Advance Care Planning (ACP) is a highly impactful service to add to a provider’s practice. However, confusion around who can deliver and bill these services keeps healthcare organizations from fully embracing and adopting the offering.
Let’s dispel some myths and clarify Medicare’s rules and requirements for ACP.
Medicare's requirements for Advance Care Planning
The Centers for Medicare & Medicaid Services (CMS) delineates reimbursement rules around ACP services, including CPT codes, time and frequency duration, and necessary documentation and activities covered.
As a quick recap, ACP is covered for traditional Medicare patients in two instances:
- ACP is delivered as an optional element of a Medical Wellness Visit (MWV), which includes the Annual Wellness Visit (AWV) or the Initial Preventive Physical Examination (IPPE).
- ACP is offered as a separate Medicare Part B medically necessary service.
Medicare waives the ACP coinsurance and the Part B deductible when ACP is performed as part of an initial or subsequent AWV visit or visits. Note that when ACP services are delivered outside the AWV, Part B cost-sharing through a deductible and coinsurance will apply.
However, the rules are different for Federally Qualified Health Centers and Rural Health Clinics. They are either paid under a special all-inclusive rate or prospective payment system (PPS), in which ACP is part of the bundled services, or as an optional element of the AWV.
Billable CPT codes for ACP
CPT code 99497 can be used for the first 16 to 30 minutes of ACP (with 16 minutes of this time focused on discussing ACP documentation).
CPT code 99498 can be used for each additional 30 minutes with at least 16 minutes that:
- Records that the ACP conversation was voluntary on behalf of the patient
- Encapsulates what was talked about
- Records who was present for the conversation
- Notes the length of time for the consultation
As an example, the following are acceptable billing scenarios:
ACP Minutes CPT Code & Units
- <15 minutes: Don’t bill any ACP services
- 16–45 minutes: Bill for one unit of CPT code 99497
- 46–75 minutes: Bill for one unit of CPT code 99497 and one unit of CPT code 99498
- 76–105 minutes: Bill for one unit of CPT code 99497 and two units of CPT code 99498
Who can provide Advance Care Planning services?
Advance Care Planning is a voluntary, face-to-face service delivered by a Medicare physician or other qualified healthcare professional.
Under Medicare Part B, CMS covers the following qualified providers in ACP delivery, including:
- Physicians of any specialty, including allopaths and osteopaths
- Nurse Practitioners
- Physician Assistants
- Clinical Nurse Specialists
Other team members may participate in the provision of ACP; however, the billing physician or qualified provider “must participate and meaningfully contribute” in addition to providing a minimum of direct supervision.
Note that non-physicians must be legally authorized and qualified to provide ACP in the state where services are provided.
ThoroughCare streamlines ACP services and billing
ThoroughCare helps healthcare organizations coordinate care in collaboration with patients. Our platform offers specialized tools for end-to-end advance directive planning, document creation, and ongoing updates.
ThoroughCare enables providers and care teams to:
- Engage patients: Start ACP conversations, including during an Annual Wellness Visit
- Document end-of-life care wishes: Easy-to-use questionnaires guide the process and help create advance directives that are legally binding in all 50 states and territories
- Identify patient values and priorities: Create a video living will and access end-of-life values and priorities exercises to enhance advance directives and guide productive healthcare proxy conversations
- Share ACP documents: The platform provides 24/7 secure, online access to advance care plans, wallet cards, and QR codes for care team members, patients, their families, and proxy or power of attorney
- ACP education: Fully inform the patient and their family on what ACP entails and how it could benefit them through materials that support different learning styles, preferences, and health literacy levels, such as videos, audio, printed worksheets, and handouts
- Care team training: Access comprehensive staff training and facilitated ACP session delivery tools
ThoroughCare seamlessly logs time spent in ACP consultation, ensures all required documentation is captured, and helps clinicians focus on engaging patients.
