Advance care planning: Billing, coding and documentation
Comprehensive guidance on providing and billing for Medicare advance care planning services.
What is advance care planning?
Definition and importance
CMS defines advance care planning (ACP) as 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. This process enables the patient to talk about the type of treatment and care they want to receive during the latter stages of life.
Who should have advance care planning discussions?
As a patient’s primary care provider, family physicians are ideally suited to facilitate what may be difficult conversations about end-of-life decisions with the patient and their family member or surrogate. Non-physician clinicians such as clinical nurse specialists, nurse practitioners and physician assistants who meet state licensing requirements also may provide ACP services.
FamilyDoctor.org: Advance directives
CPT codes for advance care planning
On January 1, 2016, CMS began paying for ACP services for traditional Medicare beneficiaries. ACP can satisfy a high-priority quality measure for reporting in the Medicare Access and CHIP Reauthorization Act (MACRA).
Advocacy efforts by the American Academy of Family Physicians (AAFP) helped pave the way for ACP payment. We supported the creation of current procedural terminology (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.
There are two CPT codes used to report and file claims for ACP services:
99497
First 30 minutes face-to-face with the patient, family member(s) and/or surrogate (minimum of 16 minutes documented)
Provided by the physician or other qualified health care professional
Advance care planning, including the explanation and discussion of advance directives such as standard forms
Completion of an advance directive is not an overall requirement for billing ACP services
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
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.
Billing guidelines and reimbursement
Medicare and private payer coverage
All traditional Medicare beneficiaries qualify for ACP services. You may determine that it is important to have end-of-life conversations 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). Physicians billing ACP on the same day as an AWV should attach modifier -33 to the ACP code. 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 providing 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.
Documentation requirements
There are specific documentation guidelines to bill for ACP services. Documentation should include:
That the patient was there voluntarily
Counseling for and explanation of an advance directive
Who was present during the encounter
The amount of face-to-face time spent discussing ACP
For additional information, contact your Medicare administrative contractor.
Advance care planning documentation
Best practices for ACP documentation
Advance directive is commonly used to describe the documents that specify the care a person wishes to have if he or she becomes unable to make medical decisions. The term generally includes a living will, a durable power of attorney for health care and “Do Not Resuscitate” orders. The language of the actual document must be consistent with the laws of the state where the patient lives.
Where to find sample forms
Bar Association of the state
A number of state-specific websites
Frequently asked questions
Who can bill for ACP?
Physicians in any specialty, and other qualified health professionals (QHPs) can bill for ACP services. QHPs include those qualified by education, training, licensure/regulation and facility privileging who perform a professional service within their scope of practice, and independently report the service. This includes non-physician practitioners such as advance practice nurses or physician assistants.
Medical assistants and registered nurses are not considered QHPs for the purposes of billing for ACP.
How often can ACP be billed?
There is no limit on the number of times or how often ACP is provided to a patient. If billed multiple times, CMS would expect to see documented changes in the beneficiary’s health status and/or wishes regarding end-of-life care.
What counts as a qualifying conversation?
Medicare considers ACP a 30-minute, face-to-face encounter. ACP cannot be provided via telephone or video. According to CPT guidelines, the time requirement for a service is met when the midway point is passed. For ACP, this would indicate that a physician should spend at least 16 minutes providing ACP. It is important to check with all payers regarding their policies on time thresholds.