Advance Care Planning (ACP) is a critical, voluntary service that involves a face-to-face discussion between a Medicare physician or other qualified healthcare professional, and a patient, their family members, and/or a surrogate. This discussion centers on the patient’s healthcare wishes, particularly if they become unable to make their own medical decisions in the future. Understanding the nuances of Coding For Advance Care Planning is essential for healthcare providers to ensure proper billing and reimbursement for these vital services.
A surrogate, in ACP terms, is defined broadly to include a healthcare agent, a designated decision-maker, a family member, or a caregiver. The involvement of these individuals is crucial in ACP discussions, ensuring a holistic approach to patient care planning. If a patient is unable to be present for the ACP discussion, it is imperative that the ACP documentation clearly states the reason for their absence.
Medicare Part B outlines specific qualified providers who can furnish ACP services. These include physicians (MD/DO), Nurse Practitioners, Physician Assistants, and Clinical Nurse Specialists. While other members of the healthcare team can participate in ACP provision, they must do so under the order and medical management of the patient’s treating physician. It’s important to note that CPT® codes specifically describe these services as being furnished by physicians or other qualified health professionals. For Medicare billing purposes, this limits the reporting of CPT® codes 99497 and 99498 to practitioners whose scope of practice and Medicare benefit category encompass these services, and who are authorized to independently bill Medicare. Therefore, only these practitioners can report these specific CPT® codes for coding for advance care planning. The billing physician or qualified provider must actively participate and contribute meaningfully to the ACP service, providing at least a minimum level of direct supervision. Standard physician fee schedule (PFS) payment rules regarding “incident to” services are applicable. It is crucial to understand that providers such as social workers, psychologists, and chaplains cannot independently report ACP codes.
ACP services are versatile and can be delivered across various healthcare settings, both facility and non-facility. This includes locations such as offices, hospitals, skilled nursing facilities (SNFs), and even patients’ homes. Furthermore, ACP can be provided via telehealth, adhering to the specific Centers for Medicare and Medicaid Services (CMS) guidelines that are in effect at the time of service. When coding for advance care planning, it is mandatory to include the appropriate Place of Service (POS) code on the claim. It’s also important to note that ACP services are not restricted to any particular medical specialty; they are relevant and applicable across the spectrum of healthcare.
For patients who are currently receiving hospice benefits, there are specific guidelines for coding for advance care planning. ACP services can be billed under Medicare Part B in these cases, but only if the practitioner providing the service is not employed by the hospice agency. If the physician or qualified provider is employed by the hospice or under arrangement with the hospice, the ACP services should be billed on the Type of Bill 081x or 082x.
Medicare does not place a limit on the number of times ACP services can be reported for a patient within a given timeframe. However, if ACP services are billed more than once for the same patient, it is essential to document a significant change in the patient’s health status and/or their wishes regarding end-of-life care. The frequency of ACP services is patient-specific; some individuals, particularly those with complex or changing health conditions, may require ACP multiple times within a year, while others may not need it at all.
Voluntary agreement is a cornerstone of ACP. Offering voluntary ACP requires agreement from the patient, a family member, or a surrogate, and this agreement must be clearly documented in the patient’s medical record.
Medicare reimbursement for ACP is structured in two ways:
- As an optional, additional component of a Medical Wellness Visit (MWV), which includes the Annual Wellness Visit (AWV).
- As a separate, medically necessary Medicare Part B service.
The CPT® codes used for coding for advance care planning, 99497 and 99498, are time-based. Healthcare practitioners should always refer to the CPT® guidelines to understand the minimum time requirements for reporting timed services. CPT® code 99497 is designated for the initial 16 to 30 minutes of ACP service. For each subsequent 30 minutes of service, CPT® code 99498 should be used as an add-on code. If the minimum required time is not met for either code, and the practitioner still provided a significant Evaluation and Management (E/M) service, they may consider billing for a different E/M service, provided that all the requirements for billing that specific E/M service are fulfilled. Crucially, when ACP codes are used, no other active management of the patient’s health problems should be undertaken during the time period accounted for by the ACP codes.
When a patient receives ACP services outside of a MWV, it’s important to inform them that standard Part B cost-sharing, including deductibles and coinsurance, will apply. However, Medicare waives both the ACP coinsurance and the Part B deductible under specific conditions:
- When ACP is delivered on the same day as a covered MWV (using HCPCS codes G0438 or G0439).
- When ACP is offered by the same provider who is also providing the covered MWV.
- When the ACP service is billed with modifier –33 (Preventive Services).
Even if a MWV claim is denied due to exceeding the once-per-year limit, Medicare may still process and pay for the ACP service as a separate, medically necessary Part B service. In such instances, the deductible and coinsurance will be applied to the ACP service.
Documentation is paramount for accurate coding for advance care planning. At a minimum, the documentation must include:
- The content of the ACP discussion and its medical necessity.
- The voluntary nature of the ACP encounter.
- The content of any advance directives discussed, and completion of advance directive forms, if performed.
- The names of all participants in the discussion.
- The total time spent in the face-to-face encounter.
Best practice for time documentation includes recording both the start and end times of the ACP conversation.
Diagnosis Coding for ACP should reflect the condition(s) for which the patient is receiving counseling. These codes should be selected according to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). When ACP is delivered as part of a MWV, the diagnosis code should indicate an administrative examination or a well exam.
CPT® Coding for ACP services is as follows:
- CPT® code 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 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.
- CPT® code 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).
It is critical to note that CPT® codes 99497 and 99498 should not be reported by the same physician or qualified health provider on the same date of service as certain high-intensity Evaluation and Management (E/M) services, specifically codes 99291-99292, 99468-99469, 99471-99472, 99475-99480, and 99483.
However, CPT® guidelines clarify that codes 99497 and 99498 can be billed on the same day or a different day as most other E/M services. They can also be reported within the same service period as transitional care management services or chronic care management services, and even within global surgical periods.
Specifically, ACP codes can be separately reported when performed on the same date of service in conjunction with a wide range of E/M codes, including 99201-99215, 99217-99226, 99231-99236, 99238-99239, 99241-99245, 99251-99255, 99281-99285, 99304-99310, 99315-99316, 99318, 99324-99328, 99334-99337, 99341-99345, 99347-99350, 99381-99397, and 99495-99496. When billing ACP codes with these E/M services on the same date, modifier -25 should be appended to the E/M code, provided that the requirements for using modifier -25 are met.
Critical Access Hospitals (CAHs) have specific billing procedures for ACP services. They may bill using type of bill 85X with revenue codes 96X, 97X, and 98X. Medicare bases the CAH Method II payment for ACP on the lesser of the actual charge or the facility-specific Medicare PFS rate.
Finally, for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), ACP provision is reimbursed under a special all-inclusive rate or prospective payment system (PPS), where ACP is considered part of the bundled services they provide. Understanding these specific payment models is crucial for proper financial management in these settings when coding for advance care planning.
