CMS clarifies advance care planning coding and billing requirements

The Centers for Medicare & Medicaid Services (CMS) has revised its advance care planning (ACP) fact sheet to clarify the documentation and time requirements for this service. It highlights the following points.

1. Documentation of ACP discussions must include the following:

• The voluntary nature of the visit,
• The explanation of advance directives,
• Who was present (the patient, family member, caregiver, or surrogate),
• The time spent discussing ACP during the face-to-face encounter,
• Any change in health status or health care wishes if the patient becomes unable to make health decisions.

2. ACP services are time based and subject to CPT rules such as the following:

• Time spent on other services performed concurrently (e.g., active management of a patient’s issues) does not count toward time spent on ACP,
• CPT code 99497 covers the first 30 minutes while code 99498 covers each additional 30 minutes,
• ACP discussions of 15 minutes or less cannot be billed as ACP services but can be billed as a different E/M service (e.g., an office visit) if the other service’s requirements are met,
• A unit of time is billable when the time spent passes the midpoint (e.g., 16-45 minutes would be 1 unit of 99497, 46-75  minutes would be 1 unit of 99497 and 1 unit of 99498, and 76-105 minutes would be 1 unit of 99497 and 2 units of 99498).

Other changes to the fact sheet include adding the following:

• Medical orders for life-sustaining treatment and psychiatric advance directives as examples of advance directives,
• Payment information for Federally Qualified Health Centers and Rural Health Clinics.

For more information, see the following resources:

• CMS local coverage article on billing and coding for ACP,
• CMS ACP local coverage determination.

— Kent Moore, AAFP Senior Strategist for Physician Payment

Read the related FPM article: Advance Care Planning: Using the Health Care Team to Make Hard Conversations Easier.

Posted on March 13, 2023