CMS Publishes FAQs about Billing for Advance Care Planning

March 25, 2016
Policy Snapshot

The Centers for Medicare & Medicaid Services (CMS) recently released a frequently asked questions document about bill advance care planning (ACP) services under Current Procedural Terminology (CPT) codes 99497 and 99498 billable under Medicare starting January 1, 2016. CPT Code 99497 includes “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.” CPT Code 99498- includes “each additional 30 minutes (List separately in addition to code for primary procedure)”.

Some of the FAQs include:

  • CPT codes 99497 and 99498 are time-based codes (a base code and an add-on code). Are there minimum amounts of time required to bill these codes?
    1. In the calendar year (CY) 2016 PFS final rule (80 Fed. Reg. 70956), we adopted the CPT codes and CPT provisions regarding the reporting of timed services. Practitioners should consult CPT provisions regarding minimum time required to report timed services. If the required minimum time is not spent with the beneficiary, family member(s) and/or surrogate to bill CPT codes 99497 or 99498, the practitioner may consider billing a different evaluation and management (E/M) service such as an office visit, provided the requirements for billing the other E/M service are met.
  • In what settings can ACP services be provided and billed- Inpatient? Nursing home? Other?
    1. There are no place of service limitations on the ACP codes. As we stated in the CY 2016 PFS final rule (80 Fed. Reg. 70956), ACP services may be appropriately furnished in a variety of settings depending on the needs and condition of the beneficiary. The codes are separately payable to the billing physician or practitioner in both facility and nonfacility settings and are not limited to particular physician specialties.
  • Does the beneficiary/practice have to complete an advance directive to bill the service?
    1. No, the CPT code descriptors indicate “when performed,” so completion of an advance directive is not a requirement for billing the service.

    Additional questions have been raised related to the minimal time necessary to bill the ACP code. Per CPT convention on time-based billing, “a unit of time is passed when the mid-point is passed. For example, an hour is attainted when 31 minutes have elapsed (more than zero and sixty minutes). A second hour is attained when a total of 91 minutes have elapsed.”* That mean that the 99497, which accounts for the first 30 minutes of ACP, can be billed at 16 minutes and the additional 99498 code can be billed at 46 minutes.


    To read the entire FAQ click here.


    *Copyright AMA CPT 2016