UPDATE: A complete FAQ about Medicare reimbursement for advance care planning conversations has been posted here.

NOTE: While we make every effort to ensure our information is accurate, staff at the Coalition for Compassionate Care of California are not Medicare billing experts. If you have detailed questions please consult with your own billing department.


cpt_codesOn Oct. 30, 2015, the Centers for Medicare and Medicaid Services (CMS) released the final 2016 Medicare Physician Fee Schedule including two CPT codes to reimburse for advance care planning.

Reimbursement for advance care planning (ACP) is a game changer for Coalition for Compassionate Care of California supporters, bringing California one step closer to our goal of promoting high-quality, compassionate care for all Californians who are seriously ill.

The two ACP codes are:

  • 99497 for an initial thirty minute voluntary advance care planning consultation (Final RVU 1.5)
  • 99498 as an add-on code for additional thirty-minute time blocks needed (Final RVU-1.4)

While both codes were included in the CY 2015 proposal, they were designed as “inactive” and were not funded. In the proposed rule for CY 2016, these codes are designated as “active” and applicable for reimbursement. CMS will begin reimbursing for these consultations starting Jan. 1, 2016.

As the lead organization in California for advance care planning, including the Physician Orders for Life-Sustaining Treatment (POLST), CCCC appreciates that CMS has recognized the value and importance of advance care planning conversations between patients and healthcare professionals.

Read our letter in support of CPT codes CMS-1631-P here.

The final rule is more than 1,300 pages in length. To view the ACP payment code section, click here.

The full final rule can be downloaded here as a PDF.

50 Responses to “Advance care planning codes included in 2016 Physician Fee Schedule”

  1. Bernard Katz, MD

    Hi, do you know if CMS is going to limit payment of 99497 and 99498 to a single incidence? In other words, if a physician has a discussion with the patient and family on Advanced Care Planning and bills 99497 but the patient chooses not to do a POLST at the time, but then at a subsequent encounter either the same or different physician spends the requisite time and again has a discussion with the patient/family which results in a POLST being completed. Can the second physician also bill the 99497 code?

    Reply
    • Bernard:
      CMS has not placed limits on utilization of the ACP codes, but will be monitoring their usage. The codes can be billed for voluntary end-of-life discussions as part of a patient’s annual check-ups, as well as during a patient’s initial visit when he or she first enrolls in Medicare. If the ACP discussion is not part of the annual wellness visit, cost share and deductible will apply. Beneficiaries should be told they are receiving ACP services and that they have the right to deny the service. – Kelley

      Reply
      • Bernard Katz, MD

        Thank you for the response. One more question: if a patient is seen at the annual wellness visit and the ACR code is billed (with the patient’s permission), will the code be paid separately or bundled into the G0438 or G0439 code?

        Reply
        • UPDATED ANSWER:

          At the beneficiary’s discretion, the ACP conversation may be included as a voluntary, separately payable element of the Medicare Annual Wellness Visit (AWV). ACP services provided in conjunction with the AWV should be reported with modifier -33.
          – Kelley

          Reply
          • If it is performed on the same day as a wellness visit can we append modifier 33 and bill them both?

          • Cherri:
            At the beneficiary’s discretion, the ACP conversation may be included as a voluntary, separately payable element of the Medicare Annual Wellness Visit (AWV). ACP services provided in conjunction with the AWV should be reported with modifier -33.
            – Kelley

  2. After the first code is billed for the 30 minute conversation, how many times can the second code be utilized for additional 30 minute-time blocks or is there no limit? In addition, do these have to be utilized in conjunction with any other code indicating serious illness? Thank you!

