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.