Guidelines to Advance Care Planning

Are You Billing for EOL Discussions or Planning?

Voluntary advance care planning (ACP), which is reimbursed by the Centers for Medicare & Medicaid Services (CMS), enables certain clinicians¹ to engage in conversations about preferences at the end of life with patients, family members and/or surrogates. Hospitals may also bill for ACP services. To successfully bill for ACP, a face-to-face discussion of short-term treatment options and/or long-term goals of care with the patient or healthcare surrogate is required.

Medicare Pays for ACP as either²

• A separate Part-B service when medically necessary
• An optional element of a beneficiary’s annual wellness visit

There are no limits on the number of times ACP can be reported for a given beneficiary in each time period. However, with each billing for the same patient, CMS expects to see a documented change in the beneficiary’s health status and/or wishes regarding end-of-life care.

Private insurance may cover the cost of the ACP discussion for non-Medicare patients. If not, physicians who have addressed ACP in a conversation about a serious illness can use “counseling and coordination of care” codes.

ACP has significantly improved multiple outcomes, particularly for patients with serious illness, including³:

• Higher rates of completion of advance directives
• Increased likelihood that clinician and family understand and comply with patient’s wishes
• Reduced use of intensive treatments and hospitalizations at the end of life
• Enrollment in hospice
• Increased likelihood of dying in the preferred place¹

Use these CPT® codes to bill for ACP²

99497 Advance care planning, including the first 30 minutes of explanation and discussion (when performed) of advance directives such as standard forms. Reimbursement equates to 1.5 RVUs.

99498 Each additional 30 minutes; reimbursement equates to 1.4 RVUs. 

Check that these reimbursement codes have been added to your billing system, as they may not be available until your facility approves them for use. 

These ACP codes can be used on the same day as other CPT codes, as long as the other services were provided outside of the time window in which the ACP service was conducted. 

Footnotes:

¹Only physicians, NPs and PAs can bill to these codes. 

²Centers for Medicare & Medicaid Services, Fact Sheet: Advance Care Planning, August 2016 https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network MLN/MLNProducts/Downloads/AdvanceCarePlanning.pdf

³Deterling, K. Advance care Planning and Advance Directives http://www.uptodate.com/contents/advance-care-planning-and-advance-directives#H37130455

CPT is a registered trademark of the American Medical Association.