Integrating Advanced Care Planning into the Medicare Annual Wellness Visit

In the ever-evolving landscape of value-based care, maximizing both patient outcomes and reimbursement opportunities is key. One such opportunity lies in conducting Advanced Care Planning (ACP) during the Medicare Annual Wellness Visit (AWV)—a natural pairing that improves care continuity and patient satisfaction.
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What is Advanced Care Planning?

Advanced Care Planning is a patient-centered process that enables individuals to make decisions about their future medical care. This typically includes discussions about:

• Goals of care
• End-of-life treatment preferences
• Designation of a healthcare proxy or durable power of attorney
• Completion of advance directives or POLST (Physician Orders for Life-Sustaining Treatment)

These conversations help ensure care aligns with the patient's values, particularly in serious illness or emergency situations.
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Why Conduct ACP During the AWV?

The AWV provides an ideal setting for ACP because it is:

• Non-acute: Patients are not in crisis, making them more receptive to discussing long-term preferences.
• Preventive-focused: The AWV is designed to develop or update a personalized prevention plan—ACP fits naturally within that scope.
• Trust-building: PCPs already have rapport with patients, which encourages open conversations.

By incorporating ACP into the AWV, providers can better align care plans with patient goals, reduce unwanted interventions, and improve overall satisfaction and quality scores.
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Billing for ACP: Know the Codes

→ Important Tip: When you bill for Advanced Care Planning during an Annual Wellness Visit, you must use a modifier 33, indicating it’s a preventative service, to ensure the deductible and coinsurance is waived. 

CPT Codes for ACP:

• 99497 – First 16 to 30 minutes of ACP, face-to-face, including explanation and discussion of advance directives.
  
• 99498 – Each additional 30 minutes of ACP.
  

Key Documentation Requirements:

• Time spent on ACP (e.g., “25 minutes discussing goals of care and advance directives”)
• Topics covered (e.g., living will, healthcare proxy)
• Voluntary nature of the discussion
• Who was present (e.g., patient alone, with family)
• Patient consent
  
  

Tips for Implementation

1. Use a Standard Script or Template: This ensures consistency and saves time.
2. Train Clinical Staff: RNs or NPs can initiate ACP discussions and prepare documentation.
3. Have Materials Ready: Provide patients with advance directive forms, educational handouts, or referrals to legal support if needed.
4. Integrate into Workflow: Schedule an extra 16–30 minutes for AWVs when ACP is anticipated.
5. Track Completion Rates: Monitor which patients have completed ACP and follow up at future visits.
   
   

Final Thoughts

ACP isn’t just about checking a box—it’s about honoring a patient's voice in their care. By integrating ACP into the Annual Wellness Visit, providers create a more holistic, values-driven care plan and unlock a valuable reimbursement opportunity.

Encourage your care teams to normalize ACP conversations. With the right workflows, you can improve patient outcomes, meet quality measures, and ensure Medicare compliance—all in a single visit.

Need help setting up your ACP workflows or improving AWV completion rates? Snap eHealth offers turnkey solutions to boost preventive care engagement and maximize Medicare reimbursement. Contact us today to learn more.