Measure Description
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
Instructions
This measure is to be submitted a minimum of once per performance period for patients seen during the performance period. There is no diagnosis associated with this measure. This measure may be submitted by Meritbased Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
NOTE: This measure is appropriate for use in all healthcare settings (e.g., inpatient, nursing home, ambulatory) except the emergency department. For each of these settings, there should be documentation in the medical record(s) that advance care planning was discussed or documented.
NOTE: Patient encounters for this measure conducted via telehealth (including but not limited to encounters coded with GQ, GT, POS 02, POS 10) are allowable. Please note that effective January 1, 2025, while a measure may be denoted as telehealth eligible, specific denominator codes within the encounter may no longer be eligible due to changes outlined in the CY 2024 PFS Final Rule List of Medicare Telehealth Services.
Measure Submission Type:
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third-party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third-party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.
Denominator
All patients aged 65 years and older
DENOMINATOR NOTE: MIPS eligible clinicians indicating the Place of Service as the emergency department will not be included in this measure.
*Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 65 years on date of encounter
AND
Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 90845, 90846, 90847, 96116, 96130, 96132, 96110*, 96112, 96156, 96105, 96125, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99291, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439
WITHOUT
Place of Service (POS): 23
AND NOT
DENOMINATOR EXCLUSION:
Hospice services received by patient any time during the measurement period: G9692
Numerator
Patients who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan
Definition:
Documentation that Patient did not Wish or was not able to Name a Surrogate Decision Maker or Provide an Advance Care Plan – May also include, as appropriate, the following:
- That the patient’s cultural and/or spiritual beliefs preclude a discussion of advance care planning, as it would be viewed as harmful to the patient's beliefs and thus harmful to the physician-patient relationship.
Numerator Instructions:
If patient’s cultural and/or spiritual beliefs preclude a discussion of advance care planning, submit 1124F.
NUMERATOR NOTE: The CPT Category II codes used for this measure indicate: Advance Care Planning was discussed and documented. The act of using the Category II codes on a claim indicates the provider confirmed that the Advance Care Plan was in the medical record (that is, at the point in time the code was assigned, the Advance Care Plan in the medical record was valid) or that advance care planning was discussed. The codes are required annually to ensure that the provider either confirms annually that the plan in the medical record is still appropriate or starts a new discussion.
The provider does not need to review the Advance Care Plan annually with the patient to meet the numerator criteria; documentation of a previously developed advanced care plan that is still valid in the medical record meets numerator criteria.
Services typically provided under CPT codes 99497 and 99483 satisfy the requirement of Advance Care Planning discussed and documented, minutes. If a patient received these types of services, submit CPT II 1123F or 1124F.
Numerator Options:
Performance Met: Advance Care Planning discussed and documented; advance care plan or surrogate decision maker documented in the medical record (1123F)
OR
Performance Met: Advance Care Planning discussed and documented in the medical record; patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan (1124F)
OR
Performance Not Met: Advance Care Planning not documented, reason not otherwise specified (1123F with 8P)
Rationale
Advance care planning is a continuous process of conversation and documentation to align a patient’s care and interventions with their beliefs, values and preferences, in the event they become unable to make those decisions. The Centers for Medicare & Medicaid Services (CMS) describe advance care planning as a face-to-face service to discuss a patient’s health wishes that may or may not include completing relevant documentation (CMS, 2019).
A number of documents may be completed as a result of the advance care planning conversation in order to capture a patient’s wishes and goals for care. These documents are generally referred to as “advance directives” and can include: Durable Power of Attorney for Health Care (DPAHC), living will, and combined directives. In addition to these documents, a patient may have a Physician Orders for Life-Sustaining Treatment (POLST), also referred to as Medical Orders for Scope of Treatment (MOLST). A patient may also identify a surrogate decision maker to serve as their representative and decision maker in the event they cannot make decisions for themselves (Silveira et al., 2020).
Although it is widely agreed that advance care planning is a critical part of patient care, only about 50% of older adults have engaged in advance care planning. Of those older adults, about one-third have documented their wishes and only 10%–20% discussed their wishes with clinicians (Yadav et al., 2017; McMahan et al., 2021). A 2017 study found that 70% of providers indicated they only have advance care planning conversations with their patients experiencing advanced illness (Nichols & Cagle, 2018). The benefits of advance care planning may only be realized if the care team has access to and follows the patient’s advance care plan.
Advance care planning can lead to decreased psychological distress and hospitalizations as well as improved end-of-life care, increased trust in providers and improved quality of life, and can facilitate hope. It has also been associated with increased knowledge about treatment options, documentation of advance care planning, patient-surrogate congruence, goal concordant care and compliance with patient wishes, among others (McMahan et al., 2021; Rosenberg et al., 2020; Martin et al., 2016; Bischoff et al., 2013).
References:
Centers for Medicare & Medicaid Services (CMS). 2019. Advance Care Planning. https://www.cms.gov/Outreachand-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AdvanceCarePlanning.pdf (July 22, 2020)
Silveira, M.J., R.M. Arnold, J. Givens. 2020. Advance Care Planning and Advance Directives. https://www.uptodate.com/contents/advance-care-planning-and-advance-directives (July 22, 2020)
Yadav, K.N., N.B. Gabler, E. Cooney, S. Kent, J. Kim, N. Herbst, A. Mante, S.D. Halpern, & K.R. Courtright. 2017. “Approximately One in Three US Adults Completes Any Type of Advance Directive for End-Of-Life Care.” Health Affairs 36(7), 1244–51. https://doi.org/10.1377/hlthaff.2017.0175
McMahan, R. D., Tellez, I., & Sudore, R. L. 2021. “Deconstructing the Complexities of Advance Care Planning Outcomes: What Do We Know and Where Do We Go? A Scoping Review.” Journal of the American Geriatrics Society 69(1), 234–244. https://doi.org/10.1111/jgs.16801
Bires, J.L., E.F. Franklin, H.M. Nichols, & J.G. Cagle. 2018. “Advance Care Planning Communication: Oncology Patients and Providers Voice their Perspectives.” Journal of Cancer Education 33(5), 1140–7. https://doi.org/10.1007/s13187-017-1225-4
Rosenberg, A.R., B. Popp, D.S. Dizon, A. El-Jawahri, & R. Spence. 2020. “Now, More Than Ever, Is the Time for Early and Frequent Advance Care Planning.” Journal of Clinical Oncology, JCO.20.01080. https://doi.org/10.1200/JCO.20.01080
Martin, R.S., B. Hayes, K. Gregorevic, & W.K. Lim. 2016. “The Effects of Advance Care Planning Interventions on Nursing Home Residents: A Systematic Review.” Journal of the American Medical Directors Association, 17(4), 284– 93. https://doi.org/10.1016/j.jamda.2015.12.017
Bischoff, K.E., R. Sudore, Y. Miao, W.J. Boscardin, & A.K. Smith. 2013. “Advance Care Planning and the Quality of End-of-Life Care in Older Adults.” Journal of the American Geriatrics Society 61(2), 209–14. https://doi.org/10.1111/jgs.12105
Clinical Recommendation Statements
Advance directives are designed to respect patient’s autonomy and determine his/her wishes about future lifesustaining medical treatment if unable to indicate wishes. Key interventions and treatment decisions to include in advance directives are: resuscitation procedures, mechanical respiration, chemotherapy, radiation therapy, dialysis, simple diagnostic tests, pain control, blood products, transfusions, and intentional deep sedation.
Oral statements:
- Conversations with relatives, friends, and clinicians are most common form; should be thoroughly documented in medical record for later reference.
- Properly verified oral statements carry same ethical and legal weight as those recorded in writing.
Instructional advance directives (DNR orders, living wills):
- Written instructions regarding the initiation, continuation, withholding, or withdrawal of particular forms of lifesustaining medical treatment.
- May be revoked or altered at any time by the patient.
- Clinicians who comply with such directives are provided legal immunity for such actions.
Durable power of attorney for health care or health care proxy:
- A written document that enables a capable person to appoint someone else to make future medical treatment choices for him or her in the event of decisional incapacity. (AGS)
The National Hospice and Palliative Care Organization provides the Caring Connection web site, which provides resources and information on end-of-life care, including a national repository of state-by-state advance directives.