Advance care planning (ACP) is a process of reflection, discussion, and communication that enables members to plan for when they’re no longer able to make or communicate their decisions about medical treatment and other care.
Effective January 1, 2016 ACP is a covered benefit for most Commercial plan members. ACP is not covered and will not be payable separately for the following plan coverage codes: 693, and 823.
Coverage is also available for Medicare Advantage members, please refer to the following CMS link for details and to the CMS or Noridian website for any updates. Please follow CMS billing guidelines.
For Medicare, if ACP is rendered on the same day and by the same provider as an Annual Wellness Visit (AWV), the ACP and AWV must be billed together on the same claim with modifier 33 in order for the member to have NO out-of-pocket costs for the services.
Effective July 1, 2021 ACP is a covered benefit under the HMSA QUEST Integration plan. The billing instructions below apply.
Billing Instructions
ACP should be billed as follows:
| Code | Description |
|---|---|
| 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) |
Diagnosis Codes
Select the appropriate ICD-10 diagnosis code(s) that describes the intent of the visit. If the patient is not being seen for an illness or injury, counseling diagnoses from the Z71.xx series may be appropriate for ACP.
Advance Care Planning Documentation
Please work with your patients to document their advance care plans in formal advance care planning documents, such as an advance directive, living will, health care power of attorney, or Physician Orders for Life-Sustaining Treatment (POLST), in their medical records. Documentation should include a record of patient's preferences, discussion, and questions relative to goals of care, advance directives, and durable power of attorney for health care. The length of time spent with the patient discussing ACP must also be documented in the medical records.
Advance Care Planning (ACP) Billed with other Evaluation & Management (E/M)
When billing ACP service with E/M services a modifier code must be appended to the E/M code to ensure that both services are paid when appropriate. Modifier 25 would generally be used for this purpose. The use of modifier 25 stipulates that the E/M service performed was a significant, separately identifiable service above and beyond the other service provided. Modifier codes should only be used when the service meets the criteria described in CPT and HMSA’s policies. HMSA will perform post-payment reviews of modifier usage as needed to verify modifiers were used as described. If post-payment review indicates that modifiers were not used appropriately, HMSA will request return of any overpayment.
For information on advance care planning concept, please see Advance Care Planning Concepts [PDF].
Please be sure to use the most up-to-date industry-standard procedure, revenue, and diagnosis codes from the current CPT ®'', HCPCS Level II, and ICD-10-CM manuals, as recommended by the American Medical Association (AMA), the Centers for Medicare & Medicaid Services (CMS), and the American Hospital Association.
** Codes may not be all inclusive as the AMA and CMS code updates may occur more frequently.
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform |