Advance Care Planning

What is Advance Care Planning (ACP)?

On January 1, 2016, the Centers for Medicare & Medicaid Services (CMS) began reimbursing for advance care planning (ACP) as a payable service for traditional Medicare beneficiaries. ACP is the face-to-face time a physician or other qualified health care professional spends with a patient, family member, or surrogate to explain and discuss advance directives. Two CPT codes are used to report ACP services: 99497 and 99498.

Requirements for CPT Code 99497

  • Advance care planning, including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed)
  • Provided by the physician or other qualified health care professional
  • First 30 minutes face-to-face with the patient, family member(s), and/or surrogate
  • As stated in the CPT code description, completion of an advance directive is only required “when performed.” It is not an overall requirement for billing ACP services.

Requirements for CPT Code 99498

  • Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed)
  • Provided by the physician or other qualified health care professional
  • Each additional 30 minutes face-to-face with the patient, family member(s), and/or surrogate
  • Listed separately in addition to code for primary procedure

The Academy’s Position on ACP

The Academy’s advocacy efforts helped pave the way for ACP payment. We supported the creation of CPT codes for ACP and applauded their inclusion in the 2016 Medicare physician fee schedule.

Medicare reimbursement for ACP gives family physicians an opportunity to be paid for the time they commit to conversations with their patients about end-of-life decisions.

On behalf of members, the Academy is continuing to advocate with private payers for full and fair reimbursement of care management services through monthly care management fees. We are also pushing private payers to make care management programs transparent to both physicians and patients.

What Members Need to Know

All traditional Medicare beneficiaries qualify for ACP services. You may determine that it is important to have conversations about end-of-life decisions with your patients and/or their caregivers annually or when a patient has a medical change in status.

Medicare Advantage and other insurance payers may reimburse for ACP (see table below). You should confirm a patient’s coverage before you provide these services. It is also important to remember that if a payer does reimburse for CPT codes 99497 and 99498, these services are subject to the insurance carrier’s billing policies like all other covered services.

Reimbursement of Advance Care Planning (CPT Codes 99497 and 99498) by Top Five Payers

Payer

Commercial Insurance

Medicare Advantage

Policy

Payer

:

Aetna

Commercial Insurance

:

Yes

Medicare Advantage

:

Yes

Policy

:

No

Payer

:

Anthem

Commercial Insurance

:

No

Medicare Advantage

:

No

Policy

:

No

Payer

:

Cigna

Commercial Insurance

:

Yes

Medicare Advantage

:

Yes

Policy

:

Yes*

Payer

:

Humana

Commercial Insurance

:

Yes

Medicare Advantage

:

Yes

Policy

:

No

Payer

:

UnitedHealthcare

Commercial Insurance

:

Yes

Medicare Advantage

:

Yes

Policy

:

No

*Per Cigna’s ACP policy, CPT codes 99497 and 99498 are only paid when a patient is terminally ill with a life expectancy of six months or less.

Payment Considerations

  • There are no place of service limitations on the use of CPT codes for ACP. CMS states: “ACP services may be appropriately furnished in a variety of settings depending on the needs and condition of the beneficiary. The codes are separately payable to the billing physician or [health care professional] in both facility and [non-facility] settings and are not limited to particular physician specialties.”
  • ACP services should not be reported on the same date of service as critical care services (i.e., CPT codes 99291 and 99292).
  • The patient has no out-of-pocket responsibility for ACP that takes place during his or her annual wellness visit. However, if ACP services are provided under any other circumstances, copays and deductibles apply.