Advance Care Planning Now a Medicare-Covered Benefit

Advance Care Planning Now a Medicare-Covered Benefit

As of Jan. 1, 2016 the Centers for Medicare and Medicaid Services (CMS) will cover advance care planning (ACP) as a separate service, when provided by physicians and other qualifying providers (e.g., nurse practitioners who bill Medicare using the physician fee schedule).

Per CPT Assistant (December 2014), “Advance care planning (ACP) involves learning about and considering the types of decisions that will need to be made at the time of an eventual life-ending situation and what the patient’s preferences would be regarding those decisions.” These services include, “counseling and discussing advance directives…. a document appointing an agent and/or recording the wishes of a patient pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at that time.”

Two new advance care planning codes were introduced in CPT® 2015:

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

+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)

Code 99497 describes an initial 30 minutes of the providers’ time (face-to-face with the patient, family, or surrogate, and 99498 reports additional 30-minute blocks.

CPT Assistant (December 2014) specifies:

Individuals who may need extra assistance and more skilled facilitation in making future health care decisions include: (1) individuals with end-stage chronic illness, such as congestive heart failure, renal disease, or acquired immune deficiency syndrome (AIDS); (2) individuals who, because of the timing of their illness or injury, have not been considered appropriate for ACP, such as those facing emergent and high-risk surgery, or those who experience a sudden event, such as a transient ischemic attack (TIA), and are at risk of repeated episodes; (3) individuals who have ACP needs beyond the more familiar decisions to withhold or withdraw life-sustaining treatment, such as those with early dementia or mental illness; (4) individuals who lack decision-making capacity (developmental disabilities) or authority (minors) and must rely on guardians or parents to make substitute decisions and plan for the inevitable.

You may report advance care planning separately, when performed on the same day as other, specified evaluation and management services: a list of E/M codes with which you may report 99497 and 99498 is included in the CPT® guidelines preceding the code listings. Per CPT® instruction, you should not report advanced care planning on the same date of service as 99291, 99292, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479, 99480.

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 406 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

8 Responses to “Advance Care Planning Now a Medicare-Covered Benefit”

  1. LTJ says:

    It is our understanding that this has to be done at the time of an annual wellness visit and billed with the appropriate G0438 or G0439 and is only billable once a year.

  2. Michele Hoshcar says:

    When will the MPFS reflect a reimbursement for these?

  3. Emy says:

    what diagnosis code would you use with these codes?

  4. hanan says:

    for a specialist can 99497 billed with e&m coding ?? does it need modifire

  5. johanna D says:

    ACP is part of the AWV , therefore co insurance and deductible doesn’t apply and can be done once per year. If you are doing it as part of the AWV you need MOD 33 (preventive service ).
    For specialist i am not sure if they would qualify for the measure but i know they can talk /counsel the pt about it and you wouldn’t use a MOD because is not a preventive service, co insurance and deductible applies

  6. Sandra C says:

    I would like to take a moment to discuss one small piece of Advance Care Planning billed with AWV – some physicians are billing in all four scenarios below and some only in three of the scenarios –
    What do you think?
    1. Discussion and patients states has living will – all docs billing
    2. Discussion and patient HAS LIVING WILL IN CHART – some docs billing and some not for the ACP.
    3. Discussion and patient doesn’t have one and doesn’t want one – all docs billing
    4. Discussion and patient doesn’t have one, information given etc – all docs billing

  7. Mona Prather says:

    What revenue code is accepted by Medicare? We used 510 and 983 and it was denied.

  8. ASaiz says:

    Thank you for your comment. You’ll find a lot of suggestions and better answers to your question in the Member Forums.

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