In this document, Independence Blue Cross (IBX) seeks to address common questions about Advance Care Planning (ACP) and its reimbursement policy for these services.
1) What is Advance Care Planning (ACP)?
Advance care planning (ACP) is a discussion between a health care provider and the patient/individual discussing their goals, values, beliefs, and preferences regarding future medical care (advance directives), with or without completing relevant legal forms. ACP services are time-based services and active management of the individual's health conditions should not be recorded under ACP service codes. Brief conversations lasting a few minutes (performed during an Evaluation and Management (E/M) service) related to wishes concerning potential emergent resuscitation do not represent ACP services. The “face-to-face" (in-person or telehealth) time is defined as only that time spent by the health care provider “face-to-face" with the individual, with or without the presence of a surrogate, such as a health care agent, designated decision maker, family member, or caregiver .
2) What is an advance directive?
An advance directive is a written document that an individual uses to appoint a representative and/or to record the individual's wishes as it relates to future medical treatment in the event the individual is incapacitated and unable to make decisions on their own. Types of written advance directives include, but are not limited to:
- Health care proxy
- Durable power of attorney for health care
- Living will
- Medical orders for life-sustaining treatment (MOLST)
- Physician orders for life-sustaining treatment (POLST)
3) Does IBX reimburse providers for ACP?
ACP services are covered and eligible for reimbursement consideration by IBX when the following requirement is met:
The individual has a face-to-face or telehealth (audio and visual) encounter with a health care provider (physician or nurse practitioner) to discuss the advance directives.
Telephone audio-only conversations with the family members and/or health care surrogates, without the individual's presence, are not considered as ACP services.
When ACP service is reported more than once in a calendar year, a change in the individual's health status and/or wishes about end-of-life care must be documented in the individual's medical record.
For more information, please view the following IBX policies:
4) Is legal document completion required to bill ACP services?
No. However, we encourage providers to formally document the patient's goals, values, beliefs, and preferences regarding future medical care to allow for this information to be readily available in the future.
5) Which CPT® codes should be used when billing for ACP?
ACP services are represented by CPT codes 99497 and 99498.
- 99497 = the first 30 minutes
- 99498 = each additional 30 minutes
6) Is there a frequency limitation on ACP services?
There is no frequency limitation on ACP services in a calendar year period. When an ACP service is reported more than once, a change in the individual's health status and/or wishes about end-of-life care should be clearly documented in the individual's medical record.
7) Will IBX conduct audits for individuals with multiple ACP claims?
IBX may conduct audits for individuals with multiple ACP claims. Documentation would be expected to support the reasonable and necessary use of ACP as evidenced by the following:
- The content and the medical necessity of the ACP-related discussion
- Voluntary participation in ACP by the individual, or in the case of absent decision-making capacity, by the family member or surrogate
- A change in health status or advance care wishes in order to support repetitive provision of ACP services
- The scenario for the service: face to face, by phone as a telehealth service including audio and/or video communication
- The time spent solely for provision of ACP services
- The names of participants involved in the discussion
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.
IBX may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to IBX upon request. Failure to produce the requested information may result in a denial for the service.
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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.