Local Coverage Article Billing and Coding

Billing and Coding: Advance Care Planning

A58664

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General Information

Article ID
A58664
Article Title
Billing and Coding: Advance Care Planning
Article Type
Billing and Coding
Original Effective Date
12/05/2021
Revision Effective Date
N/A
Revision Ending Date
N/A
Retirement Date
N/A
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Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

42 CFR 419.22(t) addresses annual wellness visits providing personalized prevention plan services.

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §280.5.1 Advance Care Planning (ACP) Furnished as an Optional Element with an Annual Wellness Visit (AWV) Upon Agreement with the Patient

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 18, §140.8 Advance Care Planning (ACP) as an Optional Element of an Annual Wellness Visit (AWV)

Federal Register, Vol. 80, No. 220, dated Monday, November 16, 2015, pages 70955-70959

Novitas 2017 Evaluation and Management (E/M) Service: Face-to-Face Documentation

Medicare Learning Network Matters®Article: MM9271/CR9271/R216BP and R3428CP

MLN Fact Sheet-Advance Care Planning: ICN MLN909289 October 2020

Frequently Asked Questions about Billing the Physician Fee Schedule for Advance Care Planning Services, July 14, 2016

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Advance Care Planning L38970.

Voluntary Advance Care Planning (ACP) is a face-to-face service between a Medicare physician (or other qualified health care professional) and a patient and/or family member(s), and/or surrogate to discuss the patient’s health care wishes if they become unable to make decisions about their care.

A surrogate is defined as a healthcare agent, designated decision maker, family member, or caregiver.

If a patient is unable to be present, ACP documentation must reflect the reason why the patient is unable to participate.

Qualified providers, defined under Medicare Part B, include physicians (MD/DO), Nurse Practitioners and Physician Assistants, and Clinical Nurse Specialists.

Other team members may participate in the provision of ACP under the order and medical management of the beneficiary’s treating physician. 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 other qualified providers, 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 and 99498. ACP services are the provenance of patients and physicians. The billing physician or qualified provider must participate and meaningfully contribute to the provision of ACP, in addition to providing a minimum of direct supervision. The usual physician fee schedule (PFS) payment rules regarding “incident to” services apply.

All other providers (social work, psychology, chaplains) may not report ACP codes independently.

ACP services can be provided in facility or non-facility settings. ACP codes can be reported when services are provided in any care setting including an office, hospital, skilled nursing facility (SNF), home, and via the specific Centers for Medicare and Medicaid Services (CMS) guidelines for telehealth in effect at the time of service. Place of service (POS) must be included when reporting ACP services.

ACP services are not limited to a particular specialty.

For patients receiving hospice benefits, ACP services can be billed under Medicare Part B, only if the practitioner is not employed by the hospice agency; otherwise the ACP services would be considered included under the Medicare Part A hospice benefit.

There is no limit on the number of times that ACP services can be reported for a given patient in a given time period. However, if these services are billed more than once, a change in the patient’s health status and/or wishes about end-of-life care must be documented. Some people may need ACP multiple times in a year if they are quite ill and/or their circumstances change. Others may not need the service at all in a year.

Voluntary ACP can be offered upon agreement with the patient, family member or surrogate. That agreement must be documented in the medical record.

Medicare pays for ACP as either:

  • An optional element of a Medical Wellness Visit (MWV), which includes the Annual Wellness Visit (AWV) or the Initial Preventive Physical Examination (IPPE); or
  • A separate Medicare Part B medically necessary service

CPT® codes 99497 and 99498 are time based codes (a base code and an add-on code). Practitioners should consult CPT® provisions regarding minimum time required to report timed services. Use CPT® code 99497 for the first 16 to 30 minutes. Use CPT® code 99498 for each additional 30 minutes. If the required minimum time is not spent with the patient, family member(s) and/or surrogate to bill CPT® codes 99497 or 99498, the practitioner may consider billing a different evaluation and management (E/M) service provided the requirements for billing the other E/M service are met. No other active management of the patient’s problems should be undertaken for the time period reported when ACP codes are used.

When a patient gets ACP services outside of MWV, the patient should be told that the Part B cost sharing (deductible and coinsurance) applies.

Medicare waives the ACP coinsurance and the Part B deductible when the ACP is:

  • Delivered on the same day as a covered MWV (HCPCS codes G0438 or G0439)
  • Offered by the same provider as a covered MWV
  • Billed with modifier –33 (Preventive Services)

If Medicare denies the MWV for exceeding the once-per-year limit, Medicare can still make the ACP payment as a separate Medicare Part B medically necessary service. In that case, Medicare applies the deductible and coinsurance to the ACP service.

Documentation:

At a minimum, and as noted above, appropriate documentation must include the content and the medical necessity of the ACP related discussion, the voluntary nature of the encounter, the content of any advance directives (along with completion of advance directive forms, when performed), the names of participants in the discussion; and the time spent in the face-to-face encounter. Best practice for the time documentation is to include the start and end time of the face-to-face conversation.

Diagnosis Coding:

The condition(s) for which the patient receives counseling in the course of ACP should be coded per the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD 10-CM). When part of an MWV, the code should report an administrative examination or a well exam diagnosis.

CPT® Coding:

Hospitals, physicians or non-physician practitioners (NPP) may bill ACP services, if the practice scope and Medicare benefit category include the services described below.

CPT® code 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 care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate

CPT® code 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 care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

CPT® codes 99497-99498 should not be reported by the same physician/qualified health provider on the same date of service as the following E/M services: 99291-99292, 99468-99469, 99471-99472, 99475-99480 and 99483.

CPT® instructions note that 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.

These codes may be separately reported when performed on the same date of service in conjunction with the following E/M services: 99201-99215, 99217-99226, 99231-99236, 99238-99239, 99241-99245, 99251-99255, 99281-99285, 99304-99310, 99315-99316, 99318, 99324-99328, 99334-99337, 99341-99345, 99347-99350, 99381-99397, and 99495-99496. Both codes should be reported with modifier-25 added presuming the requirements for use of modifier-25 are met.

Note: Critical Access Hospitals (CAHs) may bill ACP services using type of bill 85X with revenue codes 96X, 97X, and 98X. Medicare bases the CAH Method II payment on the lesser of the actual charge or the facility-specific Medicare PFS.

ACP provision by Federally Qualified Health Centers and Rural Health Clinics are paid under a special all-inclusive rate or prospective payment system (PPS), in which ACP is part of the bundled services.

Coding Information

CPT/HCPCS Codes

Group 1

(2 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
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 CARE PROFESSIONAL; FIRST 30 MINUTES, FACE-TO-FACE WITH THE PATIENT, FAMILY MEMBER(S), AND/OR SURROGATE
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 CARE PROFESSIONAL; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

No specific diagnosis is required for the ACP codes to be billed. An ICD-10 code pertaining to the condition for which counseling is being provided, or to reflect an administrative examination, or a well exam diagnosis when furnished as part of the AWV.

Group 1 Codes

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

N/A

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Other Coding Information

N/A

Revision History Information

N/A

Associated Documents

Related Local Coverage Documents
LCDs
L38970 - Advance Care Planning
Related National Coverage Documents
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
10/11/2021 12/05/2021 - N/A Currently in Effect You are here

Keywords

  • Care Planning
  • ACP