CERT: Insufficient documentation causes most improper payments for voluntary advance care services

January 22, 2018

Insufficient documentation caused most improper payments for voluntary advance care planning (ACP) services submitted during a three-month period in 2016, according to a Comprehensive Error Rate Test (CERT) report in the most recent Medicare Quarterly Provider Compliance Newsletter.

Voluntary ACP is a face-to-face service between a qualified health care professional and a patient discussing advance directives, with or without completing relevant legal forms, according to CMS. Upon agreement with a patient, an ACP service is an optional element of the annual wellness visit.

To determine common payment issues when billing for voluntary ACP services, a study was conducted by a CERT review contractor for claims with lines for ACP billed with CPT code 99497 (ACP by the physician or other qualified healthcare professional; first 30 minutes, face-to-face with the patient, family member[s], and/or surrogate) submitted from April through June 2016. Each claim was medically reviewed to determine whether it was paid properly and the reasons for improper payments.

The study found that most improper payments were due to missing data within the medical records to support payment for the services billed. Claims lacked clinical documentation to support face-to-face services and/or clinical documentation of the time spent discussing the ACP.

To learn more and help avoid insufficient documentation errors for ACP services, see section 280.5.1 of the Medicare Benefit Policy Manual and MLN Matters article 9271 on submitting an advance care plan as an optional element of an annual wellness visit.