By Jo-Anne Sheehan, CPC, CPB, CPPM, COC, CPC-I
Advance Care Planning is about having the provider do what he or she can to guarantee that the health care treatment a patient receives is consistent with the patient’s wishes should he become unable to make his own decisions or speak for himself.
There are several written documents available for the patient to express his wishes when it comes to his healthcare. The patient can appoint a surrogate decision-maker if he becomes unable to make his own decisions. Equally important is making sure that the surrogate knows and understands his care preferences.
Most people say they would prefer to die at home, yet only about one-third of adults have an advance directive expressing their wishes for end-of-life care.
Among terminally ill patients, fewer than fifty percent have an advance directive in their medical record.
Advance Care Planning can be developed at any time, whether a patient is sick or well. Once a patient is sick or disabled with a progressive illness that can last until death, a comprehensive care plan should be in place that considers the patient’s social supports, preferences and likely course.
The average person will live to be about 76 years old. While some older adults remain healthy and robust until very close to death, it is more likely that an older individual will have lived for two or more years with one or more chronic diseases and experienced substantial disability before dying. Along the way, he or she, and the family, will have to make what are sometimes difficult choices about health care. Considering those choices, and talking about what should or should not be done, is at the heart of advance care planning.
Definition of CPT Codes 99497 and 99498
CPT codes 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 care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate plus 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 care professional; each additional 30 minutes (List separately in addition to code for primary procedure) are used to report face-to-face services 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 completing relevant legal forms. When using these two codes, no active management of the problem(s) is undertaken during the time period reported .
Coding Scenario #1:
Patient John Doe turned 65 years old and became eligible for his Welcome to Medicare preventive visit. He scheduled an appointment one month after his 65 th birthday. His visit included a review of his medical and social history related to his health as well as education and counseling about preventive services, which included:
- Certain screenings, shots, and referrals for other care, if needed
- Height, weight, and blood pressure measurements
- A calculation of his body mass index
- A simple vision test
- A review of his potential risk for depression and his level of safety
- A written plan letting him know which screenings, shots, and other preventive services he needs.
The physician discussed end-of-life planning and provided written information about advance directives. The patient is currently in good health and able to prepare an advance directive in the event of an unexpected injury or illness which could affect his future health care decisions. Initial ACP discussion was 30 minutes in addition to the patient’s preventive visit.
|G0402 – Welcome to Medicare Visit||Z00.00 – Adult Exam without abnormal findings|
|99497-33 – Advance Care Planning, 1st 30 minutes||Z00.00 – Adult Exam without abnormal findings|
Note: Both the G0402 and 99497 are considered preventive in this coding scenario. A Medicare patient would be responsible for a copayment, co-insurance, and/or deductible for the 99497 service, unless it is performed on the same day as a wellness visit , (G0402, G0438 or G0439). In this case, append modifier 33 to CPT code 99497 and the patient will not be charged a copayment, co-insurance, or deductible . Document the time spent in the discussion (exclusive of other E/M services that day) in the medical record.
Coding Scenario #2:
Patient Jacob Marks, age 66, visited his physician’s office for his initial annual wellness visit but he also wanted the physician to examine his throat. He has had a sore throat for three days along with a low-grade fever. Nothing relieves his throat pain but he has rested as much as possible because the fever has caused him fatigue. Dr. Lang did an extended problem focus history and exam on Mr. Marks with a low complexity medical decision making based on information obtained from the visit. A rapid stress test was performed in the office to determine if the patient had strep throat. A prescription for Zithromax was prescribed and the patient was told to follow up in 10 days if he did not feel better. The final diagnosis was Streptococcal Pharyngitis.
For Mr. Marks’ initial wellness visit, Dr. Lang developed a personalized prevention help plan solely for the patient, to help prevent disease and disability based on his current health and risk factors. Mr. Marks filled out a Health Risk Assessment as part of his visit. His medical and family history was reviewed and a current list was comprised of Mr. Marks’ prescriptions as well as his current providers. Dr. Lang gave Mr. Marks personalized health advice and a list of risk factors and treatment options for his persistent low back and leg pain, six month status-post L4-5 discectomy.
