Advance care planning coding: answers to common questions

What physicians and other providers need to know about advance care planning.

Question: Are there documentation requirements for Advance Care Planning (ACP)?

Answer: Practitioners are advised to consult their Medicare Administrative Contractors (MACs) regarding documentation requirements. While CMS has not issued specific requirements, it has suggested the following as examples of appropriate documentation:

  • an account of the discussion with the beneficiary (or family members and/or surrogate) regarding the voluntary nature of the encounter;
  • documentation indicating the explanation of advance directives (along with completion of those forms, when performed);
  • who was present; and
  • the time spent in the face-to-face encounter.

The CPT manual defines an advance directive as a document appointing an agent and/or recording the wishes of a patient pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at that time. Relevant legal forms include, but are not limited to, a Health Care Proxy, Durable Power of Attorney for Health Care, a Living Will and/or completion of a Medical Order for Life Sustaining Treatment (MOLST).

Q: Can I report code 99497 for advance care planning (ACP) when the time of service is 20 minutes rather than the 30 minutes listed in the code descriptor?

A: Yes, as long as the required CPT elements are performed and the payer follows CPT regulations. The CPT midpoint rule, which reads, “a unit of time is attained when the midpoint is passed,” applies to codes 99497–99498 for Medicare and other payers who follow CPT instruction.

You must document the time, and you cannot include time spent on separately-billed services (e.g., time spent toward evaluation and management (E/M) elements). Report significant, separately reportable E/M services with modifier 25 appended.

Q: Can ACP codes be billed on the same date as an annual wellness visit (G0438 or G0439)?

A: Yes, and don’t forget to append modifier 33, “Preventive service,” which will avoid out-of-pocket cost to the patient. ACP is an optional element of the Welcome to Medicare physical (G0402), so check your Medicare Part B contractor's payment policy before separately reporting 99497–99498 on the same date as G0402.

Q: Are there limitations on the place of service for the ACP codes?

A: No. ACP services may be appropriately furnished in a variety of settings depending on the needs and condition of the beneficiary, including inpatient, nursing home, physician offices. The codes are separately payable to the billing physician or practitioner in both facility and non-facility settings.

Q: Which providers can bill these codes?

A: Use of the codes is not limited to particular physician specialties. The provider billing the codes must be the patient’s “managing physician” or must be providing direct supervision to the qualified health professional conducting the ACP conversation. The codes may be billed by physicians or non-physician practitioners (NPPs) whose scope of practice includes the services described by the code and who is authorized to independently bill Medicare for these services.

Q: Who can provide the ACP service billed under these codes?

A: CMS “expects the billing physician or NPP to manage, participate and meaningfully contribute to the provision of the services, in addition to providing a minimum of direct supervision.” Standard Medicare “incident to” rules apply to these CPT codes.

Q: Can the codes be used more than once?

A: According to CPT, there are no limits on the number of times or how frequently ACP can be reported for a given beneficiary in a given time period. However, when the service is billed multiple times for a single patient, CMS expects to see documentation which supports the need for multiple conversations – such as a change in health status and/or wishes regarding care.

Q: Is there a specific diagnosis to be used?

A: No specific diagnosis is required for the ACP codes to be billed. CMS has stated that it would be appropriate to report a condition for which the provider is counseling the beneficiary, an ICD-10-CM code to reflect an administrative examination, or a well exam diagnosis when furnished as part of the Medicare Annual Wellness Visit (AWV).

Q: Can ACP services be furnished without beneficiary consent?

A: ACP services are voluntary. Therefore, Medicare beneficiaries (or their legal proxies, when applicable) should be given a clear opportunity to decline to receive ACP services.

Q: Does the patient have to be present?

A: While it is preferable that the patient be present and participating, the ACP discussion can be between the physician or NPP and the family member or surrogate.

Q: Are telephonic or telehealth conversations billable under these codes?

A: The Medicare Physician Fee Schedule for Calendar Year (CY) 2017 added the advance care planning codes to the list of services eligible to be furnished under the telehealth benefit.

Q: Can the ACP codes be used with other Evaluation and Management (E/M) codes?

A: CPT codes 99497 and 99498 may be billed on the same day or a different day as most other E/M services, and during the same service period as transitional care management services or chronic care management services and within global surgical periods.

Q: Will other payers, besides Medicare, use these codes and pay for ACP services?

A: Other payers frequently adopt Medicare billing and payment rules, but they are not required to do so.Check with your local carriers before billing these codes.

Renee Dowling is a compliance auditor for Sansum Clinic, LLC, in Santa Barbara, California.