Advance Care Planning (ACP) is a crucial service that involves a face-to-face discussion between a healthcare provider and a patient, their family, or a surrogate decision-maker. This conversation focuses on the patient’s healthcare wishes, particularly if they become unable to make their own decisions in the future. Understanding the nuances of billing and coding for ACP, especially concerning the appropriate Diagnosis Code For Advance Care Planning, is essential for healthcare providers. This guide aims to clarify these aspects, ensuring accurate and compliant billing practices.
Understanding Advance Care Planning (ACP)
Voluntary Advance Care Planning is designed to facilitate patient autonomy and ensure their preferences are honored in medical decision-making. This service is provided by Medicare physicians or other qualified health professionals and involves discussing a patient’s values, beliefs, and preferences related to healthcare. A key component of ACP is the discussion and explanation of advance directives, which are legal documents that allow individuals to express their healthcare wishes and appoint a surrogate decision-maker.
A surrogate, in the context of ACP, can be a healthcare agent, a designated decision-maker, a family member, or a caregiver. It’s important to note that if a patient is unable to be present for the ACP discussion, the medical documentation must clearly state the reason for their absence.
Qualified healthcare professionals who can independently bill Medicare for ACP services include:
- Physicians (MD/DO)
- Nurse Practitioners (NP)
- Physician Assistants (PA)
- Clinical Nurse Specialists (CNS)
While other members of the healthcare team can contribute to ACP under the medical management of the treating physician, they cannot independently report ACP codes. The billing provider must actively participate and contribute meaningfully to the ACP service, providing at least direct supervision. Standard physician fee schedule rules regarding “incident to” services are applicable.
Where can ACP Services be Provided?
ACP services are versatile and can be delivered across various healthcare settings, including both facility and non-facility locations. These settings encompass:
- Offices
- Hospitals
- Skilled Nursing Facilities (SNF)
- Patient Homes
- Via Telehealth (following specific CMS guidelines)
When reporting ACP services, it is mandatory to include the Place of Service (POS) code. Furthermore, ACP services are not restricted to any particular medical specialty. Even patients receiving hospice benefits can receive ACP services billed under Medicare Part B, provided the practitioner is not employed by the hospice agency. Hospice-employed physicians, or those under arrangement with hospice, should bill ACP services under Type of Bill 081x or 082x.
There is no annual limit on how often ACP services can be reported for a patient. However, if billed more than once, documentation must reflect a significant change in the patient’s health status or their end-of-life care wishes. The need for repeated ACP sessions depends on individual patient circumstances, with some needing it multiple times a year due to illness or changing situations, while others may not require it annually. Voluntary agreement from the patient, family member, or surrogate is necessary before providing ACP, and this agreement must be documented in the patient’s medical record.
Medicare covers ACP in two primary ways:
- As an optional component of a Medical Wellness Visit (MWV), including the Annual Wellness Visit (AWV).
- As a separate, medically necessary Medicare Part B service.
Billing and Coding for ACP Services
CPT codes 99497 and 99498 are used to report ACP services. These are time-based codes, requiring practitioners to adhere to CPT guidelines regarding minimum time requirements.
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CPT code 99497: Used for the first 16 to 30 minutes of advance care planning, including the explanation and discussion of advance directives, such as standard forms, and completion of these forms when performed. This service is provided face-to-face with the patient, family member(s), and/or surrogate by a physician or other qualified healthcare professional.
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CPT code 99498: Reported for each additional 30 minutes of ACP. It is listed separately in addition to the code for the primary procedure (99497).
If the minimum required time for CPT codes 99497 or 99498 is not met, providers should consider billing a different Evaluation and Management (E/M) service, provided the criteria for that E/M service are fulfilled. It’s crucial to note that no other active management of the patient’s problems should be undertaken during the time reported when ACP codes are used.
A healthcare professional engages in advance care planning discussion with a patient and their family, highlighting the importance of face-to-face interaction in ACP services.
When ACP services are provided outside of a Medical Wellness Visit, patients should be informed that Part B cost-sharing, including deductibles and coinsurance, will apply. However, Medicare waives the ACP coinsurance and Part B deductible under specific conditions:
- When ACP is delivered on the same day as a covered MWV (HCPCS codes G0438 or G0439).
- When offered by the same provider as a covered MWV.
- When billed with modifier -33 (Preventive Services).
Even if a MWV claim is denied due to exceeding the annual limit, Medicare may still cover ACP as a separate Part B medically necessary service, although in this case, the deductible and coinsurance will apply to the ACP service.
Diagnosis Coding for ACP
Accurate diagnosis code for advance care planning is vital for proper billing. The condition(s) for which the patient receives counseling during ACP should be coded according to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). When ACP is part of a Medical Wellness Visit, the diagnosis code should reflect an administrative examination or a well exam diagnosis. This ensures that the diagnosis code for advance care planning accurately represents the context of the service provided, particularly when it is integrated into preventive care visits.
Documentation Requirements for ACP
Comprehensive documentation is essential for ACP services. At a minimum, the documentation must include:
- The content of the ACP discussion.
- The medical necessity for the ACP discussion.
- The voluntary nature of the encounter.
- The content of any advance directives discussed, including completion of forms if performed.
- Names of all participants in the discussion.
- The total time spent in the face-to-face encounter.
Documenting the start and end times of the conversation is considered a best practice for time documentation.
Key Takeaways for Accurate ACP Billing
- Qualified Providers Only: Ensure ACP services are billed only by physicians, NPs, PAs, and CNSs.
- Time-Based Coding: Utilize CPT codes 99497 and 99498 based on the duration of the face-to-face encounter.
- Proper Setting and POS: ACP can be provided in various settings; always include the correct Place of Service code.
- Documentation is Key: Thoroughly document all aspects of the ACP discussion, including time, content, and participants.
- Diagnosis Coding Accuracy: Use appropriate ICD-10-CM diagnosis codes, reflecting the reason for ACP, especially when linked to MWVs.
- Modifier -33 for MWV Integration: Use modifier -33 when ACP is delivered as part of a Medical Wellness Visit to potentially waive cost-sharing.
By adhering to these guidelines, healthcare providers can ensure accurate billing and coding for Advance Care Planning services, facilitating patient access to these important discussions about their future healthcare preferences. Always refer to the latest Medicare guidelines and CPT coding instructions for the most up-to-date information.
