Advance Care Planning FAQ

Using the CPT (current procedural terminology) description, there are two codes for advance care planning (ACP).

“99497 and 99498 are used to report the face-to-face services between a physician or other qualified health care professional and a patient, family member or surrogate in counseling and discussing advance directives, with or without completing relevant legal forms.”

According to the CPT manual, advance care planning involves the explanation and discussion of advanced directives; this document appoints an agent and/or records the wishes of the patient pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at that time. Examples of such forms include a Health Care Proxy, Durable Power of Attorney for healthcare, a Living Will, or Medical Order for Life Sustaining Treatment (MOLST).

In the final CY 2024 Physician Fee Schedule, the total work RVU for 99497 is valued at 2.23 RVUs, while the 99498 code is valued at 2.11 RVUs; rounded, this approximates to $49.11 and $45.83, respectively at a conversion factor of $32.74.

There is no specific training, specialty restrictions, or quality measures a provider must satisfy to perform and bill for ACP. As stated, an NPP can provide these services as well as part of an “Incident to” service. However, as “Incident to” does not pertain to services provided in the emergency department, Medicare expects the billing physician to manage, participate and meaningfully contribute to the provision of the services in addition to providing a minimum of direct supervision. CMS put out an FAQ regarding this and states in their FAQ 4 that "As we said in the CY 2016 FPS final rule (80 Fed. Reg. 70956), the services described by CPT codes 99497 and 99498 are appropriately provided by physicians or using a team-based approach provided by physicians, non-physician practitioners (NPPs) and other staff under the order and medical management of the beneficiary’s treating physician." 

Not necessarily. If the patient is unable to participate in the conversation due to medical illness or lack of capacity, the health care provider can engage with a family member or surrogate, so long as the discussion is face-to-face.

According to CMS, your documentation of the ACP discussion should include the nature of the visit, the explanation of advance directives, the names of participants present for the discussion, time spend discussing advance care planning and any change in the health status or health care wishes if the patient is not able to make their own decision. For example, was there an immediate change in the patient’s condition that led to this discussion? Are there features in the prior health history that increase the risk or likelihood of further deterioration of their condition? Completion of specific forms, such as, MOLST, DNR, Living Will, or other standard forms is not required to bill for the service.

Yes. The first code, 99497, covers the first 30 minutes of face-to-face conversation and documentation by the provider with the patient, family member(s) and/or surrogate. In order to qualify, at least 16 minutes must be performed and documented. Should you exceed 30 minutes, which is less likely in the ED setting, there is a second code, 99498, which includes each additional 30-minute increments of service. However, CPT requires that no active management of the problem(s) can be undertaken during the time period reported. When you perform another service concurrently as a time based service, CMS requires that you do not include the time spent on the concurrent service with the time based service.

The Advance Care Planning codes do appear in Appendix P of CPT, meaning that they may be reported via telehealth with a -95 modifier. CPT says ACP codes may be reported in addition to ED E/M codes. At least until the end of the Public Health Emergency, Medicare allows ED E/M codes to be reported via telehealth.

CPT allows the ACP E/M code to be billed in addition to a broad range of other E/M service codes. For the Emergency Provider, this service can be reported together with the Emergency Department E/Ms (99281-99285) and all the observation codes. ACP cannot, however, be reported with critical care services, 99291.

No, there are no limits on the number of times ACP can be used for a given beneficiary in a given period of time. CMS put out an FAQ and state in their FAQ 2 that:

"When the service is billed multiple times for a given beneficiary, we would expect to see a documented change in the beneficiary’s health status and/or wishes regarding his or her end-of-life care."

Advance Care Planning is an established CPT code. Therefore, technically any payer that professes to accept CPT coding current to the date of service ought to accept these codes, unless expressly stating otherwise or publishing other restrictions.

As of January 2016, the National Correct Coding Initiative (NCCI) – one of the major underpinnings supporting Medicare coding - indicated that the ACP codes are reportable. So the status indicator for both codes is “A,” meaning it is an active code in the Medicare physician fee schedule. As yet, there are no Medicare National Coverage Determinations for the ACPs, so it is possible that local Medicare contractors could make their own determinations.