Advance Care Planning 99497, 99498

Primary care practices perform countless tasks every day for which the payment is: nothing, zero, nada. CMS continually states that it wants to support primary care, and in the past few years has added payment for some non-face-to-face services, including Care Plan Oversight, Transitional Care Management and Chronic Care Management. In 2015, the AMA developed new codes to pay for discussions of end of life planning, but in 2015, CMS didn’t allow them as payable services. However, starting in January, 2016, CMS will recognize and reimburse physicians and Non-Physician Practitioners to provide this service, using CPT codes 99497 and 99498.

These are time-based codes. 99497 is for the first 30 minutes, and 99498 is an add on code, for each additional 30 minutes. These codes were defined in the 2015 CPT book.

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 professional; first 30 minutes, face- to-face with the patient, family member(s) and/or surrogate); and an add-on CPT code 99498 (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 professional; each additional 30 minutes (List separately in addition to code for primary procedure))

This service is a face-to-face service, but the beneficiary does not need to be present. The CPT code is defined as “with the patient, family member(s) and/or surrogate.” Forms may be completed, but they aren’t required. When CPT says “when performed” the service may be reported even if that portion of the service was not performed. The service may be performed on the same day as an E/M service, except for adult or pediatric critical care, and in the office or in a facility, such as a hospital or nursing home. CPT describes it as being performed by a physician or “other qualified health professional” and CMS states by a physician or “non-physician practitioner” within their scope of practice. This means physician, NP or PA. The service may be performed during a global period or in the same month as TCM or CCM.

CMS has not developed a national coverage determination. Individual Medicare Administrative Contractors will develop their own policies. CMS hasn’t placed frequency limits on the service, realizing that as a patient’s condition changes, the physician and patient and family may need to re-discuss these critical issues. There is not a limit on the specialty designation of the physician or NPP who provides the service. The service may be performed in an RHC or an FQHC, but those centers will be paid their all-inclusive rate for a visit, and won’t receive any additional payment. A Medicare patient will be responsible for a co-pay and deductible for the service, unless it is performed on the same day as a wellness visit, (G0438 or G0439). In that case, append modifier 33 to the ACP code and the patient will not be charged a co-pay or deductible.   Document the time spent in the discussion (exclusive of other E/M services that day) in the medical record.

Payment is modest: about $80 for 99497.


32 thoughts on “Advance Care Planning 99497, 99498

  1. Two questions- does 99497 require a minimum of 30 minutes (in other words if we spend 10 minutes can we bill 99497) and can some of the total time spent on advanced planning be done by a nurse or MA (or do we only report the physician/NP time)?

  2. The definition for 99497 states “First 30 minutes.” At this time, CMS has NOT stated that at least half the time (ie. 16 minutes) be met to bill for the service. It would be nice to get some guidance since there is much confusion. As it reads now, it seems that if 1-30 minutes are spent on the service, it meets criteria. For 99490, the definition reads “at least 20 minutes” so there is much more clarity.

    • CMS did state on their Open Door Forum that they would be using CPT rules, and that the threshold time would be 16 minutes. Dr. Rogers was on the call and said he thought it would take longer than 16 minutes, but the policy person confirmed the use of the CPT codes. It was the first question when they opened the phone for questions. Individual Medicare Administrative Contractors may set up their own policies, but this is what the policy folks on the Open Door Forum said.

      • Please confirm- The Idaho Medical Associated put out an article in the IMA Wire on Feb 1 2016 stating the information you stated above has since been changed per an open door forum. See article below. I cannot find information to support this and am needing clarification. Is the threshold time considered 16 minutes or not?

        UPDATE: Advanced Care Planning Time Requirement In a Centers for Medicare
        and Medicaid Services (CMS) Open Door Forum in November 2015, William Rogers, MD, director of the
        Physicians Regulatory Issues Team, was asked if CMS would follow standard CPT guidelines regarding the
        time requirement for CPT codes 99497 and 99498. These are advanced care planning codes that
        Medicare begin covering January 1, 2016. He answered that they would and he hoped that providers were
        spending at least 16 minutes having this very serious conversation with patients.
        However, during the Open Door Forum on January 29, 2016, Dr. Rogers walked back that statement and
        said he was not ready to make a definitive statement regarding whether CMS would follow CPT guidelines
        and certify that the time requirements would be met once the midway point had been reached.
        The Idaho Medical Association penned an article printed in the January 1, 2016 Wire, based on the
        information available at the time. The January article contained the statement, “As time based codes, a
        unit of time is achieved when the mid-point is passed. For example, half an hour is attained when 16
        minutes or more have elapsed.” Because of Dr. Rogers’ statement during the most recent CMS Open Door
        Forum, providers should make sure that the 30 minutes listed in the code description, is performed and
        documented to avoid any confusion.
        The IMA reimbursement staff will continue to monitor CMS communications in the hopes that they provide
        a documented clarification regarding time when billing advanced care planning codes 99497 and 99498.

      • I was on that call, and that is not my memory of what Dr. Rogers said. The policy staff agreed with using the CPT rules to document time, and meet the 50% threshold. Dr. Rogers said he believed the discussion would take more time than 16 minutes from a medical perspective, not that it was required.

  3. Betsy, I am having a problem getting any of these paid, I keep getting the denial reason wrong location. My hospitalists are providing this service for inpt’s, but I can’t find anything definitive except that outpt services are okay. but I do find “Critcal Care Access Hospitals are included. Is this only for outpt/obs pt’s in a critical care access hospital?
    My palliative care team wants to use these codes, but if the patient is “end of life” does this counseling still apply as “Advanced Planning? I’m confused!! Thanks for your help. Cheryl Shrum

    • I heard from someone in New England that NGS was denying these, but then corrected the edit. Your MAC is incorrect. See if you can get your physician to call the medical director.
      As to using it for Palliative care discussions, I would think that you could–once–if the patient’s condition changes and the patient and/or family is making new decisions. If you are implementing and discussing the decisions made at a prior time, I would not report it.

  4. We are being denied payment for 99497 when billed with hospitalist E&M codes such as 99220. We are being told this is bundled. CPT Assist indicates these are paid separately?

    • Not bundled, as both the CPT book and CPT Assistant both say. Only bundled into critical care codes. Take a good look at the documentation and be sure the ACP time is supported separate from the OBS admission. If so, I would appeal with the notes and the CPT references.

  5. Even with applying the 33 modifier they are not getting paid with Healthspring and Humana Medicare Advantage if an injection 96372 is billed on the same day. It is bundled together.

  6. Is there any definitive clarification of who must provide ACP services? Can it be billed “incident to” some other staff member? Like an Outreach/Enrollment Specialist or BSW?

    • CMS has been clear that this is physician or NPP work, as stated in CPT> For incident to, the physician or NPP should see the patient, begin the discussion. Then, if forms need to be completed, someone with training and education in this topic could help fill out the forms. CMS did not directly answer “who” could do it, but did say that it was physician and NPP work. Personally, I wouldn’t recommend having someone else do it.

      • Thanks for your response. Just to clarify your response, you wouldn’t recommend having someone else do it….you wouldn’t recommend having someone else do the discussion or fill out the forms? What we would be looking at is the physician seeing the patient, discussing with the patient, and then having a staff person help in filling out the form. Does that seem like it would be under compliance? If so, can the form completion time be billed incident to?
        Thanks again for your help!

  7. Any information about Licensed Clinical Social Worker being able to bill in a hospital setting for this service? I can bill for Mental Health sessions at my other job in a clinic. As a Medical Social Worker in a Medical Acute setting, or in a Medical Clinic, would I be able to bill? thanks for your thoughts! Ann

    • You couldn’t bill in a hospital setting if your salary is an expense on the Part A cost report. Check with your CFO. You would have to bill this incident to a physician service, and meet all incident to rules. CMS and CPT both say this is the work of a physician, NP or PA.

  8. Hello Dear Betsy i need to know about the advanced directive codes 99497 and 99498 can we use these codes when we are discussing advanced directive with patient at the time of physical,what Dx code we should use the same as physical Z00.00? and what modifier it requires modifier 33 ? please help us out …

  9. HI. Thank you for article. Please clarify what modifier to use when billing 99497 along with Inpatient E/M codes? Thank you.

  10. Dear Betsy, We were under the impression that this is part of AWE visit and our provider has been always discussing it with our patient. I heard about this benefit just a couple of weeks ago so I went ahead and billed Medicare for 99497 on a separate claim for the services we provided since Jan 2016. I also appended modifier 33 because AWE had been done on the same day and used dx Z0000. The outcome was denial from Medicare:
    B15 : Claim/service denied because this service is not paid separately
    Your thoughts on this will be appreciated.
    p.s. most of these claims were initially billed as G0439, in conjunction with E&M.

    • 99497 is included only in the Welcome to Medicare visit, (G0402) not the initial or subsequent wellness visits (G0438 and G0439.) Use a diagnosis, rather than an exam diagnosis. Appeal with this CMS document.

      Only bill 99497 if your physician/NP/PA personally spent at least 16 minutes in advance care planning in addition to the wellness visit and documented the time.

      • Dear Betsy,
        Thanks for the response. Please note I exactly followed the cms guidelines as indicated in the article below:
        Article Mm9271 downloads
        “Effective January 1, 2016, when ACP services are provided as a part of an AWV, practitioners would report CPT code 99497 (plus add-on code 99498 for each additional 30 minutes, if applicable) for the ACP services in addition to either of the AWV codes G0438 and G0439. CPT codes 99497 and 99498 used to describe ACP are separately payable under the Medicare Physician Fee Schedule (MPFS). When voluntary ACP services are furnished as a part of an AWV, the coinsurance and deductible would not be applied for ACP. Under that circumstance, both the ACP and AWV must also be billed together on the same claim. In order to have the deductible and coinsurance waived for ACP when performed with an AWV, the ACP code(s) must be billed with modifier 33 (Preventive services). Since payment for an AWV is limited to only once a year, the deductible and coinsurance for ACP billed with an AWV can only be waived once a year.”

        With all said above, what I m suspicious of is that Medicare wouldn’t want to reimburse my three services (G0439, 99214, 99497) under on claim. (?)

  11. I am a licensed clinical social worker can I bill this code if I have my own Medicare NPI Number? My thought is I would get independent referrals from the doctor to assist the patients? The doctor wants to know can I submit my own billing ? Thanks so much

  12. I’m confused I thought I read that non-physician practioners such as social workers and RNs could provide 99497 services as long as they were ordered by the physician. Can you provide the documentation where CMS says it cannot be a social worker?

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