Advance Care Planning FAQ
FAQ 1: What is “advance care planning”?
Using the CPT (current procedural terminology) description,
there are two codes for advance care planning (ACP).
“99497 and 99498 are used to report the face-to-face services
between a physician or other qualified health care professional and a patient,
family member or surrogate in counseling and discussing advance directives,
with or without completing relevant legal forms.”
According to the CPT manual, advance care planning involves the
explanation and discussion of advanced directives; this document appoints an
agent and/or records the wishes of the patient pertaining to his/her medical
treatment at a future time should he/she lack decisional capacity at that
time. Examples of such forms include a Health Care Proxy, Durable Power
of Attorney for healthcare, a Living Will, or Medical Order for Life Sustaining
FAQ 2: What are the values of the ACP codes?
In the final CY 2017 Physician Fee Schedule, the work RVU for
99497 is valued at 1.5 RVU’s, while the 99498 code is valued at 1.4 RVU’s; rounded,
this approximates to $54 and $50, respectively.
FAQ 3: What type of training is required to
bill for Advance Care Planning?
There is no specific training, specialty restrictions, or
quality measures a provider must satisfy to perform and bill for ACP. As
stated, an NPP can provide these services as well as part of an “Incident to”
service. However, as “Incident to” does not pertain to services provided
in the emergency department, Medicare expects the billing physician to manage,
participate and meaningfully contribute to the provision of the services in
addition to providing a minimum of direct supervision. CMS put out an FAQ
regarding this and states in their FAQ 4 that “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, non-physician practitioners (NPPs) and other staff
under the order and medical management of the beneficiary’s treating physician.
FAQ 4: Does the patient have to be present?
Not necessarily. If the patient is unable to participate
in the conversation due to medical illness or lack of capacity, the health care
provider can engage with a family member or surrogate, so long as the
discussion is face-to-face.
FAQ 5: What are the documentation requirements
for ACP? Do you need to have standard forms completed during the encounter?
CPT does not specify exact language to validate billing for
ACP. However, it would be reasonable to have some documentation
validating the medical necessity of why you are having this conversation, what
was discussed, and what decision was made. For example, was there an
immediate change in the patient’s condition that led to this discussion? Are
there features in the prior health history that increase the risk or likelihood
of further deterioration of their condition? Completion of specific forms, such
as, MOLST, DNR, Living Will, or other standard forms is not required to bill
for the service.
FAQ 6: Is there a time requirement for this
Yes. The first code, 99497, covers the first 30 minutes of
face-to-face conversation and documentation by the provider with the patient,
family member(s) and/or surrogate. In order to qualify, at least 16
minutes must be performed and documented. Should you exceed 30 minutes,
which is less likely in the ED setting, there is a second code, 99498, which
includes each additional 30 minute increments of service. However, CPT
requires that no active management of the problem(s) can be undertaken during
the time period reported.
FAQ 7: Can you use a telehealth model to bill
No, at this time, only face-to-face encounters are considered
FAQ 8: How does this code affect the E/M code
for the ED visit?
CPT allows the ACP E/M code to be billed in addition to a broad
range of other E/M service codes. For the Emergency Provider, this
service can be reported together with the Emergency Department E/Ms
(99281-99285) and all the observation codes. ACP cannot, however, be
reported with critical care services, 99291.
FAQ 9: Are there frequency limitations per year of using the ACP
No, there are no limits on the number of times ACP can be used
for a given beneficiary in a given period of time. CMS put out an
FAQ and state in their FAQ 2 that
“When the service is billed multiple times for a given
beneficiary, we would expect to see a documented change in the beneficiary’s
health status and/or wishes regarding his or her end-of-life care.” https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQ-Advance-Care-Planning.pdf
FAQ 10: Which payers accept these codes?
Advance Care Planning is a relatively new CPT code.
Therefore, technically any payer that professes to accept CPT coding
current to the date of service ought to accept these codes, unless expressly
stating otherwise or publishing other restrictions.
As of January 2016, the National Correct Coding Initiative
(NCCI) –one of the major underpinnings supporting Medicare coding-- indicated
that the ACP codes are reportable. So the status indicator for both codes
is “A”, meaning it is an active code the Medicare physician fee
schedule. As yet, there are no Medicare National Coverage
Determinations for the ACPs, so it is possible that local Medicare contractors
could make their own determinations.
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