Who can provide advance care planning (CPT codes 99497 and 99498)?

Only a physician or other qualified health care professional (QHP) may report these evaluation and management (E/M) services. Clinical staff such as medical assistants and registered nurses do not qualify as QHPs. CPT defines a QHP as a person qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his or her scope of practice and independently reports that professional service.The Centers for Medicare & Medicaid Services (CMS) recognized that nonphysician providers working incident-to a physician or QHP may participate in advance care planning, but the physician or other QHP billing for the service is expected to manage, participate, and meaningfully contribute to the provision of the services, in addition to providing a minimum of direct supervision. State scope of practice regulations and individual payers' policies may also impact who may provide these services.

Can advance care planning be provided by telephone?

No. Advance care planning as described by CPT is a face-to-face E/M service.

When advance care planning is provided in conjunction with a Medicare annual wellness visit, is it paid as a preventive medicine service?

Yes. Advance care planning is a preventive service only when provided in conjunction with an annual wellness visit and reported with modifier 33 attached to the advance care planning code (e.g., 99497-33). If advance care planning is provided on a date when no annual wellness visit is provided or when a claim for an annual wellness visit is denied, the advance care planning is not considered a preventive service and the patient will be responsible for the deductible and coinsurance.

Does a provider need to spend a full 30 minutes providing advance care planning in order to report code 99497?

From a CPT perspective, the time requirement for this service is met when the midpoint is passed (i.e., 16 minutes). Payers may adopt different policies requiring that time thresholds be met or exceeded.