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Coding Corner: Billing for Advance Care Planning | Dennis Yi-Shin Kuo, MD, MMM

Mar 3, 2022

Dennis Yi-Shin Kuo, MD, MMM


My patient and her family came in for a follow up. She was found to have a recurrent ovarian cancer. While she still desired further treatment, she would like to have a discussion on advance care planning (ACP) given that her family members were present for this visit. How do I bill for this visit appropriately?

It is important to note that ACP services are voluntary. Medicare patients or their legal proxies have the rights to decline this discussion. Codes 99497 and 99498 are time-based CPT codes used to report the face-to-face encounter 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 the relevant legal forms. Code 99497 is billed for the first 30 minutes of the advanced care planning conversation. To bill for the add-on code 99498, the ACP conversation must last 46 minutes or longer.

You could bill separately for the E/M service that you provided to the patient to care for her active disease on the same day that you billed for advanced care planning discussion with patient and/or her family members. Keep in mind that time for the ACP discussion could not be used to meet the time-based criteria for an E/M service code. Of note, given the ACP received by the patient or the surrogate was done outside of an annual wellness visit, CMS encourages the practitioner to inform the patient/designee that part B cost sharing will apply, similar to other physician’s services.

The ACP services can also be done again in subsequent encounters. There are no limits on the frequency and the number of times that ACP can be performed for a given beneficiary over a given time period. The ACP services can also be provided in any settings. For gynecologic oncologists, these settings include inpatient care and physician’s office. In cases when the service is done multiple times for a single patient, CMS does require documentation that supports the reasons for the multiple conversations, such as a change in health status and/or personal wishes regarding her care.

In summary, when performing ACP service with patient or her designee, the medical provider must document the voluntary nature of the encounter, explanation of the advance directives, and medical-legal forms that were completed. The medical provider should also document the people who were present for the encounter and the time spent during the face-to-face encounter. In the scenario described above, the provider must enter the appropriate code for the active management of this patient’s recurrent ovarian cancer (99213-99215) based on medical complexity or time spent for the encounter on the cancer care. In addition, the provider can enter code 99497 for the first 30 minutes spent in providing ACP service and the add-on code of 99498 for at least an additional 16 minutes spent in the same discussion, with a modifier 25 for code 99497. Otherwise, the extra time spent that was fewer than 16 minutes could be added to the total time spent for the encounter of the E & M service provided.

More information can be found at CMS: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/advancecareplanning.pdf

Dennis Yi-Shin Kuo, MD, MMM, is a Gynecologic Oncologist at Albert Einstein College of Medicine / Montefiore Medical Center in Bronx, NY.

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