Advance Care Planning CPT^® Codes Overview

Medical practices perform countless tasks every day for which there is no payment. CMS continually states that it wants to support non-procedural and in the past decade has added payment for some non-face-to-face services, including Care Plan Oversight, Transitional Care Management and Chronic Care Management.

CPT^® Codes 99497 & 99498

99497 is for the first 30 minutes, and +99498 is an add on code, for each additional 30 minutes.

CPT^® code definitions:

99497 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; first 30 minutes, face- to-face with the patient, family member(s) and/or surrogate); and an add-on

    +99498 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; each additional 30 minutes (List separately in addition to code for primary procedure))

End of Life Planning Services

This service is a face-to-face service, but the beneficiary does not need to be present. The CPT^® code is defined as “with the patient, family member(s) and/or surrogate.” Forms may be completed, but they aren’t required. When CPT^® says “when performed” the service may be reported even if that portion of the service was not performed.

The service may be performed on the same day as an E/M service, except for adult or pediatric critical care. CPT^® describes it as being performed by a physician or “other qualified health professional” and CMS states by a physician or “non-physician practitioner” within their scope of practice. This means physician, NP or PA.

CMS has not developed a national coverage determination. Individual Medicare Administrative Contractors will develop their own policies. CMS hasn’t placed frequency limits on the service, realizing that as a patient’s condition changes, the physician and patient and family may need to re-discuss these critical issues. There is not a limit on the specialty designation of the physician or NPP who provides the service.

The service may be performed in an RHC or an FQHC, but those centers will be paid their all-inclusive rate for a visit, and won’t receive any additional payment. A Medicare patient will be responsible for a co-pay and deductible for the service, unless it is performed on the same day as a wellness visit, (G0438 or G0439). In that case, append modifier 33 to the ACP code and the patient will not be charged a co-pay or deductible.   Document the time spent in the discussion (exclusive of other E/M services that day) in the medical record.

Additional details may be found in the Advance Care Planning section of Everyday Coding.

Documentation for Advance Care Planning

Question:  How much detail do I need to include in documentation for Advance Care Planning?

Answer: Document the discussion in enough detail that someone reading the note knows what was discussed. Is that a circular argument?

Here’s the example that I give. If a surgeon performs an appendectomy, we wouldn’t bill for the service if the operative report said, “I performed an appendectomy.” We require the surgeon to document the opening, the approach, the anatomy and the operation itself. Similarly, if a physician or non-physician practitioner (NPP) says, “I discussed end of life issues with the patient for 35 minutes,” we would ask the clinician to add detail to the note. What was discussed, what decisions were made (if any were made), questions and concerns and if forms were completed or given to the patient. The completion of forms is not required.

Quick reminders about ACP

• This is a service that can is done by a physician/NPP with a patient, family member or other caregiver/surrogate
• Don’t double count the time spent in any other service, such as an office visit or inpatient visit.
• The midpoint must be met. 99497 is the first 30 minutes of discussion, and the midpoint is 16 minutes. Please don’t say that all ACP discussions are “16 minutes spent.”

Do you need more detail?  CodingIntel has a 7-minute video that you can watch.

Additional ACP and Care Management Resources

• Advanced Care Planning
• Care Management and Remote Monitoring

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