Can POLST discussions still be billed to Medicare?
I co-teach a class on Advance Health Care Directives sponsored by a large Advantage plan provider. The other instructor is a health educator who is an employee of the Advantage plan, but I do not work for the Advantage plan. I volunteer my time.
The other instructor hands out the Advantage plan's Advance Health Care form which we go over in detail in the class. When it comes to the life support/CPR question, we briefly discuss what a POLST (Physician's Order for Life Sustaining Treatment) is, pointing out that an Advance Health Care Directive is NOT a DNR. The POLST is essentially a form that can be used to indicate an individuals wishes for "Do Not Resuscitate" if heart and breathing stop, and it also lets the individual define the degree of care they wish to receive if their heart and breathing have not stopped but they need hospitalization or other emergency care. The POLST is a doctor's order, and it must be signed by either a physician, nurse practitioner, or physician's assistant who has discussed the form in detail with the individual based on that person's medical condition, prognosis, and capacity to make decisions--although a surrogate decision maker (health care agent) can have the discussion and sign the form on behalf of an individual who is not able to communicate their own wishes.
This Advantage plan is a large system that employs it's own physicians and runs it's own hospitals, outpatient clinics, etc. I call it "self-contained" because members may not receive care outside of this system except in very limited circumstances.
The patient educator hands out a POLST form to everyone in the class and then tells them they can fill it out on their own and "just drop it off at the care providers office in order to have the doctor sign it." Today, she actually told the class not to make an appointment with their primary care provider to discuss the POLST.
I contradicted her because that's not the law in California. California Probate Code Section 4780(3)(c) says very clearly that "form shall be explained by a health care provider" and "The form shall be completed by a health care provider based on patient preferences and medical indications."
Neither of us who teach the class are the required "health care providers"--we are not physicians, physician's assistants, or nurse practitioners, and we spend--at most--five minutes explaining what a POLST is in the course of teaching about Advance Health Care Directives. In my own legal practice, I assist clients to complete and execute Advance Health Care Directives and will direct them to their physician if they express an interest in a POLST. I disagree with giving everyone in the class a POLST form, because I often find them improperly executed when clients do it themselves, and I also find that they don't understand all the provisions as well as they sometimes think they do. It's the role of their primary care provider (or specialist if they have a serious diagnosis) to ensure that they understand those decisions in light of their current medical condition.
But this big Advantage plan is notably understaffed with physicians, which I'm certain is at least a factor behind the policy of "don't bother us about your POLST--just send it in for signature and scanning in your EMR." I cannot agree with that policy or remain silent when it is discussed. I explained to the class my own reasoning about why they should discuss it with their PCP, though I did not cite the law off the top of my head.
My real question here is whether the Advantage Plan can still use CPT codes 99497 and 99498 for these discussions between members and their PCP's. Although the Advantage plan receives funds from Medicare per capita and collects only the co-payment from members, I see they still itemize bills as if they were FFS (my husband is on this Advantage plan). Has the reimbursement changed so that 99497 and 99498 are no longer covered by Medicare??? Is that perhaps behind the policy not to meet with their members to discuss the POLST?