In addition to the sick visit and the initial wellness exam, Dr. Lang asked Mr. Marks if he had given any thought to putting together documents for Advanced Care Planning (ACP) since the patient was already in his 66 th year and had been receiving ongoing treatment for debilitating back and bilateral leg pain for fifteen years. The physician had concerns that the patient was at high risk for falling. Both the patient and physician discussed ACP options for thirty five minutes and the physician presented the patient with a healthcare power of attorney document to be completed as well as an attorney’s name who specializes in living wills and documentation for physician orders aimed at his future scope of treatment. Mr. Marks was receptive to the information and was going to contact the attorney.
|99213-25||Level 3, established office visit||J02.0||Streptococcal Pharyngitis|
|87880-QW||CLIA Waived Rapid Strep Test||J02.0||Streptococcal Pharyngitis|
|G0438||Initial Annual Wellness Exam||Z00.00||Adult Exam without abnormal findings|
|99497-33||30 minutes face-to-face time ACP||M54.5|
|Low back pain|
Right leg pain
Left leg pain
Personal history of surgery NEC
Note: A modifier 25 was appended to CPT 99213 as a significant, separately identifiable E/M service by the same physician on the same day as another service: G0438. Modifier QW was appended to the 87880 rapid strep test which signifies CLIA WAIVED test. Modifier 33 is appended to the 99497 because the Advanced Care Planning was part of the patient’s preventive annual wellness visit . By adding the modifier 33, the patient will not be charged co-insurance, a co-payment, or a deductible for this part of his care.
Coding Scenario #3
Dr. Smith is Mary Ryan’s neurologist. Mary is a 67 year old female who has been treated by Dr. Smith for the past five years for her Parkinson’s disease. Prior to today’s visit, Mary was seen regularly for her hand tremors, muscle rigidity and other symptoms of Parkinson’s disease. Today she presents with concerns about increased difficulty thinking, understanding, and forgetfulness. Her muscle rigidity is worsening which has increased her fear of falling. Dr. Smith performs an exam on Mary and does a fall risk assessment using the 30-Second Chair Stand Test and the 4-Stage Balance Test. Mary and her spouse spend an hour going over her medications as well as her daily activities and limitations. Mary understands that her muscle rigidity and near-fall experiences are components of Parkinson’s disease. Because of Mary’s concern with recent memory lapses, she was given a six-item Cognitive Impairment Test.
Mary’s symptoms are associated with Parkinson’s disease and they continue to worsen. She and her husband are witnessing her physical health deteriorating. Because of this, Dr. Smith discussed at length with Mary and her husband the need for Mary to prepare advanced care planning (ACP) options while she is still able to think clearly and make necessary decisions regarding her care since Parkinson’s disease is a progressive disease.
Mary already has her health care proxy, also known as durable power of attorney paperwork in place and Dr. Smith has a copy scanned into her medical record. This is a document that appoints someone to make medical decisions for her if the patient is unable to do so. However, Dr. Smith discussed at length the need for her to prepare a Physician Orders for Scope of Treatment (POST). This is a document, which varies by state and is a medical order signed by Dr. Smith or another medical professional and used for Mary’s treatment.
