Advance Care Planning (ACP) is a critical service that enables patients to make informed decisions about their future healthcare. For healthcare providers, understanding the nuances of Advance Care Planning Coding is essential for accurate billing and reimbursement. This guide breaks down the complexities of ACP coding, ensuring you are well-versed in the current practices and guidelines.
What is Advance Care Planning?
Advance Care Planning is a voluntary, face-to-face interaction between a healthcare professional and a patient, which may also include family members or a surrogate decision-maker. The core purpose of ACP is to discuss and document a patient’s wishes and preferences for medical care should they become unable to make these decisions themselves.
A surrogate can be a healthcare agent, a designated decision-maker, a family member, or a caregiver, all acting in the patient’s best interest when the patient cannot express their own desires. It’s important to document why a patient cannot be present if they are unable to participate in the ACP discussion.
Who Can Provide and Bill for ACP Services?
Under Medicare Part B, specific qualified healthcare professionals are authorized to provide and bill for ACP services. These include:
- Physicians (MD/DO)
- Nurse Practitioners (NP)
- Physician Assistants (PA)
- Clinical Nurse Specialists (CNS)
While other members of a healthcare team, such as social workers, psychologists, or chaplains, may contribute to ACP, they cannot independently bill Medicare for these services. The billing provider must be a qualified professional who actively participates in and meaningfully contributes to the ACP discussion, providing at least direct supervision. Standard physician fee schedule (PFS) rules regarding “incident to” services are applicable.
Where Can ACP Services Be Provided?
ACP services are versatile and can be delivered across various healthcare settings, including:
- Physician Offices
- Hospitals
- Skilled Nursing Facilities (SNF)
- Patient Homes
- Via Telehealth (following specific CMS guidelines)
Regardless of the setting, the appropriate Place of Service (POS) code must be included when billing for ACP services. ACP services are not restricted by medical specialty, making them broadly applicable across healthcare.
For patients receiving hospice benefits, ACP services can still be billed to Medicare Part B if the practitioner is not employed by the hospice. If the practitioner is hospice-employed or under arrangement with hospice, ACP services are billed under Type of Bill 081x or 082x.
Understanding CPT Codes for Advance Care Planning Coding
The Current Procedural Terminology (CPT) codes specifically designated for advance care planning coding are time-based, reflecting the duration of the face-to-face discussion. These codes are:
- CPT code 99497: Used for the initial 16 to 30 minutes of advance care planning, which includes the explanation and discussion of advance directives, such as standard forms, and the completion of these forms when performed. This code is for the first 30 minutes of service.
- CPT code 99498: Used for each additional 30 minutes of advance care planning. It should be listed separately in addition to the primary code (99497).
It’s crucial to adhere to CPT guidelines regarding minimum time requirements for timed services. If the ACP session does not meet the minimum time for 99497, consider using a different Evaluation and Management (E/M) service code, provided the criteria for that E/M service are met. During the time billed under ACP codes, no other active management of the patient’s problems should be undertaken.
Frequency and Medical Necessity
There is no annual limit on how often ACP services can be billed for a patient. However, if ACP services are billed more than once for the same patient, documentation must clearly demonstrate a change in the patient’s health status or their wishes regarding end-of-life care. The voluntary nature of ACP must be documented in the patient’s medical record, indicating agreement from the patient, family member, or surrogate.
Medicare recognizes ACP as either:
- An optional component of a Medical Wellness Visit (MWV), including the Annual Wellness Visit (AWV).
- A separate, medically necessary Medicare Part B service.
When ACP is provided outside of a MWV, patients should be informed that standard Part B cost-sharing (deductible and coinsurance) applies.
Cost Sharing and Modifiers
Medicare may waive the ACP coinsurance and Part B deductible under specific conditions:
- When ACP is delivered on the same day as a covered MWV (HCPCS codes G0438 or G0439).
- When offered by the same provider as the covered MWV.
- When billed with modifier -33 (Preventive Services).
Even if a MWV claim is denied due to frequency limits, Medicare may still cover ACP as a separate Part B medically necessary service, in which case deductible and coinsurance will apply to the ACP service.
Documentation and Diagnosis Coding for ACP
Thorough documentation is paramount for advance care planning coding. At a minimum, documentation must include:
- The content and medical necessity of the ACP discussion.
- The voluntary nature of the encounter.
- The content of any advance directives discussed (and completion of forms, if applicable).
- Names of all participants in the discussion.
- The total time spent in the face-to-face encounter, ideally including start and end times.
For diagnosis coding, use the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes that reflect the condition for which the patient is receiving counseling during ACP. When ACP is part of a MWV, use codes for administrative or well exams.
Billing ACP with Other Services
CPT codes 99497 and 99498 should not be reported on the same date of service as certain high-intensity Evaluation and Management (E/M) services, specifically: 99291-99292, 99468-99469, 99471-99472, 99475-99480, and 99483.
However, ACP codes can be billed on the same day as most other E/M services (e.g., 99201-99215, 99217-99226, 99231-99236, etc.), transitional care management services, chronic care management services, and within global surgical periods. When billing ACP codes with these other E/M services on the same date, append modifier -25 to the E/M code, provided the requirements for modifier -25 are met, indicating a separately identifiable E/M service.
Critical Access Hospitals (CAHs) can bill ACP services using type of bill 85X with revenue codes 96X, 97X, and 98X. Federally Qualified Health Centers and Rural Health Clinics are paid for ACP under their all-inclusive rate or prospective payment system.
Conclusion
Accurate advance care planning coding is crucial for healthcare providers to receive appropriate reimbursement for these vital patient services. By understanding these guidelines, including the proper use of CPT codes 99497 and 99498, documentation requirements, and billing rules, providers can ensure compliance and facilitate valuable ACP discussions that align with patient needs and preferences. Staying informed about these coding practices is an investment in both patient care and the financial health of your practice.
