Executive Summary

The Centers for Medicare & Medicaid Services (“CMS”) issued Change Request 9271 on January 4, 2016, which informs providers to waive the deductible and coinsurance for Advanced Care Planning (“ACP”) when furnished as an optional element of an Annual Wellness Visit (“AWV”). When ACP services are performed separately from a covered AWV, the deductible and coinsurance for the ACP still apply.

Details of Advanced Care Planning

Effective January 1, 2016, CMS is including voluntary ACP services as an optional element of an AWV. When the ACP is furnished on the same day and by the same provider as an AWV, the ACP is considered a preventive service and the beneficiary’s deductible and coinsurance are waived. Voluntary ACP means a face-to-face service between a physician (or other qualified health care professional) and the beneficiary discussing advanced directives without or without completing legal forms.

ACP services are separately payable under the Medicare Physician Fee Schedule. Therefore, if ACP services are performed separately from a covered AWV, the deductible and coinsurance for the ACP should not be waived.

When ACP services are provided as part of an AWV, practitioners would report CPT code 99497 (and 99498 for each additional 30 minutes, if applicable) for the ACP services in addition to either of the AWV codes G0438 and G0439. The AWV and ACP codes must be billed together on the same claim. Additionally, practitioners must report modifier 33 (Preventive Services) with the ACP code(s)  in order to have the ACP deductible and coinsurance waived. Coverage for an AWV is limited to only once a year. Therefore, the deductible and coinsurance for ACP billed with an AWV can only be waived once a year.

Practical Takeaway

Physicians and other qualified professionals should consider allowing beneficiaries to elect to receive ACP services as part of an AWV. Billing personnel should be aware of the coding requirements so that the deductible and coinsurance for ACP services are waived when furnished with an AWV.