advance care planning - healthtechs3€¦ · • “acp enables medicare beneficiaries to make...

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Advance Care Planning:

Building Leaders – Transforming Hospitals – Improving Care

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It’s About the Conversation, not the Form

45 Years of Delivering Results

HealthTechS3 is a 45 year old, award-winning healthcare consulting and strategic hospital services firm based in Brentwood, Tennessee with clients across the United States. We are dedicated to the goal of improving performance, achieving compliance, reducing costs, and ultimately improving patient care. Leveraging consultants with deep healthcare industry experience, HealthTechS3 provides actionable insights and guidance that supports informed decision making and drives efficiency in operational performance.Our consultants are former hospital leaders and executives. HealthTechS3 has the right mix of experienced professionals that service hospital clients across the nation. HealthTechS3 offers flexible and affordable services, consulting, and technology as we focus on delivering solutions that can be implemented and provide a positive, measurable impact.

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GOVERNANCE &

STRATEGY•Affiliation Consulting

•Executive & Management Leadership Development

•Strategic Planning & Market share Analysis

•Community Health Needs Assessment

•Compliance Consulting Services

FINANCE•Performance Optimization / Margin Improvement

•Revenue Cycle & Business Office Operations

•Productivity & Staffing Consulting - Optimum Productivity Toolkit

CLINICAL CARE &

OPERATIONS•Continuous Survey Readiness

•Quality Assurance Performance Improvement

•Lean Culture

•Customer Experience

•Clinical Resource Management

•Care Coordination – Primary Care Practice

•Physician Practice & Clinic Assessment

•Long Term Care Consulting

•Swing Bed Consulting

•Perioperative Services Consulting

RECRUITMENT•Executive Recruitment

•Manager and Clinical Positions

•Physician / Provider Recruitment

•Information Technology Professionals

•Interim Placement

STRATEGY – SOLUTIONS – SUPPORT2

34TH Quarter WebinarsCMS Revises Swing Bed Standards – What’s New?–What’s the Same? – Are You Ready?

Host: Carolyn St.Charles, RN, BSN, MBA, Regional Chief Clinical Officer

October 5, 2018 at 12pm CST

https://bit.ly/2wJsa93

Relationship-Based Telehealth: Incorporating Telehealth into your Care Coordination Program

Hosts: Faith M Jones, MSN, RN, NEA-BC, HealthTechS3 Director of Care Coordination

October 11, 2018 at 12pm CST

https://bit.ly/2MoaGdY

Interim Leadership: Ensuring A Catalyst for ChangeHost: Jennifer LeMieux, CRCR, BS, MBA, Strategy Consultant, HealthTechS3October 25, 2018 at 12pm CST

https://bit.ly/2Q3ujoF

Strategies for Meeting the Healthcare Needs of At-Risk PopulationsHost: Carolyn St.Charles, RN, BSN, MBA, Regional Chief Clinical OfficerNovember 2, 2018 at 12pm CSThttps://bit.ly/2CwrmKT

Advance Care Planning: It’s about the Conversation not the FormHost: Faith M Jones, MSN, RN, NEA-BC, HealthTechS3 Director of Care Coordination November 15, 2018 at 12pm CSThttps://bit.ly/2MPqrtB

Critical Access Hospitals - Anything New for 2019?Host: Carolyn St.Charles, RN, BSN, MBA, Regional Chief Clinical OfficerDecember 7, 2018 at 12pm CSThttps://bit.ly/2NPgysk

Getting Organized with Lean: 5S for the New Year!Host: Faith M Jones, MSN, RN, NEA-BC, HealthTechS3 Director of Care Coordination and Lean ConsultingDecember 13, 2018 at 12pm CSThttps://bit.ly/2Q5OmCU

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HealthTechS3 hopes that the information contained herein will be informative and helpful on industry topics. However, please note that this information is not intended to be definitive. HealthTechS3 and its affiliates expressly disclaim any and all liability, whatsoever, for any such information and for any use made thereof. HealthTechS3 does not and shall not have any authority to develop substantive billing or coding policies for any hospital, clinic or their respective personnel, and any such final responsibility remains exclusively with the hospital, clinic or

their respective personnel. HealthTechS3 recommends that hospitals, clinics, their respective personnel, and all other third party recipients of this information consult original source materials and qualified healthcare regulatory counsel for specific guidance in healthcare

reimbursement and regulatory matters.

