BILLING FOR ADVANCE CARE PLANNING

What is Advance Care Planning (ACP)?

As a provider, ACP involves face-to-face time with a patient, family member, or surrogate to explain and discuss advance health care directives. Planning out future medical care allows you to understand your patient’s or your patient’s family’s wishes and other preferences should the occasion arise.

To refer your patients to fill out an advance care directive, please have them make an appointment on this page.

Advance Care Planning under Medicare

As of January 1, 2016, Medicare reimburses healthcare providers for ACP discussions with Medicare beneficiaries. Payment authorization is outlined in the November 2015 Final Rule, published by the Centers for Medicare and Medicaid Services (CMS).

See below for CPT codes.

ACP Reimbursement

CPT Code 99497

Eligible Health Care Professionals:

  • Physicians (any specialty)

  • Clinical nurse specialists (CNS)

  • Nurse practitioners (NPs)

  • Physician assistants (PAs)

❏ ACP, including the explanation and discussion of advance directives such as standard forms (with completion of such forms when performed)

❏ First 30 minutes face-to-face with the patient, family member(s), and/or surrogate (minimum of 16 minutes documented)

❏ The completion of an advance directive is NOT an overall requirement

CPT Code 99498

❏ Each additional 30 minutes face-to-face with the patient, family member(s), and/or surrogate (minimum of 16 minutes past the first 30 minutes documented)

❏ Listed separately in addition to 99497

You can bill a 99497 + 99498 if you spent AT LEAST 46 minutes total face-to-face time with a patient/surrogate/family member

 

Additional Facts about Codes 99497 & 99498

  • Must be voluntary; can be declined by patient, surrogate, or family

  • No specific diagnosis is required

  • The patient does not have to be present and can be with a surrogate and/or family

  • Can be offered in a variety of practice settings: inpatient, outpatient, nursing home, etc

  • Qualifies under telephonic/telehealth benefits

  • There is no limit to the frequency of ACP billing in a given amount of time, but documentation should support the need for multiple conversations (change in health status and/or wishes regarding goals of care)

  • May be billed on the same day or a different day as most other E/M services, except for critical care services

  • Covered under annual wellness visit (AWV) for Medicare beneficiaries