Does your practice provide Advance Care Planning (ACP) services? If so, read on and watch the video below.

Advance Care Planning is reported with two CPT® codes from 2015. CMS gave it a status indicator of Invalid in 2015, but in 2016 changed that to an active status and began reimbursing for the service. But, even with well-established codes, practices still have questions.

Q: Can it be billed as a group service?
A: No. It is a service to an individual beneficiary and/or their family member(s) or surrogate.

Q: Does it follow the mid-point rule? Should I start to bill 99497 at 16 minutes or 30 minutes?
A: 16 minutes. There is no CPT® citation that says, “Do not report for less than 30 minutes.” And the CMS MLN Matters article has a chart that shows 16-45 minutes for 99497.

Q: What diagnosis?
A: Report the condition that you discuss with the patient or an exam code if done at a wellness visit. MLN Matters says, “You don’t need to report a specific diagnosis to bill for ACP services.”  We know they mean a particular diagnosis to establish medical necessity.

Q: How about incident to?
A: CMS’s FAQ notes, “The CPT® code descriptors describe the services as furnished by physicians or other qualified health professionals, which for Medicare purposes is consistent with allowing these codes to be billed by the physicians and NPPs whose scope of practice and Medicare benefit category include the services described by the CPT® codes and who are authorized to independently bill Medicare for those services. Therefore, only these practitioners may report CPT® codes 99497 or 99498. The ACP services described by these codes are primarily the provenance of patients and physicians; accordingly, we expect 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.”
Don’t hand off the service to a staff member unless the physician/NPP is managing, participating, and contributing to the service. Don’t count staff time.

Q: This code must have a low error rate, right?
A: The OIG found a 67% error rate in the 691 sampled ACP claims they looked at. The time spent in ACP, distinct from another service, wasn’t documented. The discussion of ACP wasn’t documented. Some patients had ACP billed 15 times in a 12-month period!

Download Slides

Additional resources

• Overview of Advance Care Planning
• Advance Care Planning | CPT® 99497, 99498 (includes link to CMS fact sheet)