    Reply
    • Kristen: The CPT codes allow payment for ACP services of any length. Code 99497 can be billed for the first 30 minutes of ACP services, and 99498 can be billed for each additional 30 minutes of service performed on the same day, with no limit. Code 99497 does not have to be utilized in conjunction with another code. (99498 is an add-on code.) If during the ACP discussion, the physician or QHP engages in active management of the patient’s problem(s), a separate Evaluation and Management (E/M) code may be reported with the exception of critical care codes, inpatient neonatal and pediatric critical care codes or initial and continuing intensive care services. Consult with your billing department.
      – Kelley

      Reply
  3. Michelle Ramirez

    Do I2 rules apply to these codes? I am guessing the original care plan from the Physician must include ACP in order for the APP to document and charge the 99497 or 99498 under the Physicians NPI number and not their own, am I correct in that thinking?

    Reply
  4. Could you detail the type of documentation and/or forms that are required in order to support the billing of 99497?

    Reply
    • Arlene: At this point CMS has not specified any required documentation. However, these codes will be subject to audit. At a minimum, providers should document:

      -The necessity for the ACP services, such as: patient has an end stage chronic illness; will be undergoing an emergent or high risk procedure; has had a condition change that prompts the need for ACP, etc.
      -Specific time spent on the ACP service
      -With whom the conversation was held (patient and/or surrogate) -That the patient was informed that the ACP service is voluntary

      Consult with your organization’s billing office for further detail on billing specifics.

      – Kelley

      Reply
  5. Cherri:
    At the beneficiary’s discretion, the ACP conversation may be included as a voluntary, separately payable element of the Medicare Annual Wellness Visit (AWV). ACP services provided in conjunction with the AWV should be reported with modifier -33.
    – Kelley

    Reply
  6. Brianna

    Does the physician have to have an EMR/EHR to qualify to bill these codes? Just want to make sure so I can share with my clients

    Reply
  7. Bradley Howard

    If ACP services are provided during the Medicare AWV must the 30 minutes of ACP time be documented separately? Since Medicare allows 40 minutes for an AWV, to bill both codes must the visit span 70 minutes?

    Reply
  8. Is there a specific range of ICD-10 codes that have to be billed with the ACP codes?

    Reply
  9. Shannon Kincaid

    Hello,

    Our providers see patients in their homes as well as Assisted Living. Medicare is denying for invalid place of service. Is there a list that shows where the 99497 and 99498 can be billed?

    Thank you,

    Shannon

    Reply
  10. Jason Daniel

    Medicare is denying the procedure code 99497 if billed along with 99350/349 because a rep told me that this cpt can only be billed with POS 11 and with 49 independent clinic. Why this is not billable for pos 12?

    Reply
    • It looks like CMS will need provide more clarification on this particular issue. In publishing the Final Rule on the CY 2016 Physician Fee Schedule, CMS recognized that ACP services are appropriately furnished in a variety of settings, and stated, “These codes (99497 and 99498) will be separately payable to the billing physician or practitioner in both facility and non-facility settings and are not limited to particular physician specialties.”

      However, restrictions under Medicare billing for home visits and “incident to” rules appear to create roadblocks to use of the ACP codes in the home setting.

      The CPT Home Services codes (99341 – 99350) may be used only when Medicare Part B physician services are provided in the “private” residence of the patient. To bill the Home Services codes, you must be able to document the medical reason for the home visit and a medical reason that the patient cannot make the trip to the office or clinic to receive the service.

      Physicians, nurse practitioners or physician assistants providing the ACP service as part of a home visit should be able to bill 99497 or 99498 under their own provider number. However, ACP is a physicians’ service, and CMS has stated that “incident to” rules apply when these services are provided by someone other than the billing practitioner. The incident to rules require the billing physician to provide direct supervision and be on-site when the services are provided. This could be the issue with regard to application of the ACP codes in the private home setting.

      – Kelley

      Reply
  11. Hello,

    When asked about ICD-10 codes you replied “check out our FAQ”. I read your FAQ and saw no mention of diagnosis codes. Is there a list of payable codes? Thanks

    Reply
  12. I am still having a problem with billing this code and finding the right diagnosis code. Since we billed with the AWV (G0439) the diagnosis billed was Z00.00. Medicare has since denied my claims stating 99497 can not be billed with the dx code Z00.00. A rep from Medicare said any diagnosis code can be billed, but I am skeptical.

