Coding Corner:  Advance Care Planning (ACP) | Sarah H. Kim, MD, MSCE

Sarah H. Kim, MD, MSCE

What is Medicare Advance Care Planning (ACP)?

Advance care planning (ACP) is the face-to-face time a physician or other qualified health care professional spends with a patient, family member, or surrogate to explain and discuss advance directives.  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.

Requirements and Components for ACP:

• Billing for advance care planning (ACP) is similar to billing for a separate “procedure” in a clinic visit.
• ACP note documentation and billing should be done separately and independently of billing for the office visit.
  • Need two progress notes: one for the primary visit and additional APC note
• Documentation of ACP should not be included in the primary note, but should be referenced for clinical purposes: “see ACP note”
• Advance care planning, including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed)
• Provided by the physician or other qualified health care professional.
• The time reported must have been spent in person, “face-to-face with the patient and/or surrogate.”
  • CMS defines a surrogate as a healthcare agent, designated decision maker, family member, or caregiver. If a patient is unable to be present, ACP documentation should reflect the reason why the patient is unable to participate, e.g., patient has advanced dementia or is sedated on a ventilator.

ACP Documentation:

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, DNR, Living Will, or other standard forms is not required to bill for the service.

• Although there currently are no specific advance care planning documentation requirements, the following categories are suggested:
  • The names of participants
  • The voluntary nature of the conversation
  • The topics discussed
  • Any documents discussed and completed
  • The medical necessity for the conversation
  • The start and end time of the conversation

ACP Coding:

The codes for reporting ACP services are time-based.

• Use CPT 99497 for the first 16 to 30 minutes.
• Use CPT code 99498 for each additional 30 minutes.
• There are no limits to the length and number of times you can report ACP CPT codes.

ACP Billing:

• After selecting the appropriate level of service:
  • Office visit needs to bill based on the complexity of H&P and not time based.
  • Add “Modifier” – 25
  • Then you must add Additional E/M Code:
    • 99497: First 30 minutes (requires at least 16 minutes)
      • Enter under additional billing code
      • 5 RVUs
    • 99498: Includes an additional 30 minutes
      • Requires at least 46 minutes
      • Must also bill 99497
        • (99497) + 99498 for 46 minutes for APC
      • 4 RVUs (total 2.9 for ACP)

Health Care Professionals Who May Furnish and Bill ACP:

• Physicians (any specialty)
• Clinical nurse specialist (CNS)
• Nurse practitioners (NPs)
• Physician assistants (PAs)

Can you use a telehealth model to bill for ACP?

• No, at this time, only face-to-face encounters are considered acceptable.

Sarah H. Kim, MD, MSCE, is the Fellowship Director at the University of Pennsylvania Health System in Philadelphia, PA.