Advance Care Planning (ACP) is a crucial process that involves discussions between a healthcare professional and a patient (along with their family or surrogate decision-maker, if desired) about the patient’s wishes for future medical care, particularly if they become unable to make those decisions themselves. This proactive approach ensures that patient autonomy is respected and that care aligns with their values and preferences, especially in end-of-life situations. Understanding the administrative aspects of ACP, including diagnosis coding, is essential for healthcare providers. This article delves into the diagnosis codes used for Advance Care Planning, providing a clear and comprehensive guide for healthcare professionals.
Advance Care Planning services are designed to facilitate informed decisions. These services are face-to-face encounters and can be provided by Medicare physicians or other qualified healthcare professionals such as Nurse Practitioners, Physician Assistants, and Clinical Nurse Specialists. The goal is to discuss and document a patient’s healthcare wishes, ensuring these are known and respected should the patient lose the capacity to decide. A surrogate, which could be a healthcare agent, designated decision-maker, family member, or caregiver, may also be involved in these discussions. It’s important to note that if a patient cannot be present for ACP, the reason for their absence must be documented.
For billing purposes, particularly under Medicare, specific coding guidelines apply to Advance Care Planning services. While CPT codes 99497 and 99498 are used to report the ACP service itself, diagnosis codes are equally important for justifying the medical necessity and context of these discussions.
When it comes to diagnosis coding for Advance Care Planning, the primary guideline is to code for the condition(s) for which the patient is receiving counseling during the ACP session. This is in accordance with the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Essentially, the diagnosis code should reflect the patient’s health status or the reason for the advance care planning discussion.
For instance, if ACP is conducted as part of a routine Annual Wellness Visit (AWV) or Medical Wellness Visit (MWV), the diagnosis code should align with administrative examinations or well exam diagnoses. This is because the ACP is offered as a preventive service within the wellness visit framework. In such cases, codes indicating a routine check-up or general health examination would be appropriate.
However, Advance Care Planning is not limited to wellness visits. It can also be provided as a separate Medicare Part B medically necessary service. In these instances, the diagnosis coding should still reflect the reason for the ACP discussion. This could be related to a chronic condition, a recent diagnosis, or any health circumstance that prompts the patient and provider to engage in advance care planning. It is crucial to accurately document the medical necessity of the ACP discussion, and the diagnosis code plays a vital role in supporting this documentation.
Let’s clarify further with examples:
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ACP during Annual Wellness Visit: If ACP is part of an AWV, you would use a diagnosis code appropriate for a routine wellness exam, such as Z00.00 (Encounter for general adult medical examination without abnormal findings).
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ACP for a patient with a chronic condition: If a patient with heart failure is undergoing ACP to plan for potential future health scenarios related to their condition, the diagnosis code would reflect the heart failure, such as I50.9 (Heart failure, unspecified).
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ACP prompted by a new diagnosis: If a patient receives a new diagnosis of a serious illness and engages in ACP to consider their treatment preferences, the diagnosis code would be for the new diagnosis, for example, C34.90 (Malignant neoplasm of unspecified part of unspecified bronchus or lung).
It’s important to remember that the diagnosis code is not for the ACP itself, but rather for the underlying health condition or reason that necessitates or is associated with the advance care planning discussion. The focus is on the patient’s health context that makes ACP relevant and medically necessary.
In addition to diagnosis codes, it’s crucial to understand the CPT codes used for billing the ACP service itself. These are:
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CPT code 99497: 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 forms if 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: For each additional 30 minutes of ACP beyond the initial 30 minutes (reported in addition to code 99497).
These CPT codes are time-based and should be used according to the duration of the ACP session. It’s also important to note that these codes should not be reported on the same date of service as certain high-intensity evaluation and management (E/M) services, as outlined by CPT guidelines to avoid unbundling. However, ACP services can often be billed on the same day as other E/M services (with modifier -25 when appropriate) if the services are distinct and necessary.
Proper documentation is paramount for both diagnosis and CPT coding of ACP services. Documentation must include:
- The content of the ACP discussion.
- The medical necessity for the discussion.
- The voluntary nature of the encounter.
- The content of any advance directives discussed or completed.
- Names of all participants in the discussion.
- The total time spent in the face-to-face encounter, ideally with start and end times.
In summary, when billing for Advance Care Planning services, remember that the diagnosis code should reflect the patient’s underlying health condition or the reason for the ACP discussion, using ICD-10-CM guidelines. For ACP performed during a wellness visit, use codes for routine exams. For ACP provided separately, code for the relevant medical condition prompting the planning. Coupled with appropriate CPT coding (99497, 99498) and thorough documentation, accurate coding ensures proper reimbursement for this vital patient care service. Understanding these coding nuances is essential for healthcare providers to effectively offer and bill for Advance Care Planning, ensuring patients receive the support they need to plan for their future healthcare.
