General Surgery Coding Alert

Two new HCPCS codes could change how you bill ACP.

The Centers for Medicare & Medicaid Services (CMS) proposed rule for the 2027 Medicare Physician Fee Schedule (MPFS) has indicated that advance care planning (ACP) coding could be getting a long-awaited update. CMS has proposed two new HCPCS codes that would separately recognize ACP services provided by clinical staff under direct supervision, creating a clearer distinction between work performed by the billing practitioner and work performed by support staff.

At the same time, CMS proposes limiting CPT^®’s ACP codes (99497 and +99498) to time personally furnished by the billing practitioner. These changes could have important implications for documentation, reporting, and reimbursement of ACP services.

Read on to learn more about the proposed changes coming your way.

Understand Advance Care Planning

ACP involves dedicated one-on-one time between a physician or other qualified healthcare professional (QHP) and a patient, family member, or surrogate to discuss advance directives and end-of-life care preferences. A key component of ACP is the use of advance directives, which document a patient’s wishes regarding future medical care. These directives may take the form of a living will, a durable power of attorney for healthcare, or a do not resuscitate (DNR) order. Because requirements vary across jurisdictions, the documents must be drafted in accordance with state-specific laws.

The goal is to help patients make informed decisions about the medical treatment and support they would like to receive if they become unable to communicate those wishes themselves.

These ACP conversations often involve sensitive topics and complex healthcare decisions. Family physicians are particularly well suited to lead these discussions due to their ongoing relationships with patients. Depending on state requirements, other QHPs may also provide ACP services, including nurse practitioners, physician assistants, and clinical nurse specialists.

How Is Coding ACP Changing?

Currently, codes 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) and +99498 (…each additional 30 minutes (List separately in addition to code for primary procedure) generally represent ACP furnished by the physician or another QHP, although CMS has historically allowed a team-based approach that can involve clinical staff working under the practitioner’s direction.

Currently, however, this coding structure does not clearly distinguish between time personally spent by the billing practitioner and time spent with the patient by clinical staff. This can create ambiguity in how ACP work is valued.

Under the new proposal, CMS would like to create two new HCPCS codes specifically for ACP services furnished by clinical staff working under the direct supervision of the billing physician or practitioner only. This means that codes 99497 and +99498 would be reserved only for time personally spent with the patient by the billing practitioner.

Doing so will create a clearer separation between practitioner-performed ACP, reported with 99497/+99498, and clinical staff-performed ACP using the new HCPCS codes.

The proposed new HCPCS codes are:

• GACP1 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), first 20 minutes of clinical staff time with the patient, family member(s), surrogate directed by a treating physician or other treating qualified health care professional) and
• GACP2 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), each additional 20 minutes with the patient, family member(s), surrogate directed by a treating physician or other treating qualified health care professional (List separately in addition to code for primary procedure)).

Know How to Document Time for Existing and Proposed Codes

Currently, code 99497 has the following criteria:

• Must be provided by the physician or another QHP
• Must be accompanied by an explanation/discussion of advance directives with standard forms
• The first 30 minutes must be spent face-to-face with the patient, family members, or a surrogate with a minimum of 16 minutes being documented in the notes.

Add-on code +99498 has the following criteria:

• You must list +99498 separately and in addition to the primary procedure code.
• You can only use +99498 for each additional 30 minutes spent face-to-face with the patient, family members, or a surrogate with a minimum of 16 minutes past the first 30 minutes documented in the notes.

You would use the proposed new code GACP1 for the first 20 minutes of time spent with a patient, which would mean a relative value unit (RVU) of 1.00; while you would use GACP2 for each additional 20 minutes spent with a patient, which would mean an RVU of 0.7.

Make note: The new proposed codes would allow practices to bill and be reimbursed for the crucial, time-consuming explanations, form-filling, and guidance handled by clinical staff — not just by the supervising doctor.

Prepare for the Next Steps

Under the proposal, you could report the new HCPCS G codes alongside 99497 and +99498 when separate time thresholds are met by clinical staff and the billing practitioner. To bill either the existing or proposed ACP codes incident to a practitioner’s services, the practitioner must first furnish a qualifying professional service, such as an E/M visit or ACP service performed personally on the same day. According to the Medicare Benefit Policy Manual, Chapter 15, Section. 60.1.B, “[s]uch a service or supply could be considered to be incident to when furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflect his/her active participation in and management of the course of treatment.” CMS is also seeking feedback on whether a single code representing combined practitioner and staff time would be more appropriate.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC