Medicare Billing for Advance Care Planning*

Physicians, physician assistants and nurse practitioners can bill Medicare for the time they spend in face-to-face discussions about advance care planning (ACP) and end-of-life care decisions with their patients or their patient’s beneficiaries/surrogate.

Clinicians who do not file a Part A claim for ACP time lose deserved revenue and the valuable opportunity to talk honestly and openly with their patients and proxies about the types of care they—and do not want—if they are unable to decide or speak for themselves at the end of life.

These billing codes are not limited to particular physician specialties.

ACP is also Good Patient Care

ACP has significantly improved multiple outcomes, particularly for patients with serious illness, including^1-3:

• Higher rates of completion of advance directives
• Increased likelihood that clinician and family understand and comply with patient’s wishes
• Reduced use of intensive treatments and hospitalizations at the end of life
• Enrollment in hospice
• Increased likelihood of dying in the preferred place
• Enhanced care experience; studies indicate patients want their doctor to talk to them about ACP

Generally, Medicare Administrative Contractors (MACs) ask that the ACP documentation include:

• an account of the voluntary nature of the discussion with the beneficiary or family member(s)/surrogate
• explanation of advance directives and what they involve
• details about the ACP forms (when they are completed)
• who was present

Completed ACP forms are voluntary and are not required to bill for the discussion; patients can decline ACP services at any time.

Understanding Medicare Billing For ACP

Advance care planning (ACP), which is reimbursed by the Centers for Medicare & Medicaid Services (CMS), enables clinicians** to engage in conversations about preferences at the end of life with patients, family members and/or surrogates. A clinician can bill for ACP if a patient chooses hospice and the clinician makes the referral. ACP codes have no place-of-service limitations. Successful billing for ACP requires a face-to-face discussion of short-term treatment options and/or long-term goals of care with the patient or healthcare surrogate.

Medicare pays for ACP as either⁴: 

• A separate Part-B service when medically necessary; or
• An optional element of a beneficiary’s annual wellness visit

There are no limits on the number of times ACP can be reported for a given beneficiary in each time period. However, each billing for the same patients should show documented change in health status and/or goals-of-care wishes. ACP codes may be billed for patients who have elected the Medicare hospice benefit upon completing the ACP discussion.

Use these CPT® codes to bill for ACP⁴:

• 99497 Advance care planning, including the first 30 minutes of face-to-face explanation and discussion (when performed) of advance directives such as standard forms. 
• 99498 Each additional 30 minutes. For rate information, please consult CMS’ Physician Fee Schedule.

Check that these reimbursement codes have been added to your billing system, as they may not be available until your facility approves them for use.

These ACP codes can be used on the same day as other CPT codes, as long as the other services were provided outside of the time window in which the ACP service was conducted.

For best results, contact your Revenue Cycle Manager for input on how to properly capture and bill for these services.

*This information was prepared by VITAS Healthcare and may not be further distributed or modified without prior VITAS approval. It is provided for informational purposes only without a guarantee of the correctness or completeness of the material presented. This information does not constitute billing advice; providers should always consult their own billing or revenue cycle management experts for confirmation of proper billing procedures.

**Only physicians, NPs and PAs can bill to these codes; physician assistants can make hospice referrals effective Jan. 1, 2019.

¹Deterling, K. Advance Care Planning and Advance Directives http://www.uptodate.com/contents/advance-care-planning-and-advance-directives#H37130455

²Gesme, D. et. al. “Advance Care Planning with Your Patients.” Journal of Oncology Practice. 2011 Nov; 7(6).

³Dunlay et. al. “How to Discuss Goals of Care with Patients” Tends Cardiovasc Med. 2016 26(1):36-43.

⁴Centers for Medicare & Medicaid Services, Fact Sheet: Advance Care Planning, August 2016 https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AdvanceCarePlanning.pdf