Requirements and Components for ACP

Advance care planning services should not be reported on the same date of service as critical care services (i.e., CPT codes 99291 and 99292), neonatal and pediatric critical care codes, and some intensive hospital care services.

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 (minimum of 16 minutes documented)
  
• 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 (Add on code):

• 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 code for primary procedure

Health Care Professionals Who May Furnish and Bill ACP:

• Physicians (any specialty)
  
• Clinical nurse specialist (CNS)
  
• Nurse practitioners (NPs)
  
• Physician assistants (PAs)

Non-physicians must legally be authorized and qualified to provide ACP in the state in which the services are furnished.

The AAFP’s Position on ACP

The AAFP’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 payment 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.

What You 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. The patient has no out-of-pocket responsibility for ACP that takes place during his or her Medicare Annual Wellness Visit (AWV). However, if ACP services are provided under any other circumstances, Medicare coinsurance and deductibles apply.

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

Approaches to Help Your Practice Get Started

• Identify patients and families who would qualify for ACP services
  
• Start with patients scheduled for AWV (no patient copay if offered with AWV)