Advance care planning

Applies to:

Commercial HMO, EPO, POS and PPO group plans (fully funded and self-funded)

Commercial MyPriority HMO, POS and PPO individual plans

Medicare plans, individual and employer group

Definition:

Advance care planning is a process that enables individuals to make plans about their future health care. Advance care plans provide direction to healthcare professionals when a person is not in a position to either make and/or communicate their own healthcare choices. Advance care planning is applicable to adults at all stages of life. Participation in advance care planning has been shown to reduce stress and anxiety for patients and their families, and lead to improvements in end of life care.

The main components of advance care planning include the nomination of a substitute decision maker, and the completion of an advance care directive.

Medical policy

Experimental/Investigational/Unproven Care/Benefit Exceptions - 91117 - Appendix A, Advance Care Planning Assessment

Clinical practice guideline

Advance care planning billing, commercial plans

Advance care planning (ACP) is generally considered a preventive health service.

ACP benefits are therefore not subject to copays, deductibles or coinsurance. There are no limits on the number of times these codes can be billed per year.

Advance care planning billing, Medicare

Incident to physician service: ACP is covered as a separately billed service subject to member's deductible and cost share if not a voluntary element during the annual wellness visit. No limit on number of visits.

Advance care planning codes covered

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

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.)

Providers eligible

Advance care planning/counseling is payable to any qualified health provider with the training necessary to provide this service. This includes:

  • RNs
  • Certified NPs
  • PA-Cs
  • Licensed Masters Social Workers (LMSWs)
  • Psychologists (LLPs and PhDs)
  • Certified Diabetic Educators (CDEs)
  • Registered Dieticians and Masters'- trained nutritionists
  • Clinical Pharmacists
  • Respiratory Therapists

Documentation required

These are the minimum documentation requirements for advance care planning discussions:

  • (Required) A person designated to make decisions for the patient if the patient cannot speak for him or herself
  • (Required) The types of medical care preferred
  • (Required) The comfort level that is preferred
  • (Required for Medicare Advantage only): Patient consent for ACP performed as part of an annual wellness visit
  • How the patient prefers to be treated by others
  • What the patient wishes others to know

Adequate documentation also requires an indication of whether or not an advance directive or POLST (physician orders for life-sustaining treatment) document has been completed.