New Medicare-Covered Service: Advance Care Planning

Have you considered what treatments you would want or choose to forego if you had a terminal illness with no chance of recovery and you were unable to direct your care? Have you talked about your wishes with family or friends?

Do you have a written advance directive that states what your wishes are or names someone who knows you well, knows your wishes, and will serve as your advocate to speak with your doctor(s) on your behalf? Do you know if your patients have had these discussions with family or healthcare providers? Do you have a copy of patients’ advance directives on file in their medical record? Do your staff know what the clinic policy is related to advance directives?

A new Medicare payment policy may encourage nephrologists and qualified non-physician practitioners to have discussions about advance care planning (ACP) with those who have kidney disease and kidney failure. The Physician Fee Schedule for 2016 provides two new codes for a physician or other “qualified healthcare professional” to bill for face-to-face discussions with Medicare patients, family member(s), and/or their representatives. The regulation describes this patient interaction as being a “discussion about future care decisions that may need to be made, how the beneficiary can let others know about care preferences, and explanation of advance directives which may involve the completion of standard forms.” The code to use depends on whether the discussion is 30 minutes or longer.¹ Unless these discussions take place during the Medicare annual wellness physical (AWP), the patient or their other insurance is responsible for the Medicare Part B deductible and 20% coinsurance. The discussion is voluntary and Medicare beneficiaries may choose not to have it.

Dialysis staff need to be aware that ACP discussions can take place in any physician’s office. Since October 2008, when the ESRD Conditions for Coverage took effect, dialysis clinics have been required to inform patients about their right to have an advance directive and the clinic’s policy regarding advance directives.”² Therefore, it should already be routine to ask all dialysis patients if they have an advance directive (AD) or if they have changed their AD. Dialysis clinics should ask for a copy of each patient’s AD to assure that they follow the patients’ wishes as closely as possible. All staff should be well informed of the clinic’s policy related to advance directives. If that policy requires staff to always perform CPR since the event requiring CPR might have been caused by dialysis, patients with ADs who refuse CPR must be informed of that policy. If a patient objects and requests a transfer to a clinic that will honor his or her AD strictly, the dialysis clinic should offer to help that patient to transfer.

It’s not easy to think about, much less accept, that life will end one day. The thought is likely to bring up both positive and negative emotions. Discussions with patients can remind staff who care for them of their own mortality. However, such discussions can help the living know they have honored the deceased by doing exactly what he or she wanted. Isn’t that gift worth any price?