Advance Care Planning

Effective Date:March 1, 2020

Purpose:
This policy provides guidelines for reimbursement of advance care planning.

Scope:
Products included:

  • NJ FamilyCare/Medicaid Plan
  • Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

  • 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 member(s), and/or surrogate
  • 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)

Policy:
Advance care planning is a service that supports conversations between patients and their physicians and non-physician practitioners (NPPs) to decide what type of care may be right for them in the event of life-limiting conditions or incapacitating illness. During advance care planning conversations, doctors/NPPs may talk through and help the patient plan for a time when he/she cannot make his/her own medical decisions. The patient does not have to have a terminal illness in order to perform advance care planning.

Advance care planning may be provided by physicians or using a team-based approach provided by physicians, nonphysician practitioners (NPPs) and other staff under the order and medical management of the beneficiary’s treating physician.

In order for advance care planning to be reimbursed, the following must be clearly documented within the medical records:

  • Total time spent on the advance care planning discussion
    • If the required minimum time is not met to bill CPT codes 99497 or 99498, you may consider billing a different evaluation and management (E&M) code instead
  • Details of the discussion
    • Examples of details include, but are not limited to:
      • The member’s understanding
      • The people present for the discussion
      • An advanced directive discussed, provided and/or completed

Please note that completion of an advance directive form is not a requirement for reimbursement of the advance care planning CPT codes.

Should a separate evaluation and management service be performed in the same setting as the advance care planning visit, modifier -25 must be submitted with the E&M code for proper adjudication to indicate a significant, separately identifiable, evaluation and management service was performed.

Procedure:
Horizon NJ Health shall allow advance care planning codes (99497 and 99498) billed in any place of service when the documentation requirements are met. Should the time requirements not be met and documented, Horizon NJ Health shall deny the service.

If a significant, separately identifiable, evaluation and management (E&M) service was performed during the same session, modifier -25 must be appended to the E&M in order to be separately reimbursed.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Benefit Limitations
  • The terms of any applicable provider participation agreement;
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
  • Medical necessity; and
  • Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:
Medicare Claims Processing Manual, Chapter 18- Preventive and Screening Services, Section 140.8
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18.pdf

CMS Frequently Asked Questions about Billing the Physician Fee Schedule for Advance Care Planning Services, July 14, 2016
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQ-Advance-Care-Planning.pdf

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services