Can we code 99497 with G0439?

Yes, you can bill CPT code 99497 (Advance Care Planning) on the same day as HCPCS code G0439 (Subsequent Annual Wellness Visit).

Billing Requirements

• Same Claim: Both codes must be submitted on the same claim form for the same date of service and by the same provider.
• Modifier -33: Append Modifier -33 (Preventive Services) to CPT 99497. This waives the patient's Part B coinsurance and deductible.
• Time Documentation: Document at least 16 minutes of face-to-face time for 99497. This time must be separate from the time spent on the Annual Wellness Visit.

Yes, CPT code 99497 (Advance Care Planning) and HCPCS code G0439 (Subsequent Annual Wellness Visit) can be billed together.

Key Billing Requirements

• Modifier 33: You must append modifier 33 (Preventive Services) to 99497 to waive the patient's Part B deductible and coinsurance.
• Same Claim: Report both codes on the same claim form, for the same date of service, and by the same provider.
• Separate Time Documentation: Document the exact start and stop times for the advance care planning discussion in the medical record. This time must be completely separate from any time used to report the annual wellness visit or other evaluation and management (E/M) services.
• Optional Nature: Advance care planning is an optional element of the Centers for Medicare & Medicaid Services annual wellness visit, meaning it is not mandatory to perform it during every visit.

CPT code 99497 covers the first 30 minutes of face-to-face Advance Care Planning (ACP) conducted by a qualified healthcare professional.

Core Billing & Time Rules

• Time Requirement: The discussion must last at least 16 minutes to bill 99497, following standard CPT midpoint rules (16 to 45 minutes equals one unit of 99497). Discussions lasting 15 minutes or less cannot be billed as ACP.
• Add-On Code (+99498): Used for each additional 30 minutes. To bill 99497 plus the add-on code 99498, the total discussion must reach at least 46 minutes (30 minutes for 99497 plus a minimum of 16 extra minutes).
• Eligible Providers: Limited to physicians, nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs). General nursing staff or medical assistants cannot independently bill these codes.
• Setting & Frequency: Can be billed in any care setting (office, inpatient, telehealth). There is no strict annual limit on frequency, but subsequent billing requires documented changes in the patient's health status or end-of-life wishes.

Documentation Requirements

• Exact Time: Record the total face-to-face duration (or start and stop times) in the medical record.
• Voluntary Nature: Note that the service was voluntary and the patient/surrogate was given the opportunity to decline.
• Content & Participants: Document the names and relationships of attendees, specific topics discussed (such as living wills or healthcare proxies), and any forms completed or reviewed.

Cost-Sharing and Co-Billing

• Medicare Coverage: Reimbursed under Medicare Part B. Coinsurance and deductibles are waived if billed during an Annual Wellness Visit (AWV) using Modifier -33; otherwise, standard cost-sharing applies.
• Same-Day E/M Services: Can be billed on the same day as a regular Evaluation and Management (E/M) visit, provided the ACP conversation is distinct and separately documented. The time spent on ACP cannot be double-counted toward the time required for the E/M code.

Modifier 25 is typically appended to the Evaluation and Management (E/M) service code when billed on the same day as Advance Care Planning (ACP) code 99497 to indicate a significant, separately identifiable service, though some specific payer or NCCI edit guidelines may vary.

Billing Rules for Modifier 25 with 99497

• Placement: Modifier 25 generally goes on the separate E/M service code (such as an office visit), not directly on the 99497 code, to show the E/M visit was distinct from the ACP discussion.
• Separate Documentation: The medical record must clearly separate the time and clinical work spent on the general E/M service from the time spent on the voluntary face-to-face ACP conversation.
• No Time Overlap: You cannot count the time spent on ACP toward the total time used to calculate the separate E/M code.
• Payer Variations: Always verify local Medicare Administrative Contractor (MAC) or private insurance rules, as a few specific edit combinations or commercial payers may require looking closely at NCCI column 1/column 2 code pairings.

Medicare denies CPT code 99497 (Advance Care Planning) most frequently due to documentation gaps, time-threshold failures, or missing modifier errors during joint billing.

⏱️ Time-Threshold Failures

• Under 16 minutes: Conversations lasting 15 minutes or less cannot be billed under 99497.
• Missing total time: Medical records must explicitly state the start time, end time, and total face-to-face duration.

📝 Incomplete Documentation

• Voluntary status omitted: Charts must explicitly note that the advance care planning discussion was voluntary.
• Missing participant details: Documentation fails if it omits the names and relationships of family members or surrogates present.
• Unclear content: Notes must describe the specific advance directives or forms discussed, not just state "ACP performed".

🧩 Billing and Modifier Errors

• Missing Modifier -33: When billed on the same day as an Annual Wellness Visit (AWV), modifier -33 must be appended to