Advance Care Planning Services: Does Your Documentation Cut it?

Jun 28, 2023

Advance Care Planning (ACP) allows for an open discussion between the healthcare provider and the patient, family member, or surrogate about the type of care the patient wants when he or she becomes seriously ill and/or incapable of making their own medical decisions.

Prior to 2016, advance care planning conversations were not reported separately and were included in Evaluation and Management visit codes as time spent for counseling and coordination of care services.

Providers can now bill both an Evaluation and Management visit and ACP on the same day as long there is documentation
of separate and distinct services.

In 2018, the Comprehensive Error Rate Testing (CERT) program started performing documentation reviews on ACP services and identified claims that were improperly paid due to insufficient documentation (e.g., time not documented, or nature of ACP conversation not documented). In June 2020, The Office of Inspector General (OIG) added advance care planning to its work plan.

Here are some tips on how to properly report advance care planning services.

Coding for CPT Code 99497©:

  • Advance care planning, including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed). These are often referred to advance directive.
  • The discussion may be between the physician or other qualified health care professional (Nurse Practitioner or Physician Assistant) and the patient.
  • The document needs to indicate who was present during the visit (e.g., patient, family member(s), and/or surrogate or advocate).
  • The first 30 minutes of face-to-face with the patient, family member(s), legal guardian, and/or surrogate must be greater than 16 minutes. This means that the provider must spend more than half of the code’s defined time as a face-to-face with the patient. Total time must be documented. The best practice for documenting time is to include the start and end times of the face-to-face conversation.
  • Time spent actively managing the patient’s problems may not be counted toward time spent on ACP services. These are part of the E/M service.
  • Assign the appropriate ICD-10-CM code for the medical condition discussed with the patient.

Coding for CPT Code +99498© (add-on code):

  • Each additional 30 minutes face-to-face with the patient, family member(s), and/or surrogate (minimum of 16 minutes required). This means that the provider must spend more than half of the code’s defined time face-to-face with the patient. Total time must be documented. The best practice for documenting time is to include the start and end times of the face-to-face conversation.
  • List separately in addition to primary CPT code 99497.

Advance Care Planning CPT Codes and Time Reporting Guidelines:

advance care planning cpt code time reporting guidelines
Time reporting guidelines for ACP CPT codes

ACP services may be reported separately when performed on the same day in addition to Evaluation and Management (E/M) services, e.g., outpatient office visits (99202-99215), annual wellness visits, consult services (99241-99245, 99251-99255), emergency room visits (99281-99285), inpatient or observation initial care (99221-99223, 99234-99236), subsequent care (99231-99233), and discharge day management (99238, 99239).

Important Notes for ACP Coding:

  • Do not report ACP service when critical care codes are reported by the same provider, on the same date, e.g., adult, neonate, or pediatric critical care services.
  • An ACP service must be provided as a separate and distinct service; the provider’s documentation must be distinct and clearly outline the time for the E/M visit, and the time spent performing ACP services separately.
  • An ACP service may be performed during a telehealth visit. Please check specific payer requirements for reporting telehealth services.

Billing and Payment:

  • If this service is billed more than once, document the change in the patient’s health status and/or wishes about their end-of-life care plan. There’s no limit on the number of times you can report ACP for a patient.
  • For Medicare beneficiaries there is a limitation on the number of times ACP can be reported on a date of service: 99497 = 1 unit and 99498 = 3 units for both practitioner and facility.
  • Copays and coinsurance apply to ACP services except when performed with a Medicare Annual Wellness Visit (AWV).

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