CurrentPriority Health MedicarePolicy 001

Advance Care Planning

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This policy governs billing, coding, documentation, and reimbursement requirements for advance care planning services for Priority Health commercial and Medicare Advantage members. It applies to qualified health professionals submitting claims for ACP services.

Policy Summary

PayerPriority Health Medicare

PolicyAdvance Care Planning

Policy CodePolicy 001

Change TypeAdministrative update

Effective DateNovember 11, 2024

Last ReviewAug 1, 2026

Next Review DateN/A

Key ActionDocument only the time spent on the ACP discussion and exclude time spent on concurrent services.

SourceLink

POLICY UPDATE CHANGES

A disclaimer section was added in February 2025.

1 per quarterCommercial ACP preventive-service frequency

1 per yearMedicare ACP preventive-service frequency with AWV

99497 / 99498CPT codes for ACP services

Under 15 minutesACP conversation duration billed with another E&M code

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CurrentPriority Health MedicarePolicy 001

Advance Care Planning

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Sign up for priority_health_medicare Policy 001 alerts

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Policy Summary

PayerPriority Health Medicare

PolicyAdvance Care Planning

Policy CodePolicy 001

Change TypeAdministrative update

Effective DateNovember 11, 2024

Last ReviewAug 1, 2026

Next Review DateN/A

Key ActionDocument only the time spent on the ACP discussion and exclude time spent on concurrent services.

SourceLink

POLICY UPDATE CHANGES

A disclaimer section was added in February 2025.

1 per quarterCommercial ACP preventive-service frequency

1 per yearMedicare ACP preventive-service frequency with AWV

99497 / 99498CPT codes for ACP services

Under 15 minutesACP conversation duration billed with another E&M code

Qualified professionals

Providers eligible to bill ACP

Advance Care Planning Coverage

Commercial plan ACP billing

Commercial plan ACP services are covered when all applicable billing, timing, and documentation requirements are met.

ALL of the following

ACP is reimbursable as a preventive service once per quarter. Additional billings are considered only when documentation supports a change in the member's health status or wishes.
Cost share may apply according to the member's plan benefits.
ACP services are time-based; reported time must include only the period of ACP discussion and exclude time spent on concurrent services.
The time associated with ACP must be documented in the medical record.
Advance care planning includes the explanation and discussion of advance directives, including completion of standard forms when performed, by the physician or other qualified health care professional.
ACP conversations lasting less than 15 minutes should be included in another E/M code.
Modifier 33 should be billed when ACP is considered a preventive service.
The medical record documents that the visit was voluntary.
The medical record identifies who was present for the visit.
The medical record identifies a designated person to make decisions on behalf of the patient if the patient cannot speak for themselves.
The medical record documents the patient's preferred types of medical care.
The medical record documents the patient's preferred comfort level.
The medical record documents any change in health status from the previous ACP visit.
The medical record indicates whether an advance directive or POLST (physician orders for life-sustaining treatment) document has been completed and explains any advance directive.

Medicare ACP billing

Medicare ACP services are covered when the applicable annual wellness visit (AWV) or separately billed service requirements are met, with required documentation.

ALL of the following

ACP services are time-based; reported time must include only the period of ACP discussion and exclude time spent on concurrent services.
The time associated with ACP must be documented in the medical record.
ACP services are billed using the applicable ACP codes: 99497 for the first 16 to 30 minutes face-to-face with the patient, family member(s), and/or surrogate; and 99498 for each additional 30 minutes.
ONE of the following billing circumstances
- Billed with an annual wellness visit (AWV)
  - ACP is paid as a preventive service once per year when billed with an AWV.

Codes, Modifiers, and Billing Thresholds

Covered CPT CodesCPTCovered

99497	Advance care planning, including explanation and discussion of advance directives, first 16 to 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.
99498	Advance care planning, each additional 30 minutes.

Covered ModifierModifierCovered

33	Modifier 33; bill when ACP is considered a preventive service, including on the same claim as an AWV when applicable.

Diagnosis CodingICD-10

No codes listed

Initial ACP time threshold

Threshold16 to 30 minutes

CodeCPT 99497

Service formatFace-to-face with the patient, family member(s), and/or surrogate

Additional ACP time increment

IncrementEach additional 30 minutes

CodeCPT 99498

Service

Billing and Documentation Requirements

Billing Rule

Repeat ACP Billing Requires Support

Bill ACP services more than once only when the member has a change in health status or wishes, and include the change in the documentation. ACP is reimbursable as a preventive service once per quarter when not billed with an AWV; additional billings require supporting documentation. When billed with an AWV, ACP is paid as preventive once per year and does not require a change in health status or wishes.

Not billed with an AWV: ACP is separately billed and subject to the member’s deductible and cost share.
Billed with an AWV: the service must be billed on the same day and by the same provider as the AWV.

Documentation Required

Document ACP Discussion Time

ACP is time-based. Document only the time spent on the ACP discussion in the medical record; exclude time spent providing concurrent services.

