Wiki Advanced Care Planning-The new ACP


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The new ACP that can be done w/AWV, states that there is a 30 minute code of 99497, and each additional 30 minutes is code 99498. What are the guidelines if the physician only spends 20 minutes doing the Advanced Care Planning. I can not find any information on if the physician spends less than 30 minutes. Please help.


If the physician only spends twenty minutes you cannot use the ACP. The guidelines to use the ACP code and ACP add on code specifically state the time has to be thirty minutes or more.
Final rule, CMS is allowing ACP w/ AWV - Modifier 33

For the first 30 mins or less capture 99497
For advanced care planning beyond an initial 30 minutes capture 99498+ in addition to 99497.

In this procedure, the provider discusses and shares planning with a patient, his family, or an individual representing the patient, regarding the future health care needs of the patient. Use this code for the first 30 minutes of face to face time that the provider spends.

Clinical Responsibility
The provider discusses and shares advance care planning for up to 30 minutes with a patient, his family, or an individual representing the patient, regarding the future healthcare needs of the patient.

Annual Wellness Visit

In the final rule, CMS is allowing ACP as a voluntary, separately payable element of the Medicare
patient’s Annual Wellness Visit (AWV), at the beneficiary’s discretion. When ACP is furnished as an
optional element of the AWV as a part of the same visit with the same date of service, the CPT codes
99497 and 99498 “should be reported and will be payable in full in addition to the payment that is
made for the AWV.” ACP services provided in conjunction with the AWV should be reported with
modifier -33. There will be no Part B coinsurance or deductible since it is connected to the AWV,
which requires no cost sharing.
CMS states that the “current regulations for the AWV allow the AWV to be furnished under a team
approach by physicians or other health professionals under the physician’s direct supervision.”

CMS has not developed a national coverage determination. Individual Medicare Administrative Contractors will develop their own policies. CMS hasn’t placed frequency limits on the service, realizing that as a patient’s condition changes, the physician and patient and family may need to re-discuss these critical issues. There is not a limit on the specialty designation of the physician or NPP who provides the service. The service may be performed in an RHC or an FQHC, but those centers will be paid their all-inclusive rate for a visit, and won’t receive any additional payment. A Medicare patient will be responsible for a co-pay and deductible for the service, unless it is performed on the same day as a wellness visit, (G0438 or G0439). In that case, append modifier 33 to the ACP code and the patient will not be charged a co-pay or deductible. Document the time spent in the discussion (exclusive of other E/M services that day) in the medical record.

Every article I found states that CMS is currently working on NCD for 99497 and 99498.
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Thanks for the many golden nuggets. An ACP provider education piece is currently a project that I am putting together. Unfortunately, as many have found out, the guidance is sketchy.
I am under the impression Dx codes used are the patients problem diagnoses, e.g. COPD, ESRD, neoplasm, etc. and not the counseling codes. This is information gleaned from Codepediea, not official guidance.
I read that CMS is waiting to see how this code will be implemented by providers and MACS prior to making any more guidance official.
I am also working on an EMR template to insure salient points are addressed.
This is a great discussion and I look forward to reading other interpretations and implementations for these codes.
In our recent AACP meeting where we reviewed the updates to CPT, we were told that if the provider spends at least 16 minutes for the ACP counseling, we can use the 99497 code but if it is less, that it is included in the E/M code for the visit. Is that the case?
Per CPT Time guidance "a unit of time is attained when the mid-point is passed" (see CPT Introduction). For these new codes, if the time basis is 30 minutes, you can claim it as met once you reach 16 minutes.