Advance Care Planning (ACP) is a crucial service that allows patients to discuss their healthcare wishes in case they become unable to make decisions for themselves. This process involves face-to-face conversations between a Medicare physician or other qualified healthcare professional, the patient, and their family member(s) or surrogate. Understanding the Advance Care Planning Coding Guidelines is essential for healthcare providers to ensure accurate billing and compliance with Medicare regulations. This guide provides a detailed overview of these guidelines, ensuring you have the knowledge to properly code and bill for ACP services.
Who Can Provide and Bill for Advance Care Planning Services?
Medicare Part B outlines specific qualified providers who can furnish and bill for ACP services. These include:
- Physicians (MD/DO)
- Nurse Practitioners (NP)
- Physician Assistants (PA)
- Clinical Nurse Specialists (CNS)
It’s important to note that while other team members can participate in ACP discussions, the billing for these services under CPT codes 99497 and 99498 is restricted to the qualified professionals listed above. The billing physician or qualified provider must actively participate and contribute meaningfully to the ACP service, providing at least direct supervision. Standard physician fee schedule rules for “incident to” services are applicable. Professionals like social workers, psychologists, and chaplains cannot independently report ACP codes.
Where Can Advance Care Planning Services Be Provided?
ACP services are versatile and can be delivered across various healthcare settings. These include both facility and non-facility locations, such as:
- Physician Offices
- Hospitals
- Skilled Nursing Facilities (SNF)
- Patient Homes
- Via Telehealth (following specific CMS guidelines)
When reporting ACP services, it is mandatory to include the appropriate Place of Service (POS) code to reflect where the service was rendered. ACP services are not restricted to any particular medical specialty, making them broadly applicable across healthcare.
Advance Care Planning for Hospice Patients
For patients receiving hospice benefits, there are specific guidelines for ACP billing. If the practitioner providing ACP services is not employed by the hospice agency, they can bill under Medicare Part B. However, if the physician is employed by the hospice or under arrangement with the hospice, ACP services should be billed under Type of Bill 081x or 082x. This distinction is critical for correct billing in hospice care settings.
Frequency of Advance Care Planning Services
Medicare does not impose a limit on how often ACP services can be reported for a patient. This acknowledges that a patient’s health status and end-of-life care wishes can evolve. Therefore, ACP can be billed multiple times for a patient within a year if there is a documented change in their health condition or preferences. Conversely, some patients might not require ACP services at all within a year. The key is to provide ACP when it is beneficial and aligns with the patient’s needs.
Voluntary Agreement and Documentation for ACP
The initiation of Voluntary ACP must be based on an agreement with the patient, a family member, or a surrogate decision-maker. This agreement is not just a formality; it must be documented within the patient’s medical record, emphasizing the voluntary nature of the service.
Medicare Payment Structure for Advance Care Planning
Medicare covers ACP in two primary ways:
- As an optional component of a Medical Wellness Visit (MWV), which includes the Annual Wellness Visit (AWV).
- As a separate, medically necessary Medicare Part B service.
This dual pathway allows for flexibility in incorporating ACP into patient care, either as part of routine wellness checks or as a standalone service when needed.
CPT Codes for Advance Care Planning: 99497 and 99498
The Current Procedural Terminology (CPT) codes for reporting ACP services are time-based, reflecting the duration of the face-to-face discussion.
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CPT Code 99497: Used for the first 16 to 30 minutes of advance care planning, including the explanation and discussion of advance directives, such as standard forms, and completion of these forms when performed. This code is for the initial time block spent with the patient, family, and/or surrogate by a physician or other qualified healthcare professional.
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CPT Code 99498: This is an add-on code, used for each additional 30 minutes of ACP beyond the initial 30 minutes (reported with 99497). 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 minimum time threshold for 99497 or 99498 is not met, practitioners should consider billing an appropriate Evaluation and Management (E/M) service, provided the criteria for that E/M service are satisfied. Crucially, no other active management of the patient’s health problems should be undertaken during the time accounted for when ACP codes are billed.
Cost Sharing for Patients Receiving ACP Services
When ACP services are provided outside of a Medical Wellness Visit, patients should be informed that standard Part B cost-sharing, including deductibles and coinsurance, will apply.
However, Medicare waives 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 (once per year), Medicare may still cover ACP as a separate Part B medically necessary service, although in such cases, the deductible and coinsurance will apply to the ACP service.
Essential Documentation Requirements for Advance Care Planning
Thorough documentation is paramount for compliant ACP billing. 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, including completion of forms if done.
- Names of all participants in the discussion (patient, family, surrogate, providers).
- The total time spent in the face-to-face encounter.
Best practice dictates documenting the start and end times of the ACP conversation to substantiate the time-based coding accurately.
Diagnosis Coding for Advance Care Planning
The appropriate diagnosis code(s) should reflect the condition(s) for which the patient is receiving counseling during the ACP session, according to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). When ACP is part of a Medical Wellness Visit, the diagnosis code should indicate an administrative examination or a well exam.
CPT Coding and E/M Services: What to Avoid and What is Permitted
It’s important to understand the relationship between ACP codes (99497, 99498) and Evaluation and Management (E/M) codes.
Do Not Report ACP Codes (99497-99498) on the Same Date of Service As:
- Critical Care Services (99291-99292)
- Neonatal and Pediatric Critical Care (99468-99469, 99471-99472)
- Intensive Care Services (99475-99480)
- Initial Inpatient Prolonged Services (99483)
ACP Codes (99497 and 99498) Can Be Reported on the Same Day or Different Day As Most Other E/M Services, Including:
- Office or Other Outpatient Services (99201-99215)
- Hospital Observation Services (99217-99226)
- Hospital Inpatient Services (99231-99236, 99238-99239)
- Consultations (99241-99245, 99251-99255)
- Emergency Department Services (99281-99285)
- Nursing Facility Services (99304-99310, 99315-99316, 99318)
- Domiciliary/Rest Home Visits (99324-99328, 99334-99337)
- Home Visits (99341-99345, 99347-99350)
- Preventive Medicine Services (99381-99397)
- Transitional Care Management Services (99495-99496)
When reporting ACP codes on the same date of service as the E/M codes listed above, modifier -25 should be appended to the E/M code, provided the requirements for using modifier -25 are met, indicating a separately identifiable E/M service.
Special Considerations for Critical Access Hospitals (CAHs) and Federally Qualified Health Centers/Rural Health Clinics (FQHCs/RHCs)
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Critical Access Hospitals (CAHs): CAHs can bill ACP services using type of bill 85X with revenue codes 96X, 97X, and 98X. Medicare payment for CAHs under Method II is based on the lesser of the actual charge or the facility-specific Medicare Physician Fee Schedule (PFS).
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Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs): ACP provision by FQHCs and RHCs is reimbursed under a special all-inclusive rate or Prospective Payment System (PPS), where ACP services are considered part of the bundled services.
By understanding and adhering to these advance care planning coding guidelines, healthcare providers can ensure they are accurately billing for these vital services, facilitating important conversations that empower patients to direct their future healthcare decisions. Accurate coding not only ensures proper reimbursement but also supports the continued provision of these patient-centered services.
