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Advance Care Planning
CPT codes, descriptions, and other data only are copyright 2023 American Medical Association. All Rights Reserved.
Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components are
not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly
or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not
contained herein.
Copyright © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the
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What’s Changed?
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Together we can advance health
equity and help eliminate health
disparities for all minority and
underserved groups. Find resources
and more from the CMS Oce of
Minority Health:
●
Health Equity Technical
Assistance Program
●
Disparities Impact Statement
Advance care planning (ACP) is a voluntary, face-to-face
discussion between a physician or other qualied health
care professional (QHP) and your patient, their family
member, caregiver, or surrogate (as appropriate) to
discuss the patient’s health care wishes if they become
unable to make their own medical decisions.
“You” refers to a physician or
other QHP. QHPs include nurse
practitioners, physician assistants,
and clinical nurse specialists.
As part of this discussion, you may talk about
advance directives with or without helping a patient
complete legal forms. An advance directive appoints an
agent and records a patient’s medical treatment wishes
based on their values and preferences. Advance
directives can be dierent from state to state, and you
can generally nd them on your state attorney general’s
website. Examples include:
●
Do not resuscitate orders
●
Health care powers of attorney
●
Health care proxies
●
Instruction directives
●
Living wills
●
Medical orders for life-sustaining treatment
●
Psychiatric advance directives
Documentation Requirements
You must document your ACP discussion with the patient and their family member, caregiver, or
surrogate (as appropriate). In your documentation, include:
●
The fact that the visit was voluntary
●
An explanation of advance directives
●
Who was present
●
The time spent discussing ACP during the face-to-face encounter
●
Any change in the patient’s health status
●
The patient’s health care wishes if they become unable to make their own decisions
Diagnosis
Report the condition you discuss with the patient using an ICD-10-CM code. This code shows an
administrative exam or an exam diagnosis when ACP services are part of the annual wellness visit
(AWV). You don’t need to report a specic diagnosis to bill for ACP services.
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Coding
Hospitals, physicians, or QHPs may bill for ACP services if they’re within their scope of practice and
the Medicare benet category describes the services in Table 1.
Table 1. CPT Codes & Descriptors
CPT Codes Billing Code Descriptors
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 qualied health care professional; rst
30 minutes, face-to-face with the patient, family member(s), and/or surrogate
99498
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 qualied health care professional; each
additional 30 minutes (List separately in addition to code for primary procedure)
ACP Services Are Time Based
You must follow CPT rules about minimum time requirements to report and bill for ACP services.
You should only discuss ACP issues during the time you’re billing for ACP services. You shouldn’t discuss
any other active management of a patient’s issues for the time reported when you bill ACP codes.
When you perform another service concurrently as a time-based service, don’t include the time
spent on the concurrent service with the time-based service.
Don’t bill any ACP discussion of 15 minutes or less as ACP services. If you meet another service’s
requirements, bill a dierent Evaluation and Management (E/M) service, like an oce visit.
A unit of time is billable when the midpoint of the allowable unit of time passes. Table 2 has
more information.
Table 2. ACP Minutes & Corresponding CPT Codes & Units
ACP Minutes CPT Code & Units
15 or less Don’t bill any ACP services
16–45 CPT code 99497 (1 unit)
46–75
CPT code 99497 (1 unit) and
CPT code 99498 (1 unit)
76–105
CPT code 99497 (1 unit) and
CPT code 99498 (2 units)
CPT only copyright 2023 American Medical Association. All rights reserved.
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Billing & Payment
You can oer ACP services in facility and non-facility settings and bill them in any care setting, including
an oce, a hospital, a nursing home, at home, and through telehealth guidelines eective at the time
of service.
Critical access hospitals may bill ACP services using type of bill 85X with revenue codes 96X,
97X, and 98X. We base the Method II payment (optional payment method) on the lesser of the
actual charge or the facility-specic Medicare Physician Fee Schedule per Section 1834(g)(2) of
the Social Security Act. Federally Qualied Health Centers and Rural Health Clinics are paid for
ACP services under a special all-inclusive rate or prospective payment system, where ACP is
part of the bundled services.
We pay for ACP as:
●
An optional element of the AWV
●
A separate Medicare Part B medically necessary service
We waive the ACP Part B deductible and coinsurance when the ACP is:
●
Provided on the same day as the covered AWV (HCPCS codes G0438 or G0439)
●
Provided by the same provider as the covered AWV
●
Billed with modier 33 (Preventive Services)
●
Billed on the same claim as the AWV
If we deny the AWV billed with ACP for exceeding the once-per-year limit, we’ll apply the ACP
deductible and coinsurance.
There are no limits on the number of times you can report ACP for a certain patient in a certain period.
When billing ACP multiple times in a year, document changes in the patient’s health status or wishes
about their end-of-life care.
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Example
A 68-year-old person takes multiple medications for heart failure, diabetes, and a new diagnosis of
mild dementia. They see their physician for the E/M of these 3 conditions, and the physician adjusts
their medications.
While discussing short-term treatment options, the patient also wants to address long-term treatment
concerns. They talk about a possible heart transplant if the heart failure or dementia worsens. They
also discuss ACP, including the patient’s desire for care and treatment if they have a health event that
adversely aects their decision-making abilities, and the physician helps the patient complete a legal
advance directive form from their state attorney general’s oce.
According to CPT reporting instructions, the physician may report the ACP codes in addition to the
E/M visit code describing the active management of the heart failure, diabetes, and dementia if the
ACP time doesn’t overlap with actively managing those E/M conditions.
Resources
●
42 CFR, Part 489, Subpart I (advance directives policy)
●
2016 Medicare Physician Fee Schedule Final Rule (Medicare PFS policy for ACP services), pages
70955–70959
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2016 Medicare OPPS & ASC Final Rule (OPPS payment policy), pages 70305, 70451, and
70469–70470
●
Advance Care Planning (patient information)
●
Article A58664: Billing and Coding: Advance Care Planning
●
Local Coverage Determination L38970: Advance Care Planning
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Section 200.11 of the Medicare Claims Processing Manual, Chapter 4
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