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 Treatment (MOLST).
2. What are the values of the ACP codes?
In the final CY 2023 Physician Fee Schedule, the total facility RVU for 99497 is valued at 2.23 RVUs, while the 99498 code is valued at 2.11 RVUs; rounded, this approximates to $75.57 and $71.50, respectively at a conversion factor of $33.8872.
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."
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.
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.
6. Is there a time requirement for this service?
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.
7. Can you use a telehealth model to bill for ACP?
The Advance Care Planning codes do appear in Appendix P of CPT, meaning that they may be reported via telehealth with a -95 modifier. CPT says ACP codes may be reported in addition to ED E/M codes. At least until the end of the Public Health Emergency, Medicare allows ED E/M codes to be reported via telehealth.
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.
9. Are there frequency limitations per year of using the ACP codes?
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."
10. Which payers accept these codes?
Advance Care Planning is an established 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 in 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.
Updated April 2023
The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only. The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date.
The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Specific coding or payment related issues should be directed to the payer.
For information about this FAQ/Pearl, or to provide feedback, please contact David A. McKenzie, ACEP Reimbursement Director at (469) 499-0133 or firstname.lastname@example.org.