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Summary of Medicare Coverage for
Advance Care Planning
The Centers for Medicare and Medicaid Services (CMS) have finalized the 2016 Medicare Physician Fee
Schedule, which includes a provision for advance care planning (ACP). Two CPT codes have been
established for separate payment to allow practitioners additional time to have ACP discussions with
patients.
Medicare has not made a national determination regarding this service. This means that interpretation
of how these codes may be used will be left to the discretion of regional contractors that process CMS
claims.
CPT Code Description
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;
•
99497: First 30 minutes, face-to-face with the patient, family member(s) and/or surrogate.
(≈$85.00)
•
99498: Each additional 30 minutes (list separately in addition to code for primary procedure.
(≈$75.00)
ACP services must be provided face-to-face with the patient, family member(s) and/or surrogate
(patient does not have to be present); these services cannot be furnished via telehealth.
99498 cannot be used as a stand-alone code; 99497 must be billed previously. There is currently no limit
for the number of times 99498 may be used (this may change in the future as CMS will be monitoring
the use of this code).
Who can use these CPT codes?
CMS states that physicians and other “qualified health-care professionals” may bill for ACP services
using these codes. CMS defines other qualified health-care professionals as “A physician assistant, nurse
practitioner, or clinical nurse specialist” and “a medical professional (including a health educator, a
registered dietitian, or nutrition professional, or other licensed practitioner) or a team of such medical
professionals, working under the direct supervision of a physician” as defined by CMS.
NOTE: this summary does not constitute official CMS coding advice. For further information, please contact your regional CMS office.
To clarify, these codes may be billed by physicians and NPPs whose scope of practice and Medicare
benefit category include the services described by the CPT codes and who are authorized to
independently bill Medicare Part B for these services.
How should these CPT codes be used?
These codes may be used in both facility and non-facility settings and are not limited to a particular
physician specialty. Also, ACP services may be furnished “incident to” the services of the billing
practitioner, and must include a minimum of direct supervision by the billing practitioner.
99497 and 99498 may be billed on the same day or a different day for the following evaluation and
management (E/M) services:
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new and established patient office visits (99201-99215),
observation initial, subsequent and discharge care codes (99217-99220, 99224-99226),
initial, subsequent and discharge hospital service codes (99221-99233, 99238-99239),
observation or inpatient admit and discharge on the same date (99234-99236),
outpatient and inpatient consultations (99241-99255),
emergency department visit codes (99281-99285),
initial, subsequent and discharge nursing facility care codes (99304-99316),
annual nursing facility assessment code (99318),
new, established and discharge domiciliary or rest home visit codes (99234-99337),
new and established patient home visit codes (99341-99350),
initial and periodic preventive medicine codes (99381-99397), and
Transitional Care Management Service codes (99495-99496)
However, 99497 and 99498 may not be used on same date as certain critical care services including:
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critical care codes (99291, 99292),
inpatient neonatal and pediatric critical care codes (99468-99476), or
initial and continuing intensive care services (99477-99480)
ACP services are subject to the normal 20% cost-sharing requirements unless furnished in conjunction
with the Welcome to Medicare Visit or Annual Wellness Visit (AWV). If these services are included as
part of the AWV, the new CPT codes should be used with modifier -33 so no Part B coinsurance or
deductible will be charged.
It is important to note that ACP services are voluntary – CMS is not requiring patients to discuss ACPs
with their physicians. Also, nothing in this ruling prohibits individuals from seeking independent ACP
counseling either in addition to, or separately from their physician or NPP, although CMS will not cover
those services. Finally, at this time, CMS does not require of the provider any performance standards,
special training or quality measures to bill for ACP services.
Honoring Choices Minnesota is an initiative of the Twin Cities Medical Society. For further information,
please call (612) 362-3703 or visit our website at www.honoringchoices.org.
NOTE: this summary does not constitute official CMS coding advice. For further information, please contact your regional CMS office.