Medicare Pay for Advance Care Planning Doesn’t Fall That Short

By Phil Rodgers, MD FAAHPM
AAHPM Public Policy Committee Co-chair and RUC Advisor

Dr. Jennifer Brokaw’s article from Time magazine linked in the 11/10 SmartBrief concludes that CMS payment for advance care planning (ACP) services, that will start January 1, 2016, is inadequate to support the time necessary for physicians and qualified providers to provide advance care planning services. The article reaches this conclusion by citing that reimbursement amounts are limited to ‘initial’ palliative care consultation and ‘follow-up’ consultations, and thus do not allow payment for longer, more involved ACP and goals of care discussions.

Dr. Brokaw’s attention to the topic is very welcome, but her article may leave readers confused as to the use and value of the new CPT codes for advance care planning. Specifically, the new Current Procedural Terminology (CPT) codes would allow payment for ACP services of any length, including the long, complex discussions that are a practice staple of hospice and palliative care providers. 99497 (~$86) can be billed for the first 30 minutes of ACP services on a given day, and 99498 (~$75) can be billed for each additional 30 minutes of service performed on the same day, with no limit. There are no frequency limitations to these codes, so they may be used as often as the need arises.

They may be also be used in addition to most other inpatient and outpatient evaluation and management (E/M) codes, provided that the time counted to bill the ACP codes is only counted for ACP services, and not also used to meet time-based criteria for an E/M code. There are a few E/M codes (like those for some critical care services) alongside which the new ACP codes cannot be billed—so do read the fine print, preferably with your practice’s billing professional or consultant.

It is important to note that while CMS issued no specific documentation requirements for use of the new ACP CPT codes, they will be subject to audit. In fact, Medicare contractors may be watching a little more closely given that these codes are new, and there is an interest in making sure they are billed only when the services are delivered. As always, make sure you are documenting (in detail) the services that you perform.

I do agree with Dr. Brokaw that the new Advance Care Planning CPT codes are not a solution to better payment for advance care planning and palliative care services. They are, however, an important step in the right direction. In fact, AAHPM worked with other medical specialty societies to advance the new CPT codes for advance care planning, including presenting data from member surveys to the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) which suggested relative values for the codes to CMS.

For more information, please review the CMS fact sheet and full text of 2016 Medicare Physician Fee Schedule Final Rule.”

New FAAHPM – Kevin A. Ache, DO FAAHPM

Congratulations to Dr. Kevin Ache who recently earned the designation Fellow of the American Academy of Hospice and Palliative Medicine. This new Fellow of the Academy was asked – what brought you to the field of Hospice and Palliative Medicine? We are sharing his answer in this post.

“One morning on inpatient rounds, I walked into an elderly patient’s room in the beginning of my second year as a Family Medicine Resident. Her story was one that we as physicians hear much too often. She came into the Emergency Room with shortness of breath exacerbated by her congestive heart failure. It was her fourth admission in as many months.

I feel that as physicians we are trained to “fix the problem” at any cost. We continue to treat aggressively despite asking what the patient wants. We lose sight of the overall picture including the most important aspect, quality of life. Of course, this is different for everyone and I feel that it is our duty to explain to all of our patients and their families the different options they have in regards to their medical treatment. We need to present their disease process in a way they can understand, not just telling them that “their numbers are looking better/worse”. I want everyone to understand that they have the ultimate choice in how we treat their illness. Whatever decision they make I will respect, but I feel that as a profession we have lost sight of this and it is my job to help them maneuver down this journey we call life. This is what brought me into the field of Hospice and Palliative Medicine.”

Advancement to fellowship status within the academy honors dedication to and scholarship in the field of the hospice and palliative medicine. This distinction represents a minimum of 5 years of membership, participation in AAHPM activities, letters of recommendation, and board certification in hospice and palliative medicine. Dr. Ache will receive the designation during the Annual Assembly of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association in Chicago, IL on Saturday, March 12, 2016.

Check back regularly for posts from other Fellows.

Highlights of the November Issue of the Journal of Pain and Symptom Management

Listed below are a few articles from the most recent issue of the journal:

Fentanyl Buccal Tablet vs. Oral Morphine in Doses Proportional to the Basal Opioid Regimen for the Management of Breakthrough Cancer Pain: A Randomized, Crossover, Comparison Study
Sebastiano Mercadante, Claudio Adile, Arturo Cuomo, Federica Aielli, Andrea Cortegiani, Alessandra Casuccio, and Giampiero Porzio

A Pilot Randomized Controlled Trial of a Holistic Needs Assessment Questionnaire in a Supportive and Palliative Care Service
Nisar Ahmed, Philippa Hughes, Michelle Winslow, Peter A. Bath, Karen Collins, and Bill Noble

Usability and Acceptability of the QDACT-PC, An Electronic Point-of Care System for Standardized Quality Monitoring in Palliative Care
Arif H. Kamal, Dio Kavalieratos, Janet Bull, Charles S. Stinson, Jonathan Nicolla, and Amy P. Abernethy

Managing Medications During Home Hospice Cancer Care: The Needs of Family Caregivers
Jennifer Tjia, Lee Ellington, Margaret F. Clayton, Celeste Lemay, and Maija Reblin

To access the articles, you must subscribe to JPSM or be a member of the American Academy of Hospice and Palliative Medicine (AAHPM). For further information on the Academy, call 847.375.4712 or visit

Submitted by: David J. Casarett, MD, MA, Senior Associate Editor, JPSM

Notes from the Field

by Jordan Endicott, JD
Manager, Health Policy & Advocacy

I’ve worked in the health care related field for nearly the entirety of my professional career, but surprisingly, the last time I had stepped foot in a hospital was at age 10 when I broke my wrist. When I was offered the opportunity to visit Drs. Christian Sinclair and Paul Tatum at their respective hospitals, I was excited for the chance to reacquaint myself with a system that I was really only familiar with in an abstract way.

We spent the first day of our trip with Dr. Sinclair at the University of Kansas Medical Center, spending time with the interdisciplinary team there, and then seeing patients with Dr. Sinclair and a nurse from his team. The patients we saw ranged from those nearing the end of life, to cancer survivors who were left with pain and complications following treatment. The one constant though from all of the visits was that Dr. Sinclair and the nurse kept the focus on what the patient wanted and desired.

After a day spent in Kansas City, we made the short trip over to Columbia, Missouri where Dr. Tatum works at the University of Missouri. Dr. Tatum took us on a whirlwind tour that involved seeing a patient in the hospital, shadowing him during his primary care clinic hours, and ending the work day in Jefferson City to meet with Jane Moore, the CEO of the Missouri Hospice and Palliative Care Association.

When I first informed my friends and family earlier this year that I was accepting a job with the American Academy of Hospice and Palliative Medicine, the most common reaction was along the lines of “wow, that sounds terribly depressing” or “why would you want to do that to yourself?” The reaction was much the same when I told everyone that I’d actually be visiting two of our members and seeing their patients.

My usual response to the negative thoughts that people have to the field of end-of-life care is that our members are working every single day to enhance aspects of patient care that are in need of vast improvement. After seeing firsthand the relief and care that our members provide though, the biggest take away for me is that hospice and palliative care is absolutely not depressing – it’s the fact that thousands of patients across the country still lack awareness or access to this care that is a cause for sorrow. I was already proud of the work I do in supporting our members, but after my visit, I’m even more grateful for the opportunity to work for the Academy and advocate for the field of hospice and palliative medicine.

A Day in the Life…

by Jen Bose, Marketing & Membership Manager

Working with AAHPM for several years has allowed me to get to know some of our members fairly well. I look forward to the Annual Assembly and summer courses each year because I get to connect with members in real life. When the opportunity for Jordan Endicott, Manager of Health Policy and Advocacy, and I to visit Drs. Christian Sinclair and Paul Tatum came up I jumped at the opportunity. Not only would I get to see what they do on a “typical” day I would also be able to understand how the Academy impacts everyone working on the interdisciplinary team and the patients and their families.

