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Medi-CalIn another significant step forward to normalize and support advance care planning conversations—and a win for the Coalition for Compassionate Care of CaliforniaMedi-Cal is following Medicare’s lead by using codes to allow billing by providers for advance care planning discussions with beneficiaries under the Current Procedural Terminology (CPT) codes 99497 and 99498.

The federal Medicare program began reimbursing codes 99497 and 99498 on January 1, 2016, but state Medicaid programs and private payers would have to separately determine whether they would follow suit.

In March 2016, Judy Thomas, JD, CEO of CCCC, wrote a letter to the California Department of Health Care Services (DHCS) urging the state to “follow the federal government’s lead and take the next logical step – reimburse Medi-Cal providers for advance care planning discussions.”

Since then, CCCC has been closely watching Medi-Cal’s rate updates for indication that Medi-Cal providers can begin billing the advance care planning codes.

As of May 15, 2016, the rates for advance care planning, published on the Medi-Cal website, are as follows:

Procedure Type Procedure Code Procedure Descript Unit Value Basic Rate Conv Ind Non-Phys Med. Pract. Ind. *
Medical 99497 Advance care plan – 30 min 69.59 $69.59 009 Y
Medical 99498 Advance care Plan Addl 30 min 62.64 $62.04 009 Y

* A “Y” in this column signifies the procedure may be reimbursable if performed by a non-physician medical practitioner.

While specific guidance on use of the advance care planning codes with Medi-Cal beneficiaries has not yet been provided, the General Medicine/Evaluation & Management section of the Medi-Cal Provider Manual, says:

Advance care planning codes are used to report face-to-face service between a physician or other qualified health care professional and a patient, family member, or surrogate in counseling and discussing advance directives, with or without completing relevant legal forms.

CPT-4 code 99497 (advance care planning including the explanation and discussion of advance directives such as standard forms, by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family members, and/or surrogate) is reimbursable twice a year with a TAR override.

CPT-4 Code 99498 (…each additional 30 minutes) is reimbursable once a year with a TAR override.

CCCC will share additional details as they become available.

Read our FAQ about advance care planning reimbursement under Medicare.

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