The Medicare Advance Care Planning Benefit

The Medicare Advance Care Planning Benefit

Since Jan. 1, Medicare covers advance care planning (ACP) as a separate service when provided by physicians and other health professionals (such as nurse practitioners who bill Medicare using the physician fee schedule). The Centers for Medicare & Medicaid Services (CMS) enacted the new coverage as part of the 2016 Physician Fee Schedule Final Rule.
ACP is a face-to-face service that, as described by the AMA (CPT Assistant, Dec. 2014), “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.” The services include counseling and discussion of an advance directive, defined in CPT® as, “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.”
Per CMS, ACP may be reported, “when the described service is reasonable and necessary for the diagnosis or treatment of illness or injury.” The Final Rule provides one such example:

For example, this could occur in conjunction with the management or treatment of a patient’s current condition, such as a 68 year old male with heart failure and diabetes on multiple medications seen by his physician for the E/M of these two diseases, including adjusting medications as appropriate. In addition to discussing the patient’s short-term treatment options, the patient may express interest in discussing long-term treatment options and planning, such as the possibility of a heart transplant if his congestive heart failure worsens and advance care planning including the patient’s desire for care and treatment if he suffers a health event that adversely affects his decision-making capacity. In this case the physician would report a standard E/M code for the E/M service and one or both of the ACP codes depending upon the duration of the ACP service. However the ACP service as described in this example would not necessarily have to occur on the same day as the E/M service.

CPT Assistant (December 2014) specifies additional circumstances under which ACP may warranted:

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.

The AMA introduced two new advance care planning codes 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). You should report only one unit of 99497, per date of service. Code 99498 reports each additional 30-minutes of service, beyond the initial 30 minutes (at least 16 minutes must pass beyond the initial 30 minutes to report 99498). For example, for 35 minutes of face-to-face ACP, proper coding is 99497; for 57 minutes of face-to-face advance care planning, proper coding is 99497, 99498 (in addition to the primary E/M service code).
Advance care planning may be provided and reported on the same day, or a different day, as other E/M 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. Medicare also allows adding ACP as an optional element, at the beneficiary’s discretion, of the Medicare Annual Wellness Exam. 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.
Medicare payment for ACP is approximately $85 for the first 30 minutes, and $70 for each additional 30 minutes (based on 2016 Relative Value Units, before applying geographic pricing differentials).

John Verhovshek
Latest posts by John Verhovshek (see all)

About Has 606 Posts

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering 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.

9 Responses to “The Medicare Advance Care Planning Benefit”

  1. Dawn Givens says:

    Does total time spent need to be 30 minutes to bill for 99497?

  2. susan says:

    So far any of the ACP that where billed in conjunction with an inpatient stay have been denied, I keep getting a denial stating “provided in the wrong location” although it is billed out as inpatient (99221-99223; 99232-99233)

  3. Jake Harry says:

    Thank you so much for your blog.It really gives me best medical software about information that I am looking. I will come to look for new update. Keep up the very good work.

  4. H. Bhatt says:

    Regarding total time spent, the time consideration for ACP codes is as per CPT’s rule related to time based codes – total time is obtained when the time spent goes past the midpoint meaning if a code requires 30 minutes, total time is reached when the services are provided 16 minutes or more….

  5. Ranjith Murugiah says:

    How to bill procedure code 99232 with ACP

  6. Michelle Wing says:

    Patient is there for a face-to-face visit with provider at a facility. Provider spent time with patient, but patient is not mentally capable of completing decision. Provider gets patient’s POA on the phone to complete the questions regarding POLST. Does this count as “30 minutes face-to-face” when provider is with patient, but needs to call medical POA on the phone?

  7. Rob P says:

    How often can you bill for ACP? Can this be billed “Monthly” if discussed and documented?

  8. MIriah says:

    Does anyone know if time from short ACP conversations on multiple days can be combined to bill ONE 99497? I am not finding any information that says that would be incorrect. Any insight would be extremely helpful. Thanks!!

  9. Paula Burke says:

    Their are a few of us where I work who are having a dilemma I hope someone can help us with. Some are saying if a provider in the facility bills 99497/98, all other visit codes billed by ANY provider on the same day is inclusive to the ACP. A few of us disagree. I hope someone can provide the rule from CMS/AMA to set the record straight.
    Thank you