Advanced Care Planning: CPT Codes

Providers are required to make every effort to assist beneficiaries in the completion and execution of the advanced care planning process. While the topic may seem daunting to approach, educating beneficiaries on advanced care planning (ACP) allows them the opportunity to be involved in the decision-making process. Although efforts to assist patients with this sometimes-uncomfortable topic may be challenging, the following questions may arise:

What type of documentation is needed to reflect the care that was rendered?
CPT code 99497 states that ACP includes 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 is each additional 30 minutes (list separately in addition to code for primary procedure).

Guidance 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.

The discussion should:

• Confirm and review the medical facts
• Create an environment conducive to dialogue
• Allow adequate time for the patient to express their concerns and include in the documentation
• Establish what the patient knows
• Introduce or reintroduce the advanced planning service and what it entails. (Recognize that people handle information differently depending on their educational level, ethnicity, culture, religion, socio-economic status, age and developmental level.)

Note: there are no limits on the number of times ACP can be reported for a given beneficiary in a given time period.

Documentation should:

• Confirm and review the medical facts
• Include who was present
• Include completed forms (if applicable) 
• Amount of time spent face-to-face
• Plans for the next steps (additional information, tests, treatment of symptoms, referrals)

No specific diagnosis is required for the ACP codes to be billed. It would be appropriate to report a condition for which you are counseling the beneficiary, an ICD-10 CM code to reflect an administrative examination, or a well exam diagnosis when furnished as a part of the Medicare Annual Wellness Visit (AWV).

Resource: Advance Care Planning Fact Sheet