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Coding Guidelines for ACP Procedure Codes

Coding Guidelines for ACP Procedure Codes

Advance care planning (ACP) is the face-to-face time a physician or other qualified health care professional spends with a patient, family member, or surrogate to explain and discuss advance directives. As part of this discussion, physicians may talk about advance directives (ADs) with or without completing legal forms. An AD appoints an agent and/or records the person’s wishes about their medical treatment based on their values and preferences. In this article we discussed about coding guidelines for Advance Care Planning (ACP) for better insurance reimbursements.

Applicable Procedure Codes for ACP

  • CPT Code 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.
  • CPT Code 99498: each additional 30 minutes (list separately in addition to code for primary procedure)

Coding Guidelines for ACP Procedure Codes

  • CPT codes 99497 and 99498 are appropriately provided by physicians or using a team-based approach provided by physicians, nonphysician practitioners (NPPs) and other staff under the order and medical management of the beneficiary’s treating physician.
  • Minimum time required: CPT codes 99497 and 99498 are time-based codes, providers should check minimum time required to report these timed services. If the required minimum time is not spent with the beneficiary, family member(s) and/or surrogate to bill CPT codes 99497 or 99498, the practitioner may consider billing a different evaluation and management (E/M) service such as an office visit, provided the requirements for billing the other E/M service are met.
  • Frequency of use: There are no limits on the number of times ACP can be reported for a given beneficiary in a given time period. Likewise, the CMS has not established any frequency limits. When the service is billed multiple times for a given beneficiary, insurance carrier would expect to see a documented change in the beneficiary’s health status and/or wishes regarding his or her end-of-life care.
  • Place of service: There are no place of service limitations on the ACP codes and these services may be appropriately furnished in a variety of settings depending on the needs and condition of the beneficiary. The codes are separately payable to the billing physician or practitioner in both facility and non-facility settings and are not limited to particular physician specialties.
  • Other E/M services: CPT codes 99497 and 99498 may billed on the same day or a different day as most other E/M services, and during the same service period as transitional care management services or chronic care management services and within global surgical periods. CMS also adopted the CPT guidance prohibiting the reporting of CPT codes 99497 and 99498 on the same date of service as certain critical care services including neonatal and pediatric critical care.
  • Diagnosis codes: No specific diagnosis is required for the ACP codes to be billed. It would be appropriate to report a condition for which you are counseling the beneficiary, an ICD-10-CM code to reflect an administrative examination, or a well exam diagnosis when furnished as part of the Medicare Annual Wellness Visit (AWV)
  • Medicare waives the ACP coinsurance and the Part B deductible when the ACP is: Delivered on the same day as a covered MWV (HCPCS codes G0438 or G0439); offered by the same provider as a covered MWV; billed with modifier –33 (Preventive Services)
  • Documentation: Examples of appropriate documentation would include an account of the discussion with the beneficiary (or family members and/or surrogate) regarding the voluntary nature of the encounter; documentation indicating the explanation of advance directives (along with completion of those forms, when performed); who was present; and the time spent in the face-to-face encounter. Practitioners should consult their Medicare Administrative Contractors (MACs) regarding documentation requirements.

CPT codes, descriptions and other data are copyright 2020 American Medical Association.

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