Basics for CPT code 99497, 99498, 1123F & 1124F

Advance care planning (ACP) involves learning about and considering the types of decisions that will need to be made at the time of an eventual life-ending situation and what the patient’s preferences would be regarding those decisions. Discussions between the patient’s physician(s) or other qualified health care professional(s), and the patient along with family member(s), or surrogate(s) ahead of time, regarding these decisions and preferences, and preparation of an advance directive, increases the likelihood a patient will receive the care he or she prefers at the end of life.

An advance directive is a legal document that is used to appoint an agent and/or record the wishes pertaining to a patient’s medical treatment at a future time should the patient lack decisional capacity at that time. The advance directive document goes into effect only if a patient is incapacitated and unable to unable to communicate, regardless of age. Examples of written advance directives include, but are not limited to, Health Care Proxy, Durable Power of Attorney for Health Care, Living Will, and Medical Orders for Life-Sustaining Treatment (MOLST).

These services are time-based services that do not involve any active management of problems during the course of the face-to-face service between the provider and a patient, family member, or surrogate and may be reported on the same day as another E/M service. CPT code  99497 is reported  for the first 30 minutes of advance care planning and CPT code 99498 for each additional 30 minutes. Services typically provided under CPT codes 99497 and 99498 satisfy the requirement of Advance Care Planning discussed and documented, minutes. If a patient received these types of services, submit CPT II 1123F or 1124F.

The Center for Medicare & Medicaid Innovation’s (the CMS Innovation Center’s) BPCI Advanced Model rewards health care providers for delivering services more efficiently, supports enhanced care coordination, and recognizes high quality care. Hospitals and clinicians should work collaboratively to achieve these goals, which have the potential to improve the BPCI Advanced Beneficiary experience and align to the CMS Quality Strategy goals of promoting effective communication and care coordination, highlighting best practices, and making care safer and more affordable. A goal of the BPCI Advanced Model is to promote seamless, patient-centered care throughout each Clinical Episode, regardless of who is responsible for a specific element of that care.

The ACP measure is in the Administrative Quality Measures Set and applies to all inpatient and outpatient Clinical Episodes included in the BPCI Advanced Model.

The ACP measure selected for BPCI Advanced follows NCQA’s provider level measure, “Advance Care Plan,” (ACP) specifications endorsed by NQF (#0326) and appears in the Quality Payment Program (QPP) as measure #47.

Denominator

All patients aged 65 years and older

DENOMINATOR NOTE: Eligible clinicians indicating the Place of Service as the emergency department will not be included in this measure.

Denominator Criteria (Eligible Cases):

Patients aged ≥ 65 years on date of encounter 

AND

Patient encounter during the performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99291, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439

Numerator

Patients who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan

Numerator Instructions: If patient’s cultural and/or spiritual beliefs preclude a discussion of advance care planning, submit 1124F.

NUMERATOR NOTE: The CPT Category II codes used for this measure indicate: Advance Care Planning was discussed and documented. The act of using the Category II codes on a claim indicates the provider confirmed that the Advance Care Plan was in the medical record (that is, at the point in time the code was assigned, the Advance Care Plan in the medical record was valid) or that advance care planning was discussed. The codes are required annually to ensure that the provider either confirms annually that the plan in the medical record is still appropriate or starts a new discussion.

The provider does not need to review the Advance Care Plan annually with the patient to meet the numerator criteria; documentation of a previously developed advanced care plan that is still valid in the medical record meets numerator criteria.

Services typically provided under CPT codes 99497 and 99498 satisfy the requirement of Advance Care Planning discussed and documented, minutes. If a patient received these types of services, submit CPT II 1123F or 1124F.

Description of  CPT code 99497, 99498, 1123F & 1124F

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  each additional 30 minutes (List separately in addition to code for primary procedure)

1123F  Advance Care Planning discussed and documented advance care plan or surrogate decision maker documented in the medical record (DEM)1 (GER, Pall Cr)5

1124F Advance Care Planning discussed and documented in the medical record, patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan (DEM)1 (GER, Pall Cr)5

Numerator Options:

Performance Met:

Advance Care Planning discussed and documented; advance care plan or surrogate decision maker documented in the medical record (1123F)

OR

Performance Met:

Advance Care Planning discussed and documented in the medical record; patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan (1124F)

OR

Performance Not Met:

Advance care planning not documented, reason not otherwise specified (1123F with 8P)