Instructions for Today’s Webinar

You may type a question in the text box if you have a question during the presentation

We will try to cover all of your questions – but if we don’t get to them during the webinar we will follow-up with you by e-mail

You may also send questions after the webinar to our team (contact information is included at the end of the presentation)

The webinar will be recorded and the recording will be available on the HealthTechS3 web site: www.healthtechs3.com

www.healthtechs3.com

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Faith M Jones, MSN, RN, NEA-BCDirector of Care Coordination and Lean ConsultingFaith Jones began her healthcare career in the US Navy over 30 years ago. She has worked in avariety of roles in clinical practice, education, management, administration, consulting, and healthcarecompliance. Her knowledge and experience spans various settings including ambulance, clinics,hospitals, home care, and long term care. In her leadership roles she has been responsible foroperational leadership for all clinical functions including multiple nursing specialties, pharmacy,laboratory, imaging, nutrition, therapies, as well as administrative functions related to qualitymanagement, case management, medical staff credentialing, staff education, and corporatecompliance. She currently implements care coordination programs focusing on the Medicarepopulation and teaches care coordination concepts nationally. She also holds a Green Belt inHealthcare and is a Certified Lean Instructor.

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Objectives 6

Upon completion of the webinar, the participant will understand:

• The various approaches to the conversation and be able to describe the ACP process for the advance directive product

• The similarities and differences in the advance directive products/tools

• The reimbursement opportunities for providing ACP through a team based approach

7Patient Self Determination Act

In1990, the Patient Self-Determination Act was passed to preserve patient autonomy regarding end-of-life medical decision-making.

Do you have a living will or advance directive?

http://journals.lww.com/jncqjournal/Abstract/publishahead/Improving_the_Advance_Directive_Request_and.99663.aspx

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http://theconversationproject.org/

Facts to Consider 8

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“Talking with your loved ones openly and honestly, before a medical crisis happens, gives everyone a shared understanding about what matters most to you at the end of life.”

Determine What is Important

http://theconversationproject.org/starter‐kits/

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10Culture

What is it?

According to Merriam-Webster Dictionary (2015), culture is defined as

“a way of thinking, behaving, or working that exists in a place or organization”

11Success Story

http://www.forbes.com/sites/offwhitepapers/2014/09/23/how‐to‐die‐in‐america‐welcome‐to‐la‐crosse/#7d595e28572c

(1) Conversations and relationships matter. (2) Innovation in end‐of‐life care requires highly personalized local solutions (3) While the end‐of life advance directive document is standardized, the process

for each patient and family will be unique and intimate.(4) Accessibility of records.

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Changing Models 12

“Our goal is to recognize the trend toward practice transformation and overall improved quality of care, while preventing unwanted and unnecessary care”

CMS CFR 11-12-2014

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“the services described by CPT codes 99497 and 99498 are appropriately provided by physicians or using a team-based approach”

Who Can Perform ACP?

https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/PhysicianFeeSched/Downloads/FAQ‐Advance‐Care‐Planning.pdf

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Voluntary Advance Care Planning

• “ACP enables Medicare beneficiaries to make important decisions that give them control over the type of care they receive and when they receive it.”

Approach to the Conversation

MLN Matters® Number: MM9271 Related Change Request Number: 9271

15Medicare’s Definition of ACP

Voluntary Advance Care Planning• “Voluntary ACP means the face-to-face service between a physician

(or other qualified health care professional) and the patient discussing advance directives, with or without completing relevant legal forms. An advance directive is a document appointing an agent and/or recording the wishes of a patient pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at that time. ”

MLN Matters® Number: MM9271 Related Change Request Number: 9271

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Advance Care Planning = Procedure

Advance Care Planning & Advance Directives

Advance Directive = Product

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Step 1 Get Ready

Conversation Starter

http://theconversationproject.org/wp‐content/uploads/2017/02/ConversationProject‐ConvoStarterKit‐English.pdf

What do you need to think about or do before you feel ready to have the conversation?

Do you have any particular concerns that you want to be sure to talk about?

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Step 2 Get Set



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Step 2 Get Set



Now finish this sentence: What matters to me at the end of life is…

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20Go Wish

http://www.gowish.org/gowish/gowish.html

21Hello

https://commonpractice.com/hello

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After establishing what is important…

The conversation can move to determining the patient’s choices/wishes for end of life

Develop Interventions

23What Should be Captured?

Basics to Document- Health Care Proxy- Treatment options….

