CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Advance Care Planning (Advance Directives) Payment Policy

This document governs coverage and reimbursement rules for advance care planning services (including CPT 99497/99498) for Blue Cross Blue Shield - Rhode Island Medicare Advantage and commercial products, and explains documentation and billing expectations for providers.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyAdvance Care Planning (Advance Directives) Payment Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date01/01

Next Review DateN/A

Key ActionDocument total time spent and discussion details in the medical record when billing 99497/99498.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

99497primary billed CPT code covered

99498add-on CPT code status

Noneprior authorization

Time documenteddocumentation requirement

Advance Care Planning Coverage Criteria

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Advance care planning services are covered for Medicare Advantage and commercial products.

CPT 99497 is covered and reimbursed when policy guidelines are met; reimbursement is subject to the payment guidelines below.

ALL of the following

Payment and billing scenarios
- 99497 is covered but NOT separately reimbursed when rendered on the same day as a Welcome to Medicare visit (G0402), an Annual Wellness visit (G0438/G0439), or a Preventive Medicine visit (CPT 99381-99397).
  Provider should not expect separate payment in this scenario.
- 99497 is covered and separately reimbursed when billed as the only service on that date or when billed with E/M codes 99202-99215.
  When 99497 is the only service, copays and deductibles apply; when filed with 99202-99215, deductible applies.

CPT 99498 is covered as an add-on code but is not separately reimbursed.

S0257 and other non-listed codes will be denied; claims should be filed with CPT 99497/99498.

Documentation requirements: the medical record must document that the service was voluntary (patient/surrogate/family given opportunity to decline), total time in minutes spent on discussion, and details of the discussion (who was involved, topics discussed, understanding of illness, spiritual factors, whether an advance directive was offered or completed, and follow-up).

Benefits may vary by group/contract; providers should refer to the Member Certificate or Subscriber Agreement for applicable office visit coverage/benefits.

Covered Codes, Billing Notes, and Documentation Time

Covered CPT CodesCPTCovered

99497	Advance care planning; first 30 minutes, face-to-face
99498	Advance care planning; each additional 30 minutes (add-on)
S0257	Counseling and discussion regarding advance directives or end-of-life care planning

Billing notesmixed

99497_note	Covered and reimbursed when policy guidelines are met; not separately reimbursed when rendered on same day as Welcome to Medicare (G0402), Annual Wellness (G0438/G0439), or Preventive Medicine (99381-99397); covered and separately reimbursed when filed as the only service on that date or when filed with 99202-99215; copays/deductibles apply when 99497 is the only service; deductible applies when filed with 99202-99215.
99498_note	Add-on code: covered but not separately reimbursed.
S0257_note	Claims filed with this code will be denied; claims should be filed with one of the CPT codes 99497 or 99498.

Documentation-time — billing and coding expectations

Documentation requirementTotal time in minutes spent on discussion must be documented in the medical record

First 30 minutesCPT 99497 applies to the first 30 minutes of advance care planning (face-to-face)

Additional timeCPT 99498 applies for each additional 30 minutes (add-on) and is covered but not separately reimbursed

Documentation detailsRecord voluntary nature, who was present, and details of the discussion (topics, understanding, offer/completion of advance directive, follow-up)

Key Definitions

Advance care planning — definition

DefinitionAdvance care planning is a service that supports conversations between patients and their doctors and nonphysician practitioners to decide what type of care may be right for them in the event of life‑limiting conditions or incapacitating illness

Distinct from advance directiveAdvance care planning involves face‑to‑face discussion and planning and is not the same as an advance directive (legal document)

Voluntary serviceVoluntary ACP per CMS is the face‑to‑face service between a physician or qualified health care professional and the patient, with or without completing legal forms

PurposeHelps patients explore understanding of illness progression, preferences for treatments, and to guide future care decisions if incapacitated

Advance directive — definition

DefinitionAn advance directive is a legal 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 capacity

FormsAdvance directives take many forms, such as wills and durable powers of attorney for health care

Role in ACPCompletion of an advance directive is not a requirement for advance care planning services but may be offered and documented during the encounter