Coding for Advance Care Planning

The American Medical Association's CPT Assistant (December 2014) describes advance care planning (ACP) as "learning about and considering the types of decisions that will need to be made at the time of an eventual life-ending situation and what the patient's preferences would be regarding those decisions," and offers an example of a patient who may need ACP services:

A single 68 year old male with several chronic but stable conditions presents to his physician with his brother to discuss his overall prognosis, the likely disease trajectory of his illnesses, possible future complications and available treatments with their risks, burdens and likely outcomes. An explanation and discussion of advance directives takes place but no advanced directive was prepared.

According to CPT Assistant (February 2016), factors under consideration may include:

• the patient's current disease state

• disease progression; available treatments

• cardiopulmonary resuscitation/ life sustaining measures

• do not resuscitate orders; life expectancy based on the patient’s age and co-morbidities

• clinical recommendations of the treating physician, including reviews of patient’s past medical history and medical documentation/reports, and response(s) to previous treatments

CPT® provides two codes to describe time spent with a patient, family member, or surrogate discussing advanced directives, medical orders for life-sustaining treatment, living wills, or similar advance care planning:

99497 Advance care planning including 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

99498 … each additional 30 minutes (List separately in addition to code for primary procedure)

Code 99497 describes an initial 30 minutes of the providers' time (face-to-face with the patient, family, or surrogate). You should report only one unit of 99497, per date of service. Code 99498 reports each additional 30-minutes of service, beyond the initial 30 minutes (at least 16 minutes must pass beyond the initial 30 minutes to report 99498). For example, for 35 minutes of face-to-face ACP, proper coding is 99497; for 57 minutes of face-to-face advance care planning, proper coding is 99497, 99498.

Because these services are time-based, the provider must document the face-to-face time spent with the patient, family member, or surrogate. The best practices are noting start and stop times, total face-to-face time, a summary of the points discussed, and other relevant details such as the patient's response or decisions related to the discussion. The codes account only for the provider's time and expertise, and do not include active management of a problem(s).

ACP may be provided and reported on the same day, or a different day, as other evaluation and management (E/M) service. A list of E/M codes with which you may report 99497 and 99498 is included in the CPT guidelines preceding the code listings. Per CPT® instruction, do not report advanced care planning on the same date of service as 99291, 99292, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479, or 99480 (e.g., any critical care service).

Medicare will cover ACP as a separate service, or as an optional element (at the beneficiary's discretion) of the Initial Preventive Physical Examination (IPPE), or "Welcome to Medicare" exam, and of the Medicare Annual Wellness Exam. CMS stresses that ACP services are voluntary, and that Medicare beneficiaries (or their legal proxies) "should be given a clear opportunity to decline to receive ACP services."

CMS does not place frequency restrictions on the use of 99487 or 99498, but advises, "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."CMS does not impose place-of-service restrictions on ACP: The services may be reported in both facility and non-facility settings.

CMS does not limit ACP services to particular physician specialties, but does stipulate:

CPT codes 99497 and 99498 are appropriately provided by physicians or using a team-based approach provided by physicians, nonphysician practitioners (NPPs) and other staff under the order and medical management of the beneficiary's treating physician. … The ACP services described by these codes are primarily the provenance of patients and physicians; accordingly we expect the billing physician or NPP to manage, participate and meaningfully contribute to the provision of the services in addition to providing a minimum of direct supervision.

CMS instructions to document the services are similar to those given, above:

Examples 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; documentation indicating the explanation of advance directives (along with completion of those forms, when performed); who was present; and the time spent in the face-to-face encounter.

Source: Frequently Asked Questions about Billing the Physician Fee Schedule for Advance Care Planning Services (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQ-Advance-Care-Planning.pdf).