99497

Advance care planning including the explanation and discussion of advance directives such as standard forms (e.g., living will, power of attorney for healthcare, do-not-resuscitate orders), with patients and/or family; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate

CPT code 99497 represents advance care planning (ACP) services, which involve face-to-face counseling and discussion with the patient, family member(s), and/or surrogate. The service focuses on explaining and discussing advance directives, such as living wills, durable power of attorney for healthcare, and do-not-resuscitate (DNR) orders. It involves exploring the patient's preferences regarding future medical treatment, documenting their decisions, and addressing any questions or concerns. This code specifically covers the first 30 minutes of this discussion. Unlike typical E/M services, code selection for 99497 is solely based on time, and a specific Medical Decision Making (MDM) level is not a required component for reporting this service. The counseling must be distinct from any other E/M service provided on the same day.

Clinical Indications

  • Patients with serious, chronic, or life-limiting illnesses who wish to define their future healthcare preferences.
  • Elderly patients or those with progressive conditions considering end-of-life care options.
  • Patients facing complex medical treatments or procedures with significant potential for adverse outcomes.
  • Individuals seeking to designate a healthcare proxy or surrogate decision-maker.
  • Patients who express a desire to document their wishes regarding resuscitation, mechanical ventilation, artificial nutrition, and hydration.

Procedure Steps

  1. Initiate a sensitive and open discussion with the patient and/or family/surrogate regarding their values, beliefs, and goals for future healthcare.
  2. Explain the various types of advance directives (e.g., living will, durable power of attorney for healthcare, DNR orders) and their legal implications.
  3. Assess the patient's understanding of their medical condition, prognosis, and potential treatment options.
  4. Explore the patient's preferences for medical interventions, including life-sustaining treatments, in different clinical scenarios.
  5. Answer questions, clarify misconceptions, and address emotional concerns from the patient and/or family.
  6. Provide information about palliative care and hospice options, if appropriate.
  7. Assist the patient in completing or updating advance directive forms, or documenting their verbal wishes.
  8. Document the specific topics discussed, time spent (total and face-to-face), participants present, and any decisions made or forms completed in the patient's medical record.

Coding Guidelines

  • Report 99497 for the first 30 minutes of face-to-face advance care planning with the patient, family member(s), and/or surrogate.
  • For additional time beyond the first 30 minutes, use add-on code 99498 for each additional 30 minutes.
  • Time is cumulative over a single calendar day for these services.
  • Documentation must clearly reflect the time spent in counseling, the content of the discussion, and the participants present.
  • This service may be billed on the same day as an evaluation and management (E/M) service if the advance care planning is significant and separately identifiable (use modifier 25 on the E/M code).
  • Do not report if the discussion is part of a routine E/M service and not focused specifically on explaining and completing advance directives.
  • Medical necessity does not require the patient to have a terminal illness; rather, it is based on the patient's need for guidance in making future healthcare decisions.
  • These codes are not restricted by patient setting (e.g., hospital, office, skilled nursing facility).

Associated ICD-10 Codes