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OIG Audit of Advance Care Planning Billing Confirms C-TAC’s View

The Office of the Inspector General, OIG, recently issued a report on an audit they did of providers’ use of the advance care planning billing (ACP) codes that confirmed information C-TAC provided to them at the beginning of this audit. This audit could impact C-TAC members and all who bill for ACP should be up to date on documentation requirements.

As background, the OIG identifies waste, fraud, and abuse via oversight of the federal Medicare and Medicaid programs. C-TAC members may be aware of their work from the hospice oversight the OIG has been doing lately.This ACP billing audit was prompted by an initial OIG review in 2020 that found some billing irregularities. C-TAC was interviewed by OIG for our input before the audit began. We told them our members felt any billing discrepancies were likely unintentional and the result of providers being unsure about how to use and bill these codes as CMS guidance was not clear enough. 

Which is exactly what the final OIG audit and report concluded. Entitled: Medicare Providers Did Not Always Comply With Federal Requirements When Billing for Advance Care Planning, a sample of billing estimated that Medicare providers in office settings were paid approximately $42.3 million for ACP services that did not comply with Federal requirements. The report goes on to say that “these payments occurred because the providers did not understand the Federal requirements for billing ACP Services”. That led to the OIG’s recommendation that CMS educate providers on documentation and time requirements for ACP services to comply with Federal requirements. CMS has concurred with this recommendation in an appendix to the OIG report. 

C-TAC was also recognized for our expertise in this area by Hospice News in a recent story on this OIG report. Senior Regulatory Advisor Marian Grant was quoted there saying“When these billing codes were created, CMS made them very vague and open-ended, leaving room for flexible timing, frequency, and settings around these conversations…But a little more direction would be helpful to avoid inadvertent billing mistakes. What we heard from many providers was that CMS was not clear about the requirements and what [providers] needed to document to support these billing claims”.

Unfortunately, even though the over-billing was likely unintentional, these audited providers will have to pay this money back. Note: this only applies to providers who were part of the OIG audit and is only for those in office settings, not hospice or the hospital. We are therefore alerting C-TAC members who were part of this audit to be prepared to hear from CMS about repayment.  The timing and process for repaying the over-billing is still to be determined and was not in the OIG report as that is up to CMS. 

However, until revised CMS guidance is published, all C-TAC members who bill for ACP should review the existing CMS guidance on ACP billing, especially in regard to documentation. That guidance says “appropriate documentation must include the content and the medical necessity of the ACP related discussion, the voluntary nature of the encounter, the content of any advance directives (along with completion of advance directive forms, when performed), the names of participants in the discussion; and the time spent in the face-to-face encounter. Best practice for the time documentation is to include the start and end time of the face-to-face conversation”. Any providers having further questions about ACP billing should contact their Medicare Administrative Contractors, MACs

C-TAC will continue to monitor this situation and will post the revised CMS guidance once it is available. We will also continue to advocate to increase access to ACP as it is a valuable service to ensure the voices of patients and families are heard.