- Chest Compressions- Ventilator- IV fluids- Feeding tubes- Antibiotics

- Personal requests…- Spiritual care- Traditions- Rituals/Customs - Add any other directions that are important to the patient

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Forms 24

Legal DocumentsLaws regarding execution of the document varies by stateThere may be a preferred framework to be used – but there is flexibility in the content

Forms – Five Wishes 25

https://www.agingwithdignity.org/five‐wishes

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Forms – Caring Info 26

http://www.caringinfo.org/i4a/pages/index.cfm?pageid=3289

Listed by State50 States plus Puerto Rico and the District of Columbia

Forms – Living Wills 27

Old Language:• DNRs• Terminal Condition• “in the opinion of my physician”• “in the opinion of 2 physicians”

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Physician Order Life Sustaining Treatment (POLST) 28

http://polst.org/programs‐in‐your‐state/

POLST 29

http://polst.org/advance‐care‐planning/polst‐and‐advance‐directives/

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“Talking with your loved ones openly and honestly, before a medical crisis happens, gives everyone a shared understanding about what matters most to you at the end of life.”

The Point of the Advance Care Planning Conversation

http://theconversationproject.org/starter‐kits/

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Is to provide written documentation of the type of care the patient wants to receive at the end of their life

The Point of the Advance Directive 31

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Let’s Talk…32

• Advance Care Planning (ACP)– Effective January 1, 2016

• CPT code 99497 and 99498

Reimbursement for the Conversation 33

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CPT Code 99497- Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate

CPT Description


CPT Code 99498- each additional 30 minutes (List separately in addition to code for primary procedure)

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“CPT codes 99497 and 99498 are time-based codes (a base code and an add-on code). Are there minimum amounts of time required to bill these codes? • In the calendar year (CY) 2016 PFS final rule (80 Fed. Reg. 70956), we

adopted the CPT codes and CPT provisions regarding the reporting of timed services. Practitioners should consult CPT provisions regarding minimum time required to report timed services. If the required minimum time is not spent with the beneficiary, family member(s) and/or surrogate to bill CPT codes 99497 or 99498, the practitioner may consider billing a different evaluation and management (E/M) service such as an office visit, provided the requirements for billing the other E/M service are met.”

How do we count time?35


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Units Number of Minutes • 1 unit of 99497: 30 minute unit

– ≥ 16 minutes through 45 minutes

• 1 unit of 99497 and 1 unit of 99498: 30 min unit + 30 min unit– ≥ 46 minutes through 75 minutes (30 + 16 to 45)

• 1 unit of 99497 and 2 units of 99498: 30 min unit + (2) 30 min units– ≥ 76 minutes through 105 minutes (30 + 30 + 16 to 45)

• 1 unit of 99497 and 3 units of 99498: 30 min unit + (3) 30 min units– ≥ 106 minutes through 135 minutes (30 + 30 + 30 + 16 to 45)

How do we count time?36


“In what settings can ACP services be provided and billed-Inpatient? Nursing home? Other?• There are no place of service limitations on the ACP codes. As we

stated in the CY 2016 PFS final rule (80 Fed. Reg. 70956), ACP services may be appropriately furnished in a variety of settings depending on the needs and condition of the beneficiary. The codes are separately payable to the billing physician or practitioner in both facility and non-facility settings and are not limited to particular physician specialties.”

Where can ACP be performed?37


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CPT = Current Procedural Terminology

Documentation of the Procedure

Entry in the Medical Record:• Procedure note• General overview of discussion• Advance Directive status• Time spent

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“Examples of appropriate documentation would include an account of the discussion with the beneficiary (or family members and/or surrogate) regarding the voluntary nature of the encounter; documentation indicating the explanation of advance directives (along with completion of those forms, when performed); who was present; and the time spent in the face‐to‐face encounter.”


Patient Responsibility

Beneficiary Eligibility

Medicare pays for ACP as either: • A separate Part B service when it is medically

necessary • An optional element of a beneficiary’s Annual Wellness

Visit (AWV)

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Conducting ACP with AWV

When done with AWV:• Done on the same day• Billed on the same claim• Under same provider• Use Modifier 33

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• Advance Care Planning (ACP)– Effective January 1, 2017

• CPT code 99497 and 99498

– Added to the Telehealth list

Reimbursement for the Conversation 41

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42Thank you!

Dallas Office2745 North Dallas Parkway,

Suite 100, Plano, TX 75093

Brentwood Office5110 Maryland Way, Suite 200

Brentwood, TN 37027

Our PhoneMain Office: 615.309.6053

Executive Placement: 972.265.4549

EmailFaith Jones

[email protected]

307-272-2207

If you would like more information or would like to discuss implementing or expanding our care coordination program, please feel free to contact me. 43