Advance illness care planning / advance directives reimbursement
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Defines Blue Cross and Blue Shield of North Carolina reimbursement rules for advance illness care planning and advance directive counseling for eligible commercial, ASO, and Blue Card Host members and describes required documentation and billing codes.
No material clinical or coverage changes in this revision.
Coverage Criteria
Reimbursement criteria
Covered when the following conditions are met:
Services must be provided face-to-face when the patient is present for some or all of the discussion; services may be furnished by licensed providers (MSW, PA, NP, etc.) or under the supervision of a licensed physician.
This policy applies to services described herein for commercial, Administrative Services Only (ASO), and Blue Card Host members who receive care in the North Carolina service area. Coverage and payment are governed by the member’s benefit booklet, group contract, and subscriber certificate in effect at the time services are rendered; final payment is subject to claims adjudication and applicable fee schedules. Reimbursement policy is not an authorization, certification, explanation of benefits, guarantee of payment, or a contract and may be superseded by benefit language, contract terms, or legislative mandates. Providers are responsible for accurate coding and documentation and should be aware that failure to follow correct coding or reimbursement guidelines may result in claim review, denial, or recovery of payment.
Applicable Codes
| 99497 | Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed); 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); each additional 30 minutes. |
| S0257 | Counseling and discussion regarding advance directives or end of life care planning and decisions, with patient and/or surrogate |
Provider Actions & Billing Requirements
No prior authorization required
No prior authorization is required for advance care planning services; reimbursement is subject to the member’s benefits and final claims adjudication.
Documentation and E&M billing requirements
The advance care planning discussion must be clearly documented in the medical record; when billing an E&M on the same date, submit Modifier 25 to indicate a significant, separately identifiable E&M service.
- Documentation must include the face-to-face informative discussion between provider, patient, and/or family/caregiver.
- Medical record may include AI-generated content, recordings, or transcripts when applicable and these must be supported by documentation.
Risk of claim review, denial, or recovery
Failure to follow correct coding or reimbursement guidelines, or to submit required modifiers and supporting documentation, may result in claim review, denial, or recovery of payment.
- Claims are subject to final adjudication and applicable edits or fee schedules.
- Policies may be superseded by group contract, member benefit language, or legislative mandates—verify member benefits before billing.
Definitions
Background
Advance care planning enables patients to make decisions about future and end-of-life medical care before they become incapacitated. Discussions typically address cardiopulmonary resuscitation, use of ventilators, artificial hydration/nutrition, palliative care options, and completion of legal documents such as an advance directive (e.g., living will or health care power of attorney). Separate from advance directives are portable medical orders (for example, MOST or portable DNR), which are clinician-issued orders directing care when signed by the patient or their representative. These conversations are intended to inform patients and surrogates, document treatment preferences, and support care consistent with the patient’s goals; when billed, the discussion must be clearly documented in the medical record and meet the policy’s face-to-face and coding requirements.
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