Key Terms

Advance care planning (ACP)

DefinitionA process that enables individuals to make plans about their future health care

PurposeProvides direction to health care professionals when a person cannot make or communicate health care choices

Main componentsNominating a substitute decision maker and completing an advance care directive

POLST

MeaningPOLST means physician orders for life-sustaining treatment

DocumentationDocument whether the POLST document has been completed

Related explanation

Policy Summary

PayerPriority Health Medicare

PolicyAdvance Care Planning

Policy CodePolicy 001

Change TypeAdministrative update

Effective DateNovember 11, 2024

Last ReviewAug 1, 2026

Next Review DateN/A

Key ActionDocument only the time spent on the ACP discussion and exclude time spent on concurrent services.

SourceLink

On This Page

The ACP service is billed on the same day and by the same provider as the AWV.

A change in health status or wishes is not required for ACP services billed with the AWV.

Codes 99497 and 99498 are billed on the same claim as the AWV using modifier 33.

The documentation indicates that the visit was voluntary.

The documentation identifies who was present for the visit.

The documentation identifies a designated person to make decisions on behalf of the patient if the patient cannot speak for themselves.

The documentation records the patient's preferred types of medical care.

The documentation records the patient's preferred comfort level.

The documentation records any change in health status from the previous ACP visit.

The documentation includes patient consent for ACP performed as part of an AWV.

The documentation indicates whether an advance directive or POLST (physician orders for life-sustaining treatment) document has been completed and explains any advance directive.

Not billed with an annual wellness visit

ACP is covered as a separately billed service and is subject to the member's deductible and cost share when it is not a voluntary element during the AWV.
ACP benefits are coded multiple times per year only when the member has a change in health status or wishes; the changes must be included in the documentation.
The documentation indicates that the visit was voluntary.
The documentation identifies who was present for the visit.
The documentation identifies a designated person to make decisions on behalf of the patient if the patient cannot speak for themselves.
The documentation records the patient's preferred types of medical care.
The documentation records the patient's preferred comfort level.
The documentation records any change in health status from the previous ACP visit.
The documentation indicates whether an advance directive or POLST (physician orders for life-sustaining treatment) document has been completed and explains any advance directive.

Advance care planning

Short ACP conversation threshold

Conversation durationLess than 15 minutes

Billing instructionInclude the conversation in another E&M code

Applicable serviceAdvance care planning

Commercial preventive-service frequency

Standard frequencyOnce per quarter

Additional billingConsidered when documentation supports a change in health status or wishes

Cost shareMay apply according to the member’s plan benefits

Medicare AWV preventive-service frequency

Preventive-service frequencyOnce per year

Billing conditionBilled with an annual wellness visit (AWV)

Same-day requirementBilled on the same day as the AWV

The documented ACP time must reflect the actual ACP discussion period.

Documentation Required

Required ACP Documentation

Document the complete ACP discussion, including its voluntary nature, participants, the patient’s designated decision maker, care and comfort preferences, relevant changes since the prior ACP visit, and advance-care-planning documents.

State that the visit was voluntary and identify who was present.
Identify the person designated to make decisions if the patient cannot speak for themselves.
Record preferred types of medical care and the patient’s preferred comfort level.
Document any change in health status or wishes from the previous ACP visit.
Indicate whether an advance directive or POLST has been completed and explain any advance directive.
When ACP is performed as part of an AWV, document patient consent for the ACP.

Billing Rule

AWV Billing Requirements

When ACP is billed with an annual wellness visit, meet all related billing requirements: bill ACP on the same day, by the same provider, and on the same claim as the AWV. A change in health status or wishes is not required for ACP billed with the AWV.

Bill codes 99497 and 99498 on the same claim as the AWV.
Append modifier 33 when ACP is billed as part of an AWV.
ACP billed with an AWV is paid as preventive once per year.

Denial Risk

Payment Integrity and Denial Risk

Payment is subject to applicable government guidance, policy, provider-manual, contractual, authorization, medical-necessity, coding, and billing requirements. Incomplete documentation or noncompliant claims may be denied, rejected, or subject to payment recovery.

Authorization does not guarantee payment or supersede coding, billing, reimbursement, or documentation requirements.
Report CPT, HCPCS, and revenue codes only for services performed and fully documented to the highest level of specificity.
Failure to document services rendered may result in denial; Priority Health may conduct pre- or post-claim payment-integrity reviews and recover or recoup payments.
CMS and/or MDHHS guidelines apply unless otherwise specified, and applicable authorization and medical-necessity requirements remain in force.

Note

Eligible Billing Providers

ACP and counseling may be billed by a qualified health professional as defined by applicable state requirements, provided the professional has the training necessary to furnish the service.

Confirm the provider meets applicable state qualification requirements.
Confirm the provider possesses the necessary ACP training.

Document an explanation of any advance directive