Advance Care Planning (ACP) is a critical aspect of patient care, allowing individuals to voice their healthcare wishes should they become unable to make decisions themselves. For hospitals and healthcare providers navigating Medicare billing, understanding the specific guidelines for ACP coding is essential. This article provides a comprehensive guide to hospital Medicare coding for Advance Care Planning, focusing on CPT codes 99497 and 99498 and ensuring accurate and compliant billing practices.
Understanding Advance Care Planning (ACP) under Medicare
Voluntary Advance Care Planning is defined as a face-to-face service. This crucial interaction involves a Medicare physician or another qualified healthcare professional engaging with a patient, their family members, and/or a surrogate decision-maker. The core purpose is to discuss the patient’s healthcare preferences and wishes in anticipation of potential future scenarios where they might lack the capacity to make informed decisions about their medical care.
A surrogate in this context can be a healthcare agent, a designated decision-maker, a family member, or a caregiver, ensuring that the patient’s voice is represented even when they cannot directly participate.
In situations where the patient is unable to be present during the ACP discussion, it is imperative that the ACP documentation clearly states the reason for the patient’s absence. This ensures transparency and adherence to Medicare guidelines.
Who Can Provide and Bill for ACP Services in Hospitals?
Within the Medicare Part B framework, specific healthcare professionals are qualified to provide and bill for ACP services. These include physicians (both MD and DO), Nurse Practitioners (NPs), Physician Assistants (PAs), and Clinical Nurse Specialists (CNSs). These professionals are recognized by Medicare as authorized providers for these services.
While other members of the healthcare team, such as social workers or chaplains, may contribute to the ACP process, they do so under the order and medical management of the patient’s treating physician. It’s important to note that CPT codes 99497 and 99498, which are used to bill for ACP services, can only be reported by physicians and the other qualified healthcare professionals listed above. These are practitioners whose scope of practice and Medicare benefit category encompass ACP services and who are independently authorized to bill Medicare. Therefore, auxiliary staff cannot independently bill for ACP services. The billing physician or qualified provider must be actively involved and contribute meaningfully to the ACP provision, including providing direct supervision. Standard physician fee schedule (PFS) rules regarding “incident to” services are applicable.
Where Can ACP Services Be Provided in Hospital Settings?
ACP services under Medicare are versatile and can be delivered across various healthcare settings, including within hospital facilities. These settings include not only typical office environments but also hospitals themselves, skilled nursing facilities (SNFs), patients’ homes, and even via telehealth, adhering to the specific Centers for Medicare and Medicaid Services (CMS) guidelines effective at the time of service. When billing for ACP services, it is mandatory to include the appropriate Place of Service (POS) code to accurately reflect where the service was rendered.
It’s also important to note that ACP services are not restricted to any particular medical specialty. This ensures that patients can receive these vital services regardless of their primary diagnosis or the department within the hospital providing care.
Medicare Billing and Coding Specifics for Hospital ACP Services
For patients in hospitals who are also receiving hospice benefits, there are specific billing rules for ACP services. If the practitioner providing ACP is not employed by the hospice agency, these services can be billed under Medicare Part B. However, if the ACP services are performed by physicians employed by the hospice or under arrangement with the hospice, the billing must occur under Type of Bill 081x or 082x. This distinction is critical for correct hospital billing practices.
Medicare does not impose a limit on how frequently ACP services can be reported for a patient. This is particularly relevant in hospital settings where a patient’s condition can change rapidly. If ACP services are billed more than once for a patient, it is crucial to document a change in the patient’s health status or their end-of-life care wishes. The frequency of ACP should be based on patient need, with some patients requiring multiple sessions in a year due to illness or changing circumstances, while others may not need it annually.
Voluntary ACP must be offered and provided only with the agreement of the patient, family member, or surrogate. This agreement must be formally documented in the patient’s medical record to ensure compliance and transparency.
Medicare covers ACP in two primary ways:
- As an optional, additional component of a Medical Wellness Visit (MWV), which includes the Annual Wellness Visit (AWV).
- As a separate, medically necessary service under Medicare Part B.
CPT codes 99497 and 99498 are the designated time-based codes for billing ACP services. Code 99497 is used for the first 16 to 30 minutes of ACP, while add-on code 99498 is used for each additional 30 minutes increment. Healthcare providers should consult CPT guidelines for the minimum time requirements to accurately report these timed services. If the minimum time threshold for 99497 or 99498 is not met, practitioners may consider billing a different Evaluation and Management (E/M) service, provided that the requirements for that specific E/M service are fulfilled. It’s important to note that no other active patient problem management should be undertaken during the time accounted for when ACP codes are billed.
When ACP services are provided outside of a MWV, patients should be informed that standard Part B cost-sharing, including deductibles and coinsurance, will apply.
However, Medicare waives both the coinsurance and the Part B deductible for ACP when it is:
- Delivered on the same day as a covered MWV (using HCPCS codes G0438 or G0439).
- Offered by the same provider who is also delivering the covered MWV.
- Billed with modifier -33 (Preventive Services).
Even if a MWV claim is denied due to exceeding the annual limit, Medicare may still cover the ACP service as a separate, medically necessary Part B service. In such cases, the standard deductible and coinsurance will be applied to the ACP service.
Documentation and Coding Requirements for Hospital ACP
Accurate and thorough documentation is paramount for compliant Medicare billing of ACP services in hospitals. At a minimum, documentation must include:
- The content of the ACP discussion, demonstrating medical necessity.
- Evidence that the encounter was voluntary.
- The content of any advance directives discussed, including completion of forms if performed.
- The names of all participants in the discussion (patient, family, surrogate, providers).
- The total time spent in the face-to-face encounter. Best practice includes documenting both the start and end times of the conversation.
For diagnosis coding, the specific condition(s) for which the patient is receiving counseling during ACP should be coded according to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). When ACP is part of a MWV, the diagnosis code should reflect an administrative or well exam.
For CPT coding, hospitals, physicians, and non-physician practitioners (NPPs) can bill for ACP services if their practice scope and Medicare benefit category include these services. The specific codes are:
- CPT code 99497: Advance care planning, including 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.
- CPT code 99498: Advance care planning, including 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 billed on the same date of service as certain high-intensity Evaluation and Management (E/M) services, including codes 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 (99201-99215, 99217-99226, etc.), and also during the same service period as transitional care management or chronic care management services, and even within global surgical periods. When ACP is performed on the same date of service as these other E/M services, both codes should be reported with modifier -25 appended, provided that the requirements for using modifier -25 are met.
Finally, Critical Access Hospitals (CAHs) can bill for 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 PFS rate. Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) are paid for ACP services under a special all-inclusive rate or prospective payment system (PPS), where ACP is considered part of their bundled services.
By adhering to these guidelines, hospitals can ensure accurate Medicare coding for Advance Care Planning, facilitating appropriate reimbursement and supporting the delivery of these vital patient-centered services.