    Reply
  13. Samantha

    Have you tried Z51.5 (Encounter for palliative care) for diagnosis coding Monique

    Reply
  14. Who can provide this service. Can our RN Care Manager do this as long as I2 guidelines are followed?

    Reply
  15. Marti Cote

    For non-Medicare patients, is there an age limit for the Advanced Care Planning Codes?

    Reply
  16. Phillip

    Thanks for all the helpful information.
    How do we learn if the required contents of the progress note are clarified?
    -Phillip

    Reply
  17. Are ACP services bundled into the Welcome to Medicare Visit (aka IPPE) or is this separately billable from the IPPE?

    Reply
  18. Heidi

    I am wanting clarification about “incident to” billing in regards to Advance Care Planning. Am I understanding correctly that other clinical staff may provide this service? What qualifications of that staff person are required?

    Reply
  19. Hello.

    We had a provider that billed Home Visits codes (CPT 99350) back in 2015 for visits that were mainly for palliative care and advanced care planning. The level of the CPT code was driven by the time spent documented. I am currently auditing these charts. It is not documented in the charts the medical necessity of a home visit made in lieu of an office visit, example “it would be a taxing effort for the patient to leave the home without help”, however, when reading the chart, it is evident that the patient is near end of life, and discussing hospice arrangements, etc. Trying to decide if the home care code 99350 can be used…..or advanced care planning codes 99497-99498. Thank you.

    Reply
    • While the advance care planning codes (99497 and 99498) were included in the 2015 Physician Fee Schedule, the codes were not activated (and therefore not reimbursable) for services provided prior to January 1, 2016. We are not familiar enough with home care service codes to provide advice on the use of 99350. – Kelley

      Reply
  20. apmbiller

    Is 99497 billable in a hospital setting? The Hospitalist that I work for bills for ACP but I always get these denials: “This service/procedure requires that a qualifying service/procedure be received and covered.” AND “Not covered when performed during the same session/date as a previously processed service for the patient.”

    Is there a modifier I could use so that this service can get paid?

    Thanks,
    apm

    Reply
  21. If you offer the advance care plan and explain and the patient refuses can you still bill for the service as you spent the time explaining the process?

    Reply
  22. Hello, do I need to use modifier 25 to the E/M codes if the 99497 is done at the same day?

    Reply
    • Coalition for Compassionate Care of California

      Hi Patty –

      According to a senior billing specialist with CMS, if ACP and an IPPE are furnished on the same day, it would be considered one visit because ACP can be included in an IPPE or AWV.

      – Kelley

      Reply
  23. im trying to bill 99497 and on the claim it say that the cpt code is inactive what is the correct cpt code for the 99497

    Reply
  24. When we bill for an office visit 99214 and the patient also gets a procedure done such as an EKG we are not being paid for the 99497 if it is done at the same visit.

    Reply
  25. Nichole

    If the provider states went over POLST form with patient. POLST form handed to patient to take home and fill out. Can I code 99497? Also does the provider have to state in his dictation how many minutes where spent face to face going over the POLST FORM?

    Reply
    • Code 99497 can be billed for the first 30 minutes of the advance care planning conversation. That would include discussing the POLST. For an ACP conversation of less than 16 minutes, CMS suggests considering billing a different evaluation and management (E/M) service such as an office visit. (The quality of advance care planning performed in brief encounters may be questionable, therefore, brief visits for the purpose of ACP are probably best reported as part of a routine E/M service.)

      Practitioners are advised to consult their Medicare Administrative Contractors (MACs) regarding documentation requirements. While CMS has not issued specific requirements, it has suggested the following as examples of appropriate documentation: 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. – Kelley

      Reply

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