Thursday September 24
Kansas University Hospital – Kansas City, KS

We started the morning watching offsite lectures with fellows with Dr. Sinclair. After the lectures we met the three palliative care teams as they discussed the patients for the day. Then we were off to see patients with Dr. Sinclair and the nurse on his team. Each patient had a unique situation and required a slightly different approach and discussion. Some of the discussions were led by Dr. Sinclair and some were managed by the nurse. Every conversation focused around the patient. For some it was about how he or she was feeling that day and what could be done to make him or her more comfortable. For others it was finding out what their expectations were in their recovery and what their quality of life goals were. All of the conversations were warm and personable with a focus on making sure everyone was on the same page. We ended the day at the National World War I Museum before eating delicious barbeque.

Friday September 25
University of Missouri – Columbia, MO

The day started with a team meeting and shadowing a patient visit at the University. We then made our way over to the office where Dr. Tatum sees his geriatric patients. All of the patients adore Dr. Tatum and based on the appointments it is easy to see why. He knows them all very well and has very supportive conversations with them about their present situation and what they hope for in the future and suggestions on how they can get there. We were able to meet the nurse that Dr. Tatum works with in the office that serves as his right hand woman. Then we were off to Jefferson City to meet with the CEO of a state level hospice and palliative care organization. She explained some of the issues that she has been facing in the state and the amazing educational offerings that her organization has created. Our night ended at the Roots N Blues N BBQ Festival where we met up with Dr. Gregg VandeKieft to enjoy music and great food.

Final Thoughts

I was confident that I knew what our members did but in an abstract way. I have seen the process firsthand when my Grandma started a palliative care treatment plan and eventually hospice. Shadowing Dr. Sinclair and his team at the hospital and Dr. Tatum at the hospital and clinic was truly eye opening. The warmth and compassion that was present in every conversation was astonishing. I often found myself on the verge of tears and so proud to work with the amazing people working in hospice and palliative medicine every day.

Back to the Old Schoolhouse − Students of Different Professions Learn Palliative Care Together

By Joseph D. Rotella

More and more academic centers are developing interprofessional education (IPE) programs to teach palliative care− and it makes good sense. Seriously ill patients and their families suffer as whole human beings and it takes a village of palliative care providers from different disciplines working together to comfort, support, and heal them. If we train palliative care professionals in silos, how can we expect them to be prepared for effective interdisciplinary teamwork when they emerge?

The feature story in the American Academy of Hospice and Palliative Medicine (AAHPM) Fall Quarterly (2015), Interprofessional Education: The More, the Healthier, highlights some of the programs across the country that are doing groundbreaking work in IPE.

It may be easy to see the promise of interprofessional training in palliative care, but it’s hard to do it well. In an AAHPM blog post accompanying the article, Dr. V.J. Periyakoil describes her personal experience as faculty for the VA Interprofessional Fellowship Program, “A gold standard is when all IPE fellows are taught at a level that is challenging to all of them in every single session.” That sets a high bar and she adds, “This area is really ripe for discovery and new innovation.” Like the pioneer teacher with K through 12 students in one classroom, IPE instructors strive for a curriculum that can engage learners with a wide range of individual competencies. When it works well, the students learn as much from each other as they do from their teachers.

When I think back on my own development as an internist and palliative care physician, I am struck by how much I learned informally from my colleagues in other professions. When I was a green intern on my first Cardiac Care Unit (CCU) rotation, it was an experienced (and extremely patient) CCU nurse who showed me how to run a code. Counselors taught me how to deal with challenging families and support the grieving. From chaplains, I learned to understand people in the context of the meaning of their life stories. Social workers modeled how to empower patients and families and to have healthy boundaries. A pharmacist shared best practices on stopping unnecessary medications. A nurse’s aide showed me how a bed bath can be a sacred ritual. I had some great physician mentors, but I think I learned more about palliative care from the interdisciplinary team than from other doctors.

My first experience with formal IPE was about a decade ago when I was a facilitator for a discussion group of medical, nursing, social work and pastoral care students following a screening of the film Wit. One medical student resented the whole process. He said, “This is absurd; no real doctor would behave as badly as the ones in this film.” The other medical students nodded their agreement. A nursing student rolled her eyes and said, barely audibly, “Actually, that is exactly what they do.” Her peers agreed. This was a fantastic teachable moment. IPE is not just about developing knowledge and skills. It’s also about opening minds and removing cultural barriers to teamwork.

Dr. Joe Rotella, MD MBA HMDC FAAHPM is the Chief Medical Officer, AAHPM and a frequent participant in #hpm (hospice and palliative med/care) chat.

What: #hpm chat on Twitter
When: Wed 10/14/2015 – 9p ET/ 6p PT
Host: AAHPM and Steve Smith, CEO of AAHPM

Some questions to ponder for the chat:
1. Are there opportunities for interprofessional palliative care training in your program? If so, how do they work?
2. What do you find to be the biggest challenges to interprofessional learning and collaboration?
3. What is the greatest lesson you ever learned from someone outside your profession?

If you are new to Tweetchats, you do not need a Twitter account to follow along. Try using the search function on Twitter. If you do have a Twitter account, we recommend using, for ease of following.

You can access the transcripts and analytics of #hpm chats through @Symplur.

Highlights of the October Issue of the Journal of Pain and Symptom Management

Listed below are a few articles from the most recent issue of the journal:

Promoting Evidence in Practice

The Role of Ownership in Hospice Care: Commentary on Teno et al.
David G. Stevenson

Original Articles

Comparative Analysis of Informal Caregiver Burden in Advanced Cancer, Dementia and Acquired Brain Injury
Richard Harding, Wei Gao, Diana Jackson, Clare Pearson, Joanna Murray, and Irene J. Higginson

Caregiver Expectations: Predictors of a Worse than Expected Caregiving Experience at the End of Life
Emma J. Burns, Stephen J. Quinn, Amy P. Abernethy, and David C. Currow

A Quantitative Study of Triggered Palliative Care Consultation for Hospitalized Patients with Advanced Cancer
Gabrielle B. Rocque, Toby C. Campbell, Sara K. Johnson, Jonathan King, Meghan R. Zander, Renae M. Quale, Jens C. Eickhoff, and James F. Cleary

Brief Report

Characteristics of Hospice Programs with Problematic Live Discharges
Joan M. Teno, Jason Bowman, Michael Plotzke, Pedro L. Gozalo, Thomas Christian, Susan C. Miller, Cindy Williams, and Vincent Mor

To access the articles, you must subscribe to JPSM or be a member of the American Academy of Hospice and Palliative Medicine (AAHPM). For further information on the Academy, call 847.375.4712 or visit

Submitted by: David J. Casarett, MD, MA, Senior Associate Editor, JPSM

In Her Own Words: VJ Periyakoil, MD, discusses IPE

Robert L. Jesse, MD PhD, is a strong proponent of interprofessional clinical and research collaboration and leads the VA Office of Academic Affiliations, the Nation’s largest provider of graduate medical education and a major contributor to health professions education and research. “Health care is a team sport,” said Dr. Jesse. “It is very important that multidisciplinary learners train together so that they can effectively work together to provide the highest quality care to all patients and their families.”

Approved in early 2002, the VA Interprofessional Fellowship Program is located at six sites across the country, with Palo Alto serving as the hub site.

“We currently have about 40 fellows nationwide: trainees in psychology, chaplaincy, nursing, and pharmacy who train side by side with medicine fellows,” said Dr. Periyakoil. “The intent of the program is to ensure that people don’t train in silos. Fellows or trainees learn to train together and have interprofessional, respectful dialogue so that later on [in their careers], it makes working together much easier. Moreover, the best way to provide quality patient care is to have multiple experts from various disciplines working together.”

Program Features
“Our faculty members—doctors, nurses, psychologists, social workers, and chaplains—meet on a regular basis to talk about what they need for all of our fellows. We are very deliberate in creating the training curriculum for this competency-based program. Together, our fellows and faculty meet for educational didactics and in-depth discussion.

“We also meet daily to discuss all the patients on service, with the physician fellow providing medical diagnoses and the psychology fellow assessing grief and depression and how it affects health. The social worker may point out the patient is homeless, and the chaplaincy fellow may assess how a patient feels about his or her faith. When you get multidisciplinary perspectives of patients, suddenly things come to life. [A picture emerges of] this full, living, breathing patient as a person who is a member of a family and of society.

“In addition to learning and working together, the IPE fellows conduct joint projects. For example, every Winter Quarterly, our IPE fellows collaboratively teach the Stanford undergraduates about the multiple facets of palliative care. We learn from our fellows, and the fellows learn from a multidisciplinary faculty. It becomes a gold standard of how we can practice much more collaboratively in the future.”

“First, we know very little about how to train together. As a physician, if I’m left alone with several social work trainees, I have no idea how to train them other than with medical aspects. This area is really ripe for discovery and new innovation.

“Second, there is no dedicated funding to look at how to best train various disciplines together. We know how to provide interdisciplinary care, but we haven’t systematically studied how to teach interprofessional trainees concurrently without catering to the least common denominator.

“For example, we do a didactic on bereavement support, which is a topic that physicians know very little about. During the session, the social work fellows may be bored because they know it too well. How do you teach didactics and structure the curriculum in a way that we’re teaching to the highest, aspirational level for trainees of all disciplines? Likewise, to what extent do I need to teach psychologists, social workers, and chaplaincy fellows about opioids and pain management? Does it matter? If it becomes too deeply medical, it’s not really relevant, and if it is too superficial, a lot can get missed in terms of how to improve patient care.

“A gold standard is when all IPE fellows are taught at a level that is challenging to all of them in every single session. Once we figure out how to do that, the next step is to conduct research together so that we can advance quality of care.”

Beyond Palliative Care
“We practice palliative care within teams and groups; that’s not optional. How do we [share] that with other fields, such as cardiology and gastroenterology, where patients face similar challenges with fragmented care? If we systemically study what we are doing and talk in a standardized manner, other subspecialties will be eager to adopt and learn from palliative care. We have an opportunity to lead other medical subspecialties.

“Beyond that, we have a collective responsibility to mentor trainees in other disciplines. Just as team members in psychology, chaplaincy, social worker, occupational therapy, massage therapy, and music therapy are obligated to mentor the young physician trainee, an MD must support and mentor those trainees as well. By training fellows from all disciplines who practice palliative care, we can grow and innovate, and conduct research together.”

Future Plans
“There’s been a lot of interest recently within the VA to figure out what we need to do next. To me, the next natural step is for trainees to conduct research together. Right now this is a clinical fellowship, but interdisciplinary cross-pollination will open up opportunities for fascinating research in areas such as grief and depression and existential angst and pain.

“Beyond research, it’s important for the sake of all patients and families that we commit to a lifelong practice of working together.”

by Jane Martinsons, AAHPM senior writer

Highlights of the September Issue of the Journal of Pain and Symptom Management

Listed below are a few articles from the most recent issue of the journal:

Promoting Evidence in Practice

The Role of Methylphenidate in Cancer-Related Fatigue. Commentary on Mitchell et al.
Eduardo Bruera

Improving Hospice Care Through a Proactive Telephone-Based Quality Improvement Intervention: Commentary on Davis et al.
Janet Bull

Original Articles

The Effect of Methylphenidate on Fatigue in Advanced Cancer: An Aggregated N-of-1 Trial
Geoffrey K. Mitchell, Janet R. Hardy, Catherine J. Nikles, Sue-Ann S. Carmont, Hugh E. Senior, Philip J. Schluter, Phillip Good, and David C. Currow

Does Continuous Hospice Care Help Patients Remain at Home?
David Casarett, Joan Harrold, Pamela S. Harris, Laura Bender, Sue Farrington, Eugenia Smither, Kevin Ache, and Joan Teno

Improving Adherence to Cancer Treatment by Addressing Quality of Life in Patients with Advanced Gastrointestinal Cancers
Andrea L. Cheville, Steven R. Alberts, Teresa A. Rummans, Jeffrey R. Basford, Maria I. Lapid, Jeff A. Sloan, Daniel V. Satele, and Matthew M. Clark

Brief Quality Improvement Report

A Model for Effective and Efficient Hospice Care: Proactive Telephone-Based Enhancement of Life through Excellent Caring, “TeleCaring” in Advanced Illness
Malene S. Davis, Krista L. Harrison, Jams F. Rice, Alanna Logan, Barry Hess, Perry G. Fine, and J. Cameron Muir

To access the articles, you must subscribe to JPSM or be a member of the American Academy of Hospice and Palliative Medicine (AAHPM). For further information on the Academy, call 847.375.4712 or visit

Submitted by: David J. Casarett, MD, MA, Senior Associate Editor, JPSM

A Fellowship Does Matter

I entered my Palliative Care and Hospice Fellowship in July of 2014, having previously weighed the benefits and burdens of grandfathering in vs. fellowship training. Encouraged by colleagues and my employer I hoped to pursue an experience that would be richer than on the job training and book learning. I did my research before applying to programs. I asked a lot of hard questions to my potential programs. My program director questioned me about what I would want to accomplish since I was already a Hospice Medical Director and had years of physician experience. I laid out my goals and eagerly anticipated the start of my year of learning. Now I am confident that the value of my experience needs to be shared so that other contemplating such a move can be reassured.

I knew it was not going to be easy to move my established life. I resigned from my clinical and administrative positions. I said goodbye to many wonderful coworkers, and patients. I packed my bags and returned to life as a student. My medical career has always been about caring for populations at risk. I embraced the growth that comes from ongoing transitions in my medical career.

I quickly was amazed by the talent of my co-fellows and attendings. As palliative care and hospice providers, we learn amazing skills and invaluable tools for patients in need of care and compassion. Now I realize that I am past the eleven months mark and the time has flown. The experience of my fellowship year has far exceeded my expectations.

I now know how to manage patients and families who appear at the doorsteps of a busy inpatient unit in the worst of situations. I understand the dynamics of highly trained interdisciplinary teams when providing for the physical and emotional needs of patients with advanced suffering. I have learned to palliate the terrible suffering in bodies that cease to sustain themselves. I can feel the deep gratitude as families leave us through the same entrance that greeted them only hours or days earlier.

I have worked in multiple palliative care settings, from solo physicians to full interdisciplinary teams. I have gathered the wisdom of the physicians and other team members to maximize communication across the many levels of human despair. I have gained wisdom from hearing and contrasting multiple attendings’ approaches on symptom management. I know about triaging scarce team resources, the dance of consultant etiquette, and the need to enhance the primary physician’s relationship with the patient.

We care for more than just the patients and their families. We serve and care for the entire range of hospital staff: from medical students to attendings, from CNAs to directors of nursing. We support and coach the new social workers trying to grasp the nuances of hospice placement. We continue to define our role and our skills within hospital systems that barely have time to breathe and reflect. We respect and serve our patients and their families. We advance the science of palliative medicine as we gather data that shows our value to administrators eager to improve quality, satisfaction, and cost savings. All in all, we do great work.

I have grown personally and professionally in ways I never imagined. The need to be in a fellowship is reinforced every day. The year of intense experience is balanced by the beautiful and unwavering support of the attending faculty. The confusion of new places and new rotations is organized and simplified by amazing support staff. When we feel lost, we are given a path and encouragement. When we stress, we are given support and relief. When we look to the future, we are prepared for change and reminded that our mentors are always there for us.

This experience has transformed my initial goals, allowing me to envision the future of palliative care. I see myself able to work in all of the settings of hospice and palliative care. In our developing specialty I see myself returning not only to clinical work but also to a position of leadership and advocacy. I see a great opportunity for supporting teams during the explosion of need for palliative care across the continuum of health care. I hear the warnings about burnout in hospice teams and palliative care teams that need to stay strong now more than ever. I see the need for networking and support among our professions at all levels.

My program is supporting me in my quest to learn about business strategies for hospice and palliative programs. I am actively connecting with our national and international organizations. This amazing fellowship has given me and my co-fellows an environment, a model, and a vision of how to care for patients, families, coworkers, healthcare teams, and ourselves. I am excited because I now see vast opportunities in my life. I look forward to working with hospital systems and healthcare systems as our profession carries forward the recommendations from the Institute of Medicine’s recent report on Dying in America. It is clear to me that this transformation and world of opportunities would have been missed if I simply grandfathered in to board certification. I will forever be thankful that I chose this fellowship experience.

Whit Dunkle, MD, ABFP
Medstar Washington Hospital Center/Capital Caring Fellowship