Advanced Care Planning and Medicare
Medicare covers advanced 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).
Advanced care planning 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.” 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 advanced 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 2017 Relative Value Units, before applying geographic pricing differentials).