It is generally used when the patient is nearing the end of life, such as with a terminal illness or is seriously ill. This is the document that was discussed at length with Mary and her spouse during her visit regarding Advanced Care Planning. The document would be used together with the Living Will/Advance Directive to guide all Mary’s doctors in the event that she is unable to make his/her own decisions. Once paperwork has been completed, Mary will return to the neurologist’s office to go over her Advance Directive documentation and provide a copy for her medical record.
|99214||Level 4 established patient visit||G20|
Dementia in other diseases classified elsewhere without behavioral disturbance
|99497||First 30 minutes face-to face ACP with patient||G20|
Dementia in other diseases classified elsewhere without behavioral disturbance
|99498||Additional 30 minutes face to face ACP with patient and family member|
Note: Based on the National Correct Coding Initiative, there are no edits for the combined codes E/M CPT code 99214 and ACP codes 99497 and 99498. No modifier 25 should be appended to E/M code 99214. Payer rules do vary. If an E/M or ACP deny without a modifier, query the health plan.
Common Mistakes Healthcare Providers and Coders Should Avoid When Reporting Advanced Care Planning (ACP) Services
- Only a physician or other qualified healthcare professional (QHP) may report Advanced Care Planning (ACP) codes 99497 and 99498. Medical assistants and nurses are not considered QHP.
- Incident-to billing is acceptable but the physician or QHP must manage, partake, and meaningfully give to the provision of services.
- ACP cannot be billed if services are provided over the telephone. The wording in the CPT description indicates face-to-face.
- Documentation must stipulate the time spent on ACP and who discussed this information with the physician. A patient’s family member or surrogate is acceptable if the patient is not available to speak.
- Documentation is imperative.
- Remember this is a voluntary service. Patients must be asked if they are interested in discussing ACP services. They have the option to decline.
Tips for Coders and Providers
- The definition of time in ACP codes 99497 and 99498 indicates the first 30 minutes and each additional 30 minutes. From a CPT perspective, the time requirement for this service is met when the midpoint is passed, which is 16 minutes. Verify with payers regarding their policy.
- There are no limits on the number of times ACP can be reported for a given beneficiary in a given period of time. If this service is billed multiple times, make certain documentation supports the coding.
- There is no place of service limitation.
- ACP is easier to manage if the service is provided at the same time as an Annual Wellness Visit which is performed annually. Remember, if the ACP is completed on the same day as a preventive visit, add modifier 33 to the 99497 and/or 99498 so that the ACP assumes preventive status and the patient will not be liable for a copayment, co-insurance, or deductible.
- You can bill an ACP when no annual visit is provided. However, the claim will not be considered preventive and a copayment, coinsurance or deductible will be applied if applicable.
- Make sure documentation indicates there was discussion of advance directives, with or without completing legal forms. Always indicate the amount of time spent on this service. An advanced directive is a document appointing an agent and/or recording the wishes of a patient pertaining to his or her medical treatment at a future time should he or she lack decisional capacity at that time.
- ACP can occur any time.
- ACP can be done at the same time as an Annual Wellness Visit (AWV), as part of an E/M service, Transition Care Management or Chronic Care Management.
- When scheduling an appointment, ask patients to bring in any relevant documents to serve as a guide when discussing ACP with the physician.
- In order to remain organized and effectively reach your patients, the practice can send out a letter regarding ACP at the beginning of the year and schedule this service during the AWV or whenever the patient chooses to schedule the visit. Because this is voluntary on the patient’s part, the letter will allow him or her to decide if this is something he would like to move forward with.
- ACP may be provided by any specialty, including the primary care physician, cardiologist, oncologist, and/or other specialist during the same period of time.
- Link diagnoses to the ACP codes supporting the need for ACP, if applicable or use a preventive diagnosis code with the preventive visit.
- Physician Orders for Life Sustaining Treatment (POLST) – This website has links to the programs in every state that has an end-of-life program. (Five states currently do not: AK, AL, AR, NE, & SD.)
- Maryland’s Medical Order for Life Sustaining Treatment (MOLST) – This form is used by NY, MA, OH, and MD.
- For patients who do not have a living will/advanced directive, the National Hospice and Palliative Care Organization has information as well as links to every state’s advanced directive forms. http://www.caringinfo.org/i4a/pages/index.cfm?pageid=1
- Advance Care Planning (ACP) as an Optional Element of an Annual Wellness Visit (AWV)