What Is Advance Care Planning (ACP)?

Advance Care Planning (ACP) is a structured process that helps individuals prepare for future healthcare decisions. It allows patients to document their values, preferences, and goals of care — especially for situations where they may be unable to speak for themselves.

ACP conversations often include:

Designating a healthcare proxy or decision-maker
Exploring what matters most to the patient
Discussing potential medical scenarios and care preferences
Documenting choices in an advance directive or medical record

Advance Care Planning is not limited to end-of-life care. It’s relevant for anyone with chronic conditions, serious illness, or simply a desire to proactively guide their care.

Core Elements of Advance Care Planning

Patient Values & Goals:
Clarify what matters most in future care decisions
Healthcare Proxy Selection:
Identify and document a trusted decision-maker
Scenario-Based Preferences:
Discuss treatments the patient would or would not want under certain conditions
Advance Directive Documentation:
Record choices in legally recognized formats and clinical notes
Ongoing Review:
Revisit and update preferences regularly as health status changes

Infographic titled ‘Advance Care Planning Conversation Roadmap’ showing five steps: Start the Conversation, Identify Preferences, Choose a Proxy, Document in Record, and Revisit Over Time.

Who Should Participate in Advance Care Planning?

Advance Care Planning isn’t just for patients at the end of life. It’s appropriate for anyone who wants to make their healthcare preferences known — especially those with chronic conditions, serious illnesses, or complex care needs.

ACP is particularly relevant for:

Patients managing multiple chronic conditions
Adults with early-stage cognitive decline
Individuals facing serious diagnoses (e.g., cancer, heart failure)
Older adults living alone or without a designated caregiver
Anyone preparing for a high-risk procedure or hospitalization

Healthcare providers, care coordinators, and family members all play a role in facilitating these discussions and documenting decisions. In value-based care models, ACP helps ensure treatment aligns with patient values and avoids unwanted interventions.

Illustration of four patient personas who benefit from Advance Care Planning: older adult living alone, person with chronic illness, patient with early cognitive decline, and individual preparing for surgery.

Where Advance Care Planning Fits in the Care Journey

Advance Care Planning isn't a one-time event — it’s a process that integrates across the continuum of care. From primary care to hospital discharge, ACP supports alignment between treatment and patient values.

Here’s how ACP fits at key care stages:

Primary Care
Proactively introduce ACP during annual wellness visits, chronic care check-ins, or preventive care appointments.
Specialty & Serious Illness Care
Use ACP to guide decisions in cardiology, oncology, neurology, and other high-risk specialties.
Transitional Care
After hospitalization, revisit ACP as patients recover or adjust to new diagnoses and prognoses.
Long-Term & Palliative Care
Document updated preferences as conditions evolve and care goals shift toward comfort or quality of life.

Clinically, ACP enables shared decision-making. Administratively, it supports risk adjustment, quality reporting, and care team coordination — all central to value-based care delivery.

Documenting and Billing for Advance Care Planning

When conducted and documented correctly, Advance Care Planning (ACP) can be billed as a separate service under specific CPT codes. This encourages providers to dedicate time for meaningful conversations about future care preferences.

Documentation Should Include:

Patient consent to participate in ACP
Total time spent in discussion (face-to-face or via telehealth, as allowed)
Topics covered (e.g., values, goals, advance directives, proxy selection)
Who facilitated the conversation (physician, NP, PA, or clinical staff under supervision)

Common CPT Codes:

99497 — First 30 minutes of face-to-face ACP discussion
99498 — Each additional 30 minutes (add-on code)

ACP services may be billed in both inpatient and outpatient settings. These codes can be used alongside annual wellness visits and certain chronic care services when requirements are met.

Why Advance Care Planning Is Central to Patient-Centered Care

Advance Care Planning empowers patients to define their goals, guide their care, and make their voices heard — even if they can’t speak for themselves.

For healthcare organizations, ACP supports:

Informed Consent – Ensuring patients understand their options
Personalized Care Plans – Tailored to the individual’s wishes and priorities
Reduced Unwanted Interventions – Especially in high-acuity situations
Improved Family and Caregiver Communication – Reduces stress and uncertainty
Stronger Value-Based Metrics – Supports care alignment, utilization efficiency, and quality reporting

By embedding ACP across the care journey, provider organizations can deliver care that reflects what matters most to patients — not just what’s medically possible.

Frequently Asked Questions about Advance Care Planning (ACP)

1. What’s the difference between advance care planning and an advance directive?

Advance care planning is the ongoing process of discussing and documenting healthcare preferences. An advance directive is a legal document that may result from those discussions — outlining specific wishes and naming a healthcare proxy.

2. Who can facilitate an ACP conversation?

In most cases, ACP can be conducted by physicians, nurse practitioners, or physician assistants. Some organizations allow trained clinical staff to facilitate the discussion under supervision, especially when billing under CPT 99497.

3. Can advance care planning be billed during an annual wellness visit (AWV)?

Yes. CPT 99497 for advance care planning can be reported on the same day as an AWV, provided the ACP service is voluntary, separately documented, and all billing requirements are met.

4. Is ACP only for end-of-life situations?

No. While ACP is often associated with end-of-life planning, it is appropriate for any adult who wants to ensure their healthcare preferences are understood — especially those with chronic illness or complex care needs.

5. Does ACP require a signed advance directive to be billable?

No. While documentation is required, a completed legal directive is not necessary for billing. The focus is on the conversation, not just the paperwork.