Advance Care Planning – Frequently Asked Questions & Answers

ADVANCE CARE PLANNING -Frequently Asked Questions & Answers

Advance Care Planning (ACP) is a faceto-face discussion between a physician and a patient/family member/surrogate about the medical care and treatment options the patient would like to receive if they become unable to speak for themselves.

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At any specific age or any point of time, a serious medical crisis can occur which could leave someone too ill or incapable to make his/her healthcare decisions. The concept of advance care planning (ACP), one of the prominent services offered by family physicians, becomes significant at this stage. Advance care planning involves the process of making decisions about the care people want to receive if they are unable to speak for themselves. As billing for these services involves considering several important aspects, most physicians or healthcare providers depend on the services of medical billing and coding companies to get the task done efficiently.

Reports from the Population Reference Bureau suggest that the number of Americans aged 65 years and older is expected to grow more than double from 46 million (in the year 2016) to about 98 million by the end of 2060. It is estimated that the share of 65 plus age group in the total population will rise to nearly 24% from 15%. Prior to January 2016, the Centers for Medicare and Medicaid (CMS) had provided coverage for advance care planning (ACP) only for an initial visit when patients first get enrolled in the program. However, beginning from January 2016, CMS added ACP as a separate payable service or billing code. This offers greater flexibility and provides an opportunity for both physicians and patients to discuss the individual options for the patient both before an illness progresses and during the course of treatment. Let’s look at some of the frequently asked questions and answers about advance care planning services (ACP).

Q: What is Advance Care Planning (ACP)?

A: Advance care planning (ACP) is about making formal plans about the kind of healthcare a person would want to receive at the end of his/her life. It is a face-toface discussion between a patient/family member/surrogate anda physician or other qualified health professional about the kind of care and the choices of treatment the patient would like to receive if he/she becomes unable to speak for themselves.

ACP includes the explanation and discussion of advance directives including the completion of such forms if the patient desires.

Q: What is an Advance Care Directive (ACD)?

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A: It is a written legal document that records a person’s future healthcare wishes and preferences. It appoints or designates another individual to make future healthcare decisions on your behalf if you are not able to speak for yourself.

Q: What is the purpose of an advance care directive, if patients just want their family members to make decisions for them?

A: Giving your immediate family member the necessary instructions or the liberty to take medical decisions regarding your health would relieve them from a great deal of stress. First, you can designate a particular person (or persons) to carry out your wishes. In fact, this person (or persons) does not necessarily have to be a family member at all. Secondly, you can make your views clearly known on a variety of circumstances. An ACD helps both the family and physicians to understand and respect a patient’s personal healthcare choices and preferences. In addition, documenting things is convincing evidence about the patient’s wishes and makes it more likely that a patient will receive the adequate care they require.

Q: What happens if a person does not complete his/her own ACD? A: There is no specific answer to this question. In most cases, physicians immediately consult the patient’s family members if they are not able to speak for themselves or make their treatment decisions individually. If anACD is available, it will help avoid conflicts regarding medical treatments (or lack of treatments) among family members.

Q: After documenting an advance directive, can a patient change his/her mind, (through the course of illness/life)? If so, how to go about it?

A: It is possible to change instructions in an advance care directive (ACD) any time.

Patients can create a new form with changed instructions and discard the earlier one. Make it a point to discuss with the physician or healthcare professional about the changing medical choices and preferences, including specifics about when and what medical treatment options preferred.

Q: What does an Advance Care planning process involve?

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A: The process of advance care planning involves – 

Choosing a healthcare advocate to represent your choices if you are unable to speak for yourself

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Learning about the available life-sustaining treatment options

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Talking with your family and doctor about how you want to be treated

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Thinking about your values and talking about your decisions

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Documenting your wishes

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Designating a decision maker on your behalf (if and when the need were to arise)

Q: Who should make an advance care plan?

A: Advance care planning is particularly important for – 

Aged and elderly people who are frail

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People suffering from multiple chronic diseases such as stroke, diabetes and heart failure

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People with early memory loss or diagnosed with dementia

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People approaching their end-of-life with progressive and life-limiting conditions

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People who don’t have a person who could act as their substitute decision maker

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People whose families have different ideas about the treatment and care they would want

Q: What CPT codes are used for reporting advance care planning services?

A: Regarded as an ‘unusual service’, advance care planning is intended to address a patient’s wishes for medical care, if there arises a time or situation when they are unable to speak or make the decision individually for themselves. This is a face-toface time that a healthcare professional spends with a patient, family member or surrogate in order to discuss advance directives. Medical billing and coding service providers who have thorough knowledge about coding rules help eligible

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providers receive optimal reimbursement for end-of-life planning services. The two CPT codes to report ACP services 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 healthcare professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.

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+99498 - Each additional 30 minutes (List separately in addition to code for primary procedure).

Q: What are the requirements for CPT codes - 99497 and 99498?

A: According to the American Academy of Family Practitioners (AAFP), the requirements for code 99497 include 

Advance care planning that includes the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed)

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Is provided by the physician or other qualified health care professional

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Discussion of ACP for first 30 minutes face-to-face with the patient, family member(s), and/or surrogate

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Completion of an advance directive is only required “when performed,” and is not an overall requirement for billing ACP services.

Code 99497 can be billed on the same day as an E&M visit or [Annual Wellness Visit]. If billed with another E&M, modifier 33 should be included so the patient has no co-pay or deductible.

Code 99498 is an add-on code that is used when the encounter goes beyond 30 minutes. AAFP lists the requirements for code 99498 as follows 

Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed)



Is provided by the physician or other qualified health care professional

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

Should be used for each additional 30 minutes face-to-face with the patient, family member(s), and/or surrogate

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To be listed separately in addition to code for primary procedure

Q: What is beneficiary eligibility for advance care planning?

A: Medicare pays for ACP as either 

A separate Part B service when it is medically necessary

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An optional element of a beneficiary’s Annual Wellness Visit (AWV)

Q: Is patient presence necessary during ACP process?

A: The patient presence is not necessary during end-of-life planning process. If the patient is not in a position to participate in the conversation due to any medical illness or lack of capacity, the physician or healthcare provider can engage with an immediate family member or surrogate, as long as the discussion is face-to-face.

Q: Does the beneficiary/healthcare practice have to complete an advance directive to bill the service?

A: No, the CPT code descriptors indicate the term “when performed”, hence the completion of an advance directive is not a requirement for billing this service.

Q: Are there any specific limits on how often CPT codes 99497 and 99498 can be billed?

A: As per CPT rules, there are no limits on the number of times advance care planning services (ACP) can be reported for a given beneficiary in a given period of time. Similarly, the CMS has not established any frequency limits. When the specific service is billed multiple times for a given beneficiary, a documented change in the beneficiary’s health status and/or medical care preferences regarding his or her end-of-life care is visible.

Q: In what settings can ACP services be provided and billed- inpatient, nursinghome or others?

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A: Advance care planning services may be billed by physicians and non-physician practitioners (whose scope of practice and Medicare benefit category include the services described by the CPT codes above). In addition, they may be billed by hospitals. These services can be furnished in both facility and non-facility settings and are not limited to particular physician specialties.

Q: Can ACP be billed the same day as an Evaluation and Management (E/M) code?

A: Yes, ACP can be billed the same day as an E/M code. ACP can be billed on the same day as – 

Welcome Visit

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As a voluntary separately payable part of the AWV. Modifier 33, preventive service should be appended to the ACP code. Deductible and coinsurance do not apply.

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As a stand-alone service (Medicare deductible and coinsurance apply).

If coding the E/M by time, the documentation must clearly indicate that the ACP time does not overlap the counseling/coordination of care time for the E/M code.

Medicare deductible and coinsurance are applicable.

Q: What specific diagnosis must be used for ACP codes?

A: No specific diagnosis is required for billing ACP codes.

Q: Do deductible/coinsurance amounts apply to this code?

A: Deductible and coinsurance amounts apply only when ACP is included as an optional element of the annual wellness visit.

Coding and billing for advance care planning services (ACP) can be made simpler with reliable support from a specialist. Outsourcing medical billing tasks to a good service provider can ensure accurate claim submission and full and fair reimbursement for care management services.

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Disclaimer: The information provided in the above content has been obtained from various internet resources, and is for informational purposes only. OSI (Outsource Strategies International) cannot guarantee that the information contained in the above FAQ is in every respect accurate, complete, or up-to-date. Payment policies may vary from one payer to another and OSI assumes no responsibility for, and disclaim liability for damages of any kind, arising out of or relating to any use, nonuse, interpretation of, or reliance on the information contained in this FAQ.

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