Advance Care Planning Toolkit: CPT 99497 and 99498

Why advance care planning matters

CMS describes advance care planning as a voluntary, face-to-face talk about the care a patient would want if they could not decide. You may discuss advance directives with or without completing forms.

Patients get a chance to name what matters before a crisis. Families get words to follow instead of a guess. Clinics get a documented conversation that can be billed when the time and documentation rules are met.

CMS says physicians and non-physician practitioners, including nurse practitioners, physician assistants, and clinical nurse specialists, may bill when the service is inside their scope and Medicare benefit category and they may bill Medicare independently. Hospitals may bill in the settings the fact sheet describes. Federally Qualified Health Centers and Rural Health Clinics are paid under their own bundled rates. Hospice-employed clinicians have extra Part B limits. Use the fact sheet for those settings.

Billing basics for 99497 and 99498

99497 is the code for the first 30 minutes of face-to-face advance care planning. The visit explains advance directives, such as standard forms. Completing forms can be part of the visit when you do that work. The patient, family, or a surrogate may be present.

99498 is an add-on for each additional 30 minutes. It is not used alone. The official descriptors are on the CMS fact sheet. They are copyrighted by the American Medical Association, so this page does not reprint them.

Count only the minutes you spend on advance care planning. Do not include time spent actively managing other problems. If another timed service happens in the same visit, keep that time separate.

CMS says a unit of time is billable when the midpoint of the unit passes. There is no limit on how many times you may report ACP for a patient. When you bill it more than once, document a change in health status or in wishes about end-of-life care, or both.

What to document

• The visit was voluntary.
• You explained advance directives.
• Who was present.
• The face-to-face time spent on advance care planning.
• Any change in health or wishes if this is not the first ACP bill.

You do not need a specific diagnosis. Report the condition you discussed, an administrative exam code, or a wellness-visit diagnosis when ACP is part of the Annual Wellness Visit.

Annual Wellness Visit and modifier 33

CMS pays ACP as an optional element of the Annual Wellness Visit and as a separate Part B service. Medicare's patient page Opens in a new tab. says the patient pays nothing when this planning is part of the Welcome to Medicare visit or the yearly wellness visit and the provider accepts assignment. If planning is part of other treatment, the Part B deductible and coinsurance apply. That page states the coinsurance as 20% of the Medicare-approved amount after the deductible. This page does not convert that into a dollar fee.

CMS waives the ACP Part B deductible and coinsurance only when all of these are true:

• ACP is on the same day as a covered Annual Wellness Visit, G0438 or G0439.
• The same provider furnishes the ACP and the wellness visit.
• The ACP line uses modifier 33 (Preventive Services).
• The ACP and the wellness visit are on the same claim.

If Medicare denies the wellness visit because it was already billed this year, CMS still may pay the ACP, and it will apply the deductible and coinsurance. The waiver is not a reason to bill a second wellness visit.

CMS also says ACP may be billed in an office, a hospital, a nursing home, or at home, and through the telehealth rules in effect on the date of service. Those telehealth rules change. Check them for the date you bill. Verify this with the current CMS fact sheet before you bill.

A short conversation guide

Teams that want a tested clinical tool should use the Serious Illness Conversation Guide from Ariadne Labs Opens in a new tab.. The lines below are a plain script we wrote for a visit. They are not the Ariadne Labs guide, and they are not a complete goals-of-care curriculum.

1. Ask permission. Would it be all right to talk about the care you would want if you got sicker and could not speak for yourself?
2. Ask what they understand. What have you heard from your doctors about your health?
3. Ask what matters. If time were short, what would you want your days to be like?
4. Name the decision in plain words. Some people want CPR and a breathing machine. Some people would not want those steps if they would not get back to a life they value. What are your thoughts?
5. Name a person. Who should speak for you if you cannot speak?
6. Offer a next step. We can write this down today, or you can think about it and bring that person next time.
7. If you complete a state POLST or DNR, follow that state's signature rules. Do not hand a patient a POLST to complete alone.

Patient handouts you can print

Each family page has a print button. The hospice page also has a chart-only print button.

• Hospice, palliative care, and comfort care chart
• What a DNR order means
• POLST compared with a DNR and a living will
• Family conversation checklist
• State living will and health care power of attorney forms

A flyer patients can take home

Print this page and cut out the box, or hand the phone so a patient can scan the code.

LifeWishGuardian

Record health care wishes on video, in your own words.

Share them with the family and care team you choose.

A video does not replace a DNR, a POLST, or an advance directive.

Free on iPhone. Scan the code or search LifeWishGuardian on the App Store.

Partnerships

Hospices, palliative care teams, insurers, and health plans can ask about a branded version. Use the form on the hospices and health plans page. This toolkit does not collect a separate contact form.