CPT code 99497: Medicare allows $83.50 for first 30 minutes

Physicians and their staffs can receive free training on advance care planning from SOCI coaches. The training is free thanks to a grant from the Northern Colorado Medical Society and Northern Colorado Pain Management.

The training

SOCI coaches will provide on-site or classroom style training on advance care directives to physicians and their staff in Larimer and Weld counties. Topics will include:

• How to complete the advance care directive forms (Medical Power of Attorney, Living Will, CPR Directive, MOST)
• Tips on having conversations with patients and documenting their wishes.
• Hospice & Palliative Care
• Organ Donation

Who should participate:

Billing providers (physicians, NPs, PAs, social workers) can initiate the conversation with patients and trained non-billing team members can assist with the conversation and completion of the advance care directives.  Having the conversation with patients about advance care directives is a billable service. The goal will be to have more practices initiate the conversation about advance care directives with their patients and to have more patients complete their directives.

About SOCI:

Systems of Care Initiative (SOCI) is a 501(c)3 non-profit community based organization that is providing advance care planning to people in Larimer and & Weld County. The SOCI board includes representatives of UCH, Banner Health, the Health District of Northern Larimer County, NCMS, Office of Aging, Northern Colorado IPA, Telligen, Family Medicine Center, Northern Colorado Rehab Hospital and others.

To arrange training, call 970-449-6840 or email Theresa Darras CMA, theresa@socicoaching.com

About advance care planning:

Advance care planning is making those decisions that will guide health care decisions at the end of life. It is recommended for anyone 18 years or older regardless of health status and is intended to provide for an individual’s care according to their wishes should something happen such that they cannot speak or otherwise communicate. Making an Advance Care Plan involves knowing about care choices and making informed decisions when both the individual and his or her family are not in a stressful situation. It is frequently referred to as a “gift” to one’s family and loved ones to remove the burden of making painful decisions during a time of high stress.

About billing for advance care planning conversations:

CPT code 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 members(s), and/or surrogate

(Medicare allowable is $86.00)

CPT code 99498: An add-on code for additional 30-minutes time blocks (Medicare allowable is $76.00)

Both 99497 and 99498 may be billed on the same day. 99497 must always be billed for the first 30-minute period of the discussion. If the conversation goes longer, 99498 (the add-on code) is billed for each additional 30 minutes, with no limit. If an ACP discussion is initiated later in the same day, or on a separate day, 99497 is again used for the first 30 minutes and 99498 is used for each subsequent 30-minute period of those discussions.

In order to be billable under Medicare, advance care planning discussions must be face-to-face conversations with Medicare patients and/or their surrogates (the patient does not need be present), and cover the patient’s specific health conditions, their options for care and what care best fits their personal wishes, and the importance of sharing those wishes in the form of a written document.

Completion of legal advance directive forms or medical orders such as a living will, medical power of attorney, or Medical Orders for Scope of Treatment, is not required as an outcome of the conversation. The provider billing the codes must be the patient’s “managing physician” or must be providing direct supervision to the qualified health professional conducting the ACP conversation. If the billing provider does not actually conduct the ACP conversation, there is an expectation that he or she will manage, contribute, or participate meaningfully in the provision of the ACP services. The codes may be billed by physicians or “non-physician practitioners” (NPPs) whose scope of practice includes the services described by the code and who is authorized to independently bill Medicare for such services. Providers must be in compliance with all applicable Medicare rules regarding authorization to bill (hold an active license, etc.)

Can ACP be reported in addition to an E/M service (e.g., an office visit)?

CMS adopted the CPT codes and CPT provisions regarding the reporting of CPT 99497 and 99498 (see #1). This includes the CPT instructions that CPT codes 99497 and 99498 may be billed on the same day or a different day as most other E/M services, and during the same service period as transitional care management services or chronic care management services and within global surgical periods. CMS also adopted the CPT guidance prohibiting the reporting of CPT codes 99497 and 99498 on the same date of service as certain critical care services including neonatal and pediatric critical care.

What diagnosis must be used?

No specific diagnosis is required for the ACP codes to be billed. It would be appropriate to report a condition for which you are counseling the beneficiary, an ICD-10-CM code to reflect an administrative examination, or a well exam diagnosis when furnished as part of the Medicare Annual Wellness Visit (AWV).

Where can I find additional information?

See final rule policies for ACP delineated in the CY 2016 PFS final rule (80 Fed. Reg. 70955 through 70959, available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html).