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Advance Care Planning


HBMA Billing July/August 2016 Issue

Read more from the latest issue of Billing.

Advance Care Planning

Advance care planning (ACP) involves making decisions about the care one wants to receive at the end of life. Medicare began reimbursing for ACP effective January 1, 2016, and billing professionals should work with their clients to ensure they are capturing the revenue for this important service.

Advance Directives

In most cases, ACP includes executing an advance directive, which is a legal form that spells out the patient's wishes. There are two general categories of advance directives:

  • A living will contains instructions for caregivers, such as whether or not the patient wants mechanical ventilation or tube feedings.
  • A healthcare power of attorney, also called a durable medical power of attorney, appoints someone to make treatment decisions for the patient if he becomes incapacitated.

Some advance directive forms combine a living will (instructions about care) with a healthcare power of attorney (appointment of a proxy decision-maker).

Requirements for advance directives vary from state to state and it is important for healthcare providers to be familiar with their state's laws. Downloadable advance directive forms for each state can be found on the AARP website at:

Advance Care Planning Codes

Advance directives can be executed without the participation of a physician or nonphysician practitioner (NPP). For example, senior centers and agencies on aging often provide free advance directive workshops. However, a physician or practitioner can provide valuable assistance with advance care planning, particularly when there are complex medical factors to consider, as in the case of persons with end-stage chronic illness, developmental disabilities, early dementia, or mental illness.

Advance care planning is reported with the following CPT codes:

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 ... each additional 30 minutes (List separately in addition to code for primary procedure).

CPT coding guidelines for ACP are spelled out in the CPT manual and in the December 2014 issue of CPT Assistant. Medicare billing guidelines can be found in the following publications:

Service Time

The ACP codes are defined in terms of face-to-face time. The face-to-face encounter can involve the patient, family members, and/or surrogate decision-makers, such as the person appointed under the patient's healthcare power of attorney. If the patient is not present, the CMS FAQ document says the provider should document "that the beneficiary is impaired and unable to participate effectively and that ACP was instead conducted face-to-face with family or other legal surrogate(s)."

By CPT guidelines, a unit of time is attained when the mid-point is passed, which means that code 99497 can be reported only if the face-to-face service lasts at least 16 minutes. CMS has chosen to follow the CPT time guidelines for ACP, so 16 minutes is also the minimum time for Medicare billing. If the minimum time requirement is not met, CMS states in its FAQ document that the provider may consider billing a different evaluation and management code, assuming that the requirements for that code are met.

The CPT manual states that "no active management of the problem(s) is undertaken during the time period reported." In other words, time spent managing the patient's medical problems cannot be counted as ACP time.


Who Can Provide ACP?

Both physicians and NPPs can bill for advance care planning, and the service is not limited to a particular specialty or to a particular site of service.

ACP can be provided on an "incident to" basis as long as all of the applicable requirements are met. For example, the incident-to policy applies only to services performed in a non-institutional setting (i.e., a setting other than a hospital or nursing facility). However, the physician or NPP cannot simply hand the patient off to ancillary staff such as office nurses to complete an advance directive form. The CMS FAQ document states:


As we said in the CY 2016 FPS final rule (80 Fed. Reg. 70956), the services described by CPT codes 99497 and 99498 are appropriately provided by physicians or using a team-based approach provided by physicians, nonphysician practitioners (NPPs) and other staff under the order and medical management of the beneficiary's treating physician. . . 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. The usual PFS payment rules regarding ''incident to'' services apply, so that when the services are furnished incident to the billing physician or practitioner all applicable state law and scope of practice requirements must be met and there must be a minimum of direct supervision in addition to other incident to rules.

In other words, the physician or NPP must be involved in the advance care planning process, and this involvement must be documented in the medical record.

ACP with Other Services

By CPT guidelines, ACP can be reported on the same day as other E/M services, and CMS follows these same guidelines. For example, ACP may be reported in conjunction with an office visit, subsequent hospital care, home visit, etc.

ACP can be billed during the same service period as transitional care management or chronic care management. It can also be billed during a global surgery period. However, it may not be billed on the same date as critical care codes 99291-99292, 99468-99476, and 99477-99480.

ACP may be reported separately when it is provided on a voluntary basis on the same day as the annual wellness visit. In this situation the ACP is considered a preventive service. Modifier 33 should be applied to the ACP code, and the deductible and coinsurance will be waived for the ACP.


Documentation of ACP

The CMS FAQs state that providers should consult their Medicare Administrative Contractors regarding documentation requirements. The FAQs also state:

Examples of appropriate documentation would include an account of the discussion with the beneficiary (or family members and/or surrogate) regarding the voluntary nature of the encounter; documentation indicating the explanation of advance directives (along with completion of those forms, when performed); who was present; and the time spent in the face-to-face encounter.

Note that completion of an advance directive form is not required in order to report the ACP codes. Following the planning session, the patient may want to discuss the plan further with family members before actually completing a directive, and in this situation the physician or NPP may still bill for the ACP.

Other Guidelines

CMS has not established frequency limits for advance care planning. However, the CMS FAQs state that if the service is billed more than once, there should be "a documented change in the beneficiary's health status and/or wishes regarding his or her end-of-life care." Except when ACP is provided in conjunction with the AWV (in which case it is considered a preventive service), it must be "reasonable and necessary" in order to qualify for Medicare payment, so the physician or practitioner should document the reason why a repeat planning session was needed.

Additionally, because ACP is a voluntary service, the CMS FAQs note that the patient should have an opportunity to refuse the service. It is important to keep in mind that the ACP service involves additional out-of-pocket payments for the patient except when it is provided together with the AWV. CMS stated in the 2016 Medicare Physician Fee Schedule Final Rule that "we encourage practitioners to notify the beneficiary that Part B cost sharing will apply as it does for other physicians' services."

Healthy Revenue Stream

The rules for reporting ACP are not burdensome and the reimbursement is not trivial. Code 99497 has a Medicare national average payment of $85.93 in the office setting and $79.49 in the facility setting. By appropriately documenting the ACP service, physicians can generate a healthy revenue stream while providing a service that patients will value.

Jackie Miller, RHIA, CCS-P, CPC, is vice president of product development at Coding Strategies, Inc.

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