Last Modified: 2/9/2023
Location: FL, PR, USVI
Business: Part A, Part B
ACP is a separate Part B service enabling Medicare patients to make important decisions over the type of care they receive and when they receive it.
ACP services may be billed by physicians and non-physician practitioners (NPPs) whose scope of practice and Medicare benefit category include the services described by the CPT codes.
There are no place-of-service limitations on ACP codes. ACP services can be appropriately furnished in both facility and non-facility settings and are not limited to specific physician specialties.
• 99497 -- ACP including explanation and discussion of advance directives (first 30 minutes)
• 99498 -- each additional 30 minutes, list separately in addition to code for primary procedure
Note: This is an add-on code; therefore, payment for the service is unconditionally packaged (assigned status indicator ‘‘N’’) under OPPS.
• No set frequency guidelines
• When the service is billed multiple times for a patient, we would expect to see a documented change in the patient’s health status and/or wishes regarding end-of-life care.
• Waived when billed with annual wellness visit (AWV) (code G0438 or G0439) on the same claim, same day and furnished by the same provider.
• Waived for ACP once per year.
• Payment for an AWV is limited to once per year.
• Add modifier 33 if billed along with AWV.
• If the AWV billed with ACP is denied for exceeding the once per year limit, the deductible and coinsurance will be applied to the ACP.
• ACP can be an optional element of initial or subsequent AWV upon agreement with the patient.
• Face-to-face by physician or other qualified health care professional with patient, family members(s) and/or surrogate.
• Voluntary ACP means the face-to-face service between a physician (or other qualified health care professional) and the patient discussing advance directives, with or without completing relevant legal forms.
• An advance directive is a document appointing an agent and/or recording the wishes of a patient pertaining to medical treatment at a future time should the patient lack decisional ability at that time.
• Document time for ACP separately.
• Critical access hospitals (CAHs) may also bill for ACP using type of bill 85X with revenue codes 96X, 97X, and 98X.
• CAH Method II payment is based on the lesser of the actual charge or the facility-specific Medicare physician fee schedule.
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