Care Model Eligibility – CMS Advance Care Planning

All Medicare patients are eligible for CMS Advance Care Planning

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Patient Segment Eligibility Description Data Source
All Medicare patients Patient identified as not having an Advance Care Planning (ACP) directive in place or beneficiary identified as needing to update ACP directive Claims

Procedure HCPCS codes to determine if ACP was previously billed

Care Model Eligibility – End of Life Care (general)

Patients who are entitled to Part A of Medicare and have been certified as terminally ill.

Patient Segment Eligibility Description Data Source
Patients certified as terminally ill Patients are considered terminally ill if the medical prognosis is that the individual’s life expectancy is 6 months or less if the illness runs its normal course. Claims

  • Develop predictive model (e.g. PRISM) to determine if a patient’s life expectancy is most likely 6 months or less
  • Alternatively, able to retroactively look back at patients’ last 6 months of life and determine if patient received hospice care

Care Model Implementation – CMS Advance Care Planning

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Time Frame Action
Trigger event Beneficiary identified as not having an Advance Care Planning (ACP) directive in place or beneficiary identified as needing to update ACP directive
Within 30 days of trigger event (flexible) Provide the ACP service, either as an optional element of a beneficiary’s AWV, or as a separate part B service:

  • A minimum of 30 minutes face-to-face between the physician or NPP and the beneficiary, family members, and/or surrogate
  • Discussion about the care the beneficiary would want to receive if he/she became unable to speak for his/herself, including the explanation and discussion of advance directives
  • Completion of an advance directive

Care Model Implementation – End of Life Care (general)

Time Frame Action
Trigger event Beneficiary identified as having 6 months or less to live. The beneficiary has no curative options or has chosen not to pursue treatment because the side effects outweigh the benefits.
Within 30 days of trigger event (flexible) Admit beneficiary to hospice care:

  • Services typically include physical care, counseling, drugs, equipment, and supplies for the terminal illness and related conditions.
  • Care is generally provided in the home.
Within 2 days after hospice care is initiated Medical director of the hospice agency and the beneficiary’s attending physician must provide oral or written certification of the terminal illness
Within 3 months after hospice care is initiated, recertify hospice care if beneficiary is still eligible Medical director of the hospice agency must provide oral or written certification of the terminal illness

Care Model Compliance – CMS Advance Care Planning

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Intervention Intervention Description Data Source
Furnish ACP services Provide the ACP service, either as an optional element of a beneficiary’s AWV, or as a separate part B service.

See previous slide Care Model: End of Life Planning and Care – Implementation for additional details.

 Claims:

Procedure HCPCS codes to determine if ACP was billed

Care Model Compliance – End of Life Care (general)

Intervention Intervention Description Data Source
Provide hospice care for patient Services typically include physical care, counseling, drugs, equipment, and supplies for the terminal illness and related conditions. Care is generally provided in the home. Claims:

Claim type codes to determine if patient was in hospice