• My Account
    • Login
  • Contact Us

CodingIntel

Medical coding resources for physicians and their staff. CodingIntel was founded by consultant and coding expert Betsy Nicoletti.

  • Join Today
  • What is CodingIntel
    • About
    • Become a Member
    • FAQ
  • Pricing
  • Free Resources
    • Overview
    • Blog
    • Everyday Coding Q&A
    • Newsletter
    • Can I get paid
  • Coding Library
    • Coding Guides
    • Quick Reference Sheets
    • E/M Services
    • How Physician Services Are Paid
    • Prevention & Screening
    • Care Management & Remote Monitoring
    • Surgery, Modifiers & Global
    • Diagnosis Coding
    • New & Newsworthy
    • Speciality
    • Practice Management
    • E/M Rules Archive
  • Webinars

September 30, 2023

Documentation for Advance Care Planning

Print Friendly, PDF & Email

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

Want unlimited access to CodingIntel's online library?

Including updates on CPT® and CMS coding changes for 2023

Join Today

Last revised June 21, 2023 - Betsy Nicoletti
Tags: care management

CPT®️️ is a registered trademark of the American Medical Association. Copyright American Medical Association. All rights reserved.

2023 E/M guidelines for hospital, nursing facility, home and residence services | Webinar

Effective January 1, 2023, the AMA has revised the definitions and guidelines for hospital and other E/M services, including ED visits, nursing facility services, home services, and domiciliary care codes. Also, coding for prolonged care services gets another overhaul with revised codes and guidelines. Watch this webinar about all these changes.

Watch it now

Latest Intel

How do we code for “meet and greet” visits?

Question: What code can I use when a patient … Read More...

E/M services: high volume, high risk | Webinar

E/M Services: high volume, high risk October 19, … Read More...

Is ChatGPT Coming to Coding?

Question: What’s all this I hear about ChatGPT? … Read More...

A Conversation with Two Auditors: Lessons learned about MDM | Webinar

A Conversation with Two Auditors: Lessons Learned … Read More...

Browse By Categories

Browse Content

  • Articles
  • Coding Guides
  • Everyday Coding Q&A
  • Videos
  • Can I Get Paid to
  • Blog
  • Webinars

Tags

behavioral health_cpt codes behavioral health_E/M services care management CMS updates Code sets and reimbursement compliance issues CPT codes for preventive services CPT updates critical care services dermatology_essential resource dermatology_procedures E/M frequency data E/M medical decision making E/M overview E/M reference sheets FQHC general surgery_diagnosis coding general surgery_E/M services general surgery_modifiers general surgery_procedures global surgery issues HCC diagnosis coding hospital inpatient/observation ICD-10 coding level of service_history level of service_MDM level of service_time medicare incident-to and shared services minor procedures modifiers newborn care Preventive and problem visits preventive services for medicare primary care_diagnosis coding primary care_E/M services primary care_essential resource primary care_modifiers primary care_other E/M services primary care_preventive services primary care_procedures prolonged care remote physiologic monitoring screening and counseling for behavioral conditions teaching physician rules telehealth

All content on CodingIntel is copyright protected. Any resource shared within the permissions granted here may not be altered in any way, and should retain all copyright information and logos.

  • What is CodingIntel
  • FAQs
  • Terms of Use
  • Privacy Policy
  • Contact

Our mission is to provide up-to-date, simplified, citation driven resources that empower our members to gain confidence and authority in their coding role.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions.

Copyright © 2023, CodingIntel
Privacy Policy