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