For the first time, the Centers for Medicare & Medicaid Services (CMS) made the Current Procedural Terminology (CPT) codes for Advance Care Planning (ACP) separately payable by Medicare. CPT codes 99497 & 99498 are used to report the 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. So what is an Advance Directive? It is a document appointing an agent and/or recording the wishes of a patient pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at that time. Examples of written advance directives include, but are not limited to, Health Care Proxy, Durable Power of Attorney for Health Care, Living Will, and Medical Orders for Life-Sustaining Treatment (MOLST). When using codes 99497 & 99498, no active management of the problem(s) is undertaken during the time period reported. The description of these two CPT codes are:

  • 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) (+ = add-on code, report in conjunction with an appropriate base code)

Use 99498 in conjunction with 99497, but do not report 99497 and 99498 on the same date of service as 99291, 99292,99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479, 99480) In addition, CMS is also including voluntary ACP, upon agreement with the patient, as an optional element of the Annual Wellness Visit (AWV).  Voluntary ACP means the face-to-face service between a physician (or other qualified health care professional) and the patient discussing advance directives, with or without completing relevant legal forms. ACP services furnished on the same day and by the same provider as an AWV are considered a preventive service. Therefore, the deductible and coinsurance are not applied to the codes used to report ACP services when performed as part of an AWV. Effective January 1, 2016, when ACP services are provided as a part of an AWV, practitioners would report CPT code 99497 (plus add-on code 99498 for each additional 30 minutes, if applicable) for the ACP services in addition to either of the AWV codes G0438 and G0439. CPT codes 99497 and 99498 used to describe ACP are separately payable under the Medicare Physician Fee Schedule (MPFS). When voluntary ACP services are furnished as a part of an AWV, the coinsurance and deductible would not be applied for ACP. Under that circumstance, both the ACP and AWV must also be billed together on the same claim. In order to have the deductible and coinsurance waived for ACP when performed with an AWV, the ACP code(s) must be billed with modifier 33 (Preventive services). Since payment for an AWV is limited to only once a year, the deductible and coinsurance for ACP billed with an AWV can only be waived once a year. However, the deductible and coinsurance does apply when ACP is not furnished as part of a covered AWV. Medicare does not require a form to be filled out, but it is always a good idea to do so. There is no single form in use to document a patient’s wishes, however, state laws require certain provisions to appear in the patient’s health care directive. The following forms could be used and are from the California Hospitals Association:

Once the forms are completed, copies should be given to each person named as agent, or proxy, and to the primary care physician so that it can be added to the patient’s medical record.  

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