Date of Award


Degree Name

Nursing (D.N.P.)


College of Nursing

First Advisor

Dianne Conrad

Second Advisor

Jean Barry

Third Advisor

Iris Boettcher


Today’s healthcare landscape is saturated with an aging U.S. population that is living longer and with more chronic conditions. One way to manage care for this aging population, especially those with chronic conditions, is through advance care planning (ACP). Healthcare providers are capable of engaging patients in these important healthcare discussions, yet use of methods to appropriately document and code for these services are lacking. There are Current Procedural Terminology (CPT) codes in existence that would be applicable for these services; however, they are not widely understood nor routinely used in clinical practice. Administrators at a large Midwestern healthcare organization’s home based primary care program (HBPC) recognized this gap in care delivery and were open to a quality improvement initiative to address this clinical problem.

The purpose of this project was to close this practice gap by establishing a standardized documentation protocol using CPT codes for ACP services. A retrospective chart analysis of all patients enrolled in the HBPC program (N=430) determined that ACP is a major aspect of care delivery at HBPC, with a total of 98% (n=419) of the total patient population having a documented resuscitation order and 81% (n=347) of patients having a documented durable power of attorney; two crucial aspects of any ACP discussion.

A second chart audit (n=28) based on a simple random sampling of patients enrolled in HBPC in the last 60 days was completed to focus on CPT code utilization and associated documentation for ACP services. None of the charts in the second chart audit included the use of ACP CPT codes or the associated documentation. Ten charts did include documentation on time spent on ACP services, and therefore were used to create a projected return on investment (ROI) for ACP CPT codes. The projected ROI for ACP CPT codes found that HBPC missed opportunities on 22 relative value units and reimbursement of $1,234.30 on 10 single face-to-face patient encounters where ACP was discussed because ACP CPT codes and correct documentation were not utilized.

The second chart audit strengthened the need for an educational session with clinical staff to promote the use of a standardized documentation protocol using CPT codes for ACP services. An educational session was completed with staff to identify staff knowledge and attitude regarding ACP services codes and included a pre/post-education survey. The mean score for the pre-survey was 9.4; with one being strongly disagree to five being strongly agree for a total of five questions adding up to 25. The mean score for the post-survey was 19.3. In comparing the two scores, the post-survey score increased by 39.6% representing a small to medium effect size statistically. This revealed that staff knowledge and attitude regarding CPT codes for ACP services had a positive change following the educational session.

A final chart audit using a convenience sample of patients with an ACP discussion three weeks after the education session (n=55) was completed to assess for changes in documentation for ACP services. Documentation requirements that align with the CMS (2016) requirements for ACP CPT codes did not significantly improve following the educational session. Despite the lack of significant change in documentation, the educational session was still beneficial for staff knowledge regarding ACP CPT codes. Additionally, both chart audits identified three variables (consent, explanation of advance directives, and time spent on ACP discussions) that were most likely to be missed in documentation. This strengthened the need for continued employee education regarding implementation of CPT codes for ACP services as well as a standardized documentation protocol to guide providers through the implementation process in the future.

Upon completion of this project, a standardized documentation protocol for ACP services now exists at the HBPC practice. This scholarly project has major implications for practice. The estimated return on investment from the use of CPT codes for ACP services highlighted the potential increase in relative value units for provider productivity as well as increases in reimbursement (for a standard fee-for-service model) captured by utilizing these codes. The educational session received support from the staff, and educational materials from the session can be utilized for future practice. Finally, the protocol will help to standardize workflow around ACP services, which are a large component of routine patient care delivery at HBPC. A standardized documentation protocol using CPT codes for advance care planning is one way to address the current gap in practice and promote quality, cost-effective care delivery at a home based primary care program.

Available for download on Saturday, April 13, 2019

Included in

Nursing Commons