submitted with the E&M code for proper adjudication to indicate a significant, separately identifiable, evaluation and management service was performed.

Rationale

Services must be provided face-to-face at a time when the patient is present for some or all of the discussion.

Services must be provided by a licensed care provider (MSW, PA, NP, etc.) or provided under the supervision of a licensed physician. Counseling may include completion of legal advance directive documents, such as a living will or health care power of attorney, portable medical orders such as the Medical Orders for Scope of Treatment (MOST), and/or other instructions for preferred medical treatment.

Other evaluation and management (E&M) services may be billed for the same patient on the same date of service; however Modifier 25 must be used to indicate that the evaluation and management service was significant and separately identifiable.

The codes in this policy may be included in other editing such as Correct Coding Initiative instituted by CMS. Providers may use C3 to check various code combinations being submitted for possible edits and applicable rationale.

For additional federal information on Advanced Care Planning from the NIH, please visit:

National Institute on Aging http://www.nia.nih.gov/health/publication/advance-care-planning

National Cancer Institute National Cancer Institute (NCI)

For additional state-wide/local information on resources related to Advanced Care Planning, please visit:

The North Carolina Partnership for Compassionate Care: http://compassionatecarenc.org 

The North Carolina Department of the Secretary of State Advance Health Care Directive Registry North Carolina Secretary of State Advance Health Care Directives Advance Health Care Directives (sosnc.gov)

For provider training modules, resources, and information please visit:

The Center to Advance Palliative Care: Palliative Care Tools, Training & Technical Assistance http://www.capc.org/ (Membership Needed)

Vital Talk http://www.vitaltalk.org/clinicians

The American Medical Association American Medical Association (ama-assn.org)

The California State University Institute for Palliative Care http://www.csupalliativecare.org/

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at Blue Cross NC.

The codes in this policy may be included in other editing such as Correct Coding Initiative instituted by CMS. Providers may use C3 to check various code combinations being submitted for possible edits and applicable rationale.

Related policy

Telehealth (*EDIT: Link broken KS)

References

See Rationale section

Senior Medical Director 1/2016

National Institute on Aging http://www.nia.nih.gov/health/publication/advance-care-planning 

The North Carolina Department of the Secretary of State Advance Health Care Directive Registry https://www.sosnc.gov/divisions/advance_healthcare_directives

History

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This policy does not apply to Blue Cross NC members who seek care in other states.

This policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.