As CMS and the administrative contractors develop guidance for billing these codes, we stress advance care planning services should include both completing standardized forms, like advance directives and POLST, and also documentation in the medical record of goals, values and patient preferences for care. If CMS adopts guidelines regarding how many times the code may be charged or billed, allowances should be made for patient requests to change the advance care plan and changes in the patient’s medical condition which warrant re-evaluation of the plan.