In the intricate world of medical coding, accuracy and clarity are paramount. For healthcare providers and billing professionals, understanding the nuances of each service and its corresponding codes is crucial for proper reimbursement and compliance. One such service that requires careful attention is Advance Care Planning (ACP). But What Is Advance Care Planning In Medical Coding, and why is it important?
This guide will delve into the specifics of ACP within the medical coding framework, particularly focusing on Medicare guidelines and CPT codes. We aim to provide a comprehensive understanding that goes beyond the basics, ensuring you have the knowledge to accurately code and bill for these vital patient-centered discussions.
Understanding Advance Care Planning (ACP) in Healthcare
Advance Care Planning is a voluntary consultation between a healthcare professional and a patient (along with family members or surrogates, when appropriate). The core purpose of ACP is to discuss and document a patient’s wishes for their future healthcare, especially in situations where they might become unable to make their own decisions. This proactive approach ensures that patient autonomy is respected and that care aligns with their values and preferences, even in challenging medical circumstances.
ACP conversations often revolve around:
- Advance Directives: These are legal documents, such as living wills and durable power of attorney for healthcare, that allow patients to express their wishes and appoint a healthcare agent to make decisions on their behalf.
- Goals of Care: Exploring what is most important to the patient in terms of their health and well-being, including preferences for different types of medical treatment.
- End-of-Life Care: Discussing wishes related to palliative care, hospice, and treatment limitations in the face of serious illness.
Key Components of ACP in Medical Coding
When it comes to medical coding, ACP is specifically recognized and reimbursable under certain conditions, particularly by Medicare. Here are the key components to understand for accurate coding:
Eligible Providers
Medicare specifies which healthcare professionals can bill for ACP services. These include:
- Physicians (MD/DO): Medical Doctors and Doctors of Osteopathic Medicine.
- Nurse Practitioners (NP)
- Physician Assistants (PA)
- Clinical Nurse Specialists (CNS)
These qualified providers are authorized to independently bill Medicare for ACP services, provided they actively participate and meaningfully contribute to the discussion, offering at least direct supervision. While other team members like social workers or chaplains may contribute to ACP under the physician’s management, they cannot independently bill using ACP codes.
Covered Settings
ACP services are versatile and can be delivered in various healthcare settings. You can report ACP codes when services are provided in:
- Office settings
- Hospitals
- Skilled Nursing Facilities (SNF)
- Patient’s Home
- Via Telehealth: Following specific Centers for Medicare & Medicaid Services (CMS) guidelines for telehealth at the time of service.
It’s essential to include the correct Place of Service (POS) code when reporting ACP services to ensure accurate billing.
CPT Codes for Advance Care Planning
The Current Procedural Terminology (CPT) codes specifically designated for Advance Care Planning are time-based and include:
- 99497 – Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 16 to 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. This is the primary code for the initial period of ACP discussion.
- 99498 – Advance care planning including the explanation and discussion of advance directives, such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure). This is an add-on code used for each additional 30 minutes of ACP discussion beyond the initial 30 minutes.
It’s crucial to note the time-based nature of these codes. Providers should consult CPT guidelines regarding minimum time requirements. If the minimum time isn’t met for code 99497, an Evaluation and Management (E/M) service code might be more appropriate, provided the requirements for that E/M service are met. Critically, no other active patient management should be undertaken during the time reported for ACP codes.
Medicare Guidelines for ACP Coding and Reimbursement
Medicare recognizes the value of ACP and offers reimbursement under specific conditions. Here’s a breakdown of Medicare’s guidelines:
ACP as Part of a Wellness Visit or Separate Service
Medicare pays for ACP in two primary ways:
- Optional element of a Medical Wellness Visit (MWV): This includes the Annual Wellness Visit (AWV). When ACP is provided as part of an MWV, it can often be covered with waived cost-sharing.
- Separate Medicare Part B medically necessary service: ACP can be billed independently as a medically necessary service under Part B, subject to standard deductible and coinsurance.
Cost-Sharing, Deductibles, and Coinsurance
When ACP is delivered outside of a Medical Wellness Visit, patients are generally responsible for Part B cost-sharing, including deductibles and coinsurance. However, Medicare waives these costs when ACP is:
- Delivered on the same day as a covered MWV (HCPCS codes G0438 or G0439)
- Offered by the same provider as the MWV
- Billed with modifier -33 (Preventive Services)
Even if a Medicare Wellness Visit is denied due to frequency limits, ACP services provided on the same day can still be paid as a separate Part B service, although in this case, the deductible and coinsurance would apply.
Billing Limitations and Special Cases
- Hospice Patients: ACP can be billed under Part B for patients receiving hospice benefits, but only if the practitioner is not employed by the hospice agency. Hospice-employed or contracted physicians should bill ACP under specific hospice claim types (Type of Bill 081x or 082x).
- Frequency: There is no strict limit on how often ACP can be billed for a patient. However, if billed more than once, documentation must justify the medical necessity by demonstrating a change in the patient’s health status or wishes regarding end-of-life care.
- Same-Day E/M Services: CPT codes 99497 and 99498 should not be billed on the same date of service as certain high-intensity E/M services (e.g., critical care, intensive neonatal/pediatric care, and hospital discharge day management). However, ACP codes can be reported with most other E/M services (like office visits, hospital visits, consultations, emergency department visits, and nursing facility care) when appropriately appended with modifier -25, signifying a separately identifiable E/M service.
Critical Access Hospitals (CAHs) and Federally Qualified Health Centers (FQHCs)/Rural Health Clinics (RHCs)
- CAHs: May bill ACP services using specific type of bill codes (85X) and revenue codes (96X, 97X, 98X). Payment is based on the lesser of the actual charge or the facility-specific Medicare Physician Fee Schedule.
- FQHCs/RHCs: ACP services are typically included in their all-inclusive rate or prospective payment system (PPS) and are considered part of bundled services.
Documentation and Diagnosis Coding for ACP
Accurate documentation is essential for compliant ACP coding and billing. At a minimum, documentation must include:
- Content and Medical Necessity: Clearly describe the topics discussed during the ACP session and the medical reason for the discussion.
- Voluntary Nature: Document that the ACP discussion was voluntary and agreed upon by the patient, family, or surrogate.
- Advance Directives: Note the content of any advance directives discussed and whether any forms were completed.
- Participants: Record the names of all individuals who participated in the ACP discussion.
- Time: Document the total face-to-face time spent in the ACP conversation. Best practice is to include both the start and end times.
For diagnosis coding, the primary condition for which the patient receives counseling during ACP should be coded using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). When ACP is part of a Medical Wellness Visit, an administrative examination or well exam diagnosis code is appropriate.
Conclusion: Ensuring Accurate ACP Medical Coding
Understanding what advance care planning is in medical coding is more than just knowing the CPT codes. It requires a grasp of Medicare guidelines, eligible providers, appropriate settings, documentation requirements, and the nuances of billing in different healthcare environments. By mastering these elements, healthcare providers and coding professionals can ensure they are accurately capturing and billing for these critical patient-centered services. This not only supports the financial health of healthcare practices but also reinforces the importance of patient autonomy and proactive healthcare discussions.
