According to the Population Reference Bureau, the number of Americans ages 65 and older would more than double from 46 million in 2016 to over 98 million by 2060, and the share of the 65 plus age group in the total population will rise to nearly 24% from 15%. This indicates the significance of advance care planning (ACP), one of the important services offered by family physicians. There are various aspects to billing these services and many physicians rely on medical billing and coding companies to get the task done efficiently.

In January 2016, the Centers for Medicare and Medicaid (CMS) added advance care planning (ACP) as a payable service for traditional Medicare beneficiaries. Keeping track of ever-changing coding and billing rules, reliable medical billing service providers help physicians get optimal reimbursement for ACP. Considered an ‘unusual service’, ACP is meant to address a patients’ wishes for medical care, if there comes a time when they are unable to make the decision on their own. ACP is important not only for those with a chronic condition such as heart failure, but for anyone planning ahead for the future, and benefits patients, family members and/or surrogates.

ACP is the face-to-face time that a physician or other qualified health care professional spends with a patient, family member, or surrogate to explain and discuss advance directives. The two CPT codes to report ACP services are 99497 and 99498.

Requirements for CPT Code 99497

According to the American Academy of Family Practitioners (AAFP), the requirements for code 99497 are:

  • Advance care planning that includes the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed)
  • Is provided by the physician or other qualified health care professional
  • Discussion of ACP for first 30 minutes face-to-face with the patient, family member(s), and/or surrogate
  • Completion of an advance directive is only required “when performed,” and is not an overall requirement for billing ACP services.

Code 99497 can be billed on the same day as an E&M visit or [Annual Wellness Visit]. If billed with another E&M, modifier 33 should be included so the patient has no copay or deductible.

Requirements for CPT Code 99498

Code 99498 is an add-on code that is used when the encounter goes beyond 30 minutes. AAFP lists the requirements for code 99498 as follows:

  • Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed)
  • Is provided by the physician or other qualified health care professional
  • Should be used for each additional 30 minutes face-to-face with the patient, family member(s), and/or surrogate
  • To be listed separately in addition to code for primary procedure

Example of ACP

CMS gives the following example to illustrate the use of the ACP codes: A 68-year-old male has heart failure and diabetes and is on multiple medications. His physician provides Evaluation and Management (E/M) for these two conditions, including appropriate adjustments of medications. When talking about the patient’s short-term treatment options, the patient expresses his wish to discuss long-term treatment options. The doctor and patient discuss the possibility of a heart transplant if his congestive heart failure deteriorates, and ACP. The discussion includes the patient’s desire for care and treatment if he suffers a disability or injury that adversely affects his decision-making abilities.

In this situation, the physician should report a standard E/M code for the E/M service as well as one or both of the ACP codes – 99497 and 99498 – depending on the duration of the ACP service. For 99497 alone, 16 minutes is enough. In the above example, the ACP service does not necessarily have to occur on the same day as the E/M service.

Hospitalists should note that

  • ACP services cannot be reported with critical care codes (99291- 99292) or initial and subsequent inpatient neonatal critical care (99468-99476)
  • ACP is a “voluntary, separately payable” element of Medicare’s annual wellness visit
  • The patient has no out-of-pocket responsibility for ACP that takes place during the annual wellness visit. Copays and deductibles apply if ACP services are provided under any other circumstances
  • When billing ACP, documentation details in the progress note should indicate the parties involved, the nature of the conversation and the decisions made as well as the face-to-face time spent

Coding and billing is much easier with help from a specialist. Family practice medical billing and coding companies have AAPC-certified coders who are well-versed and up-to-date with the changing codes and reimbursement rules of Medicare, Medicaid, and commercial payers. They will also confirm the patient’s coverage ACP before services are provided. Outsourcing medical billing to a reliable service provider can ensure clean claim submission and full and fair reimbursement for care management services.

To learn more about Medical Coding we have written a new blog “Reporting End-of-life Discussion Codes Correctly” on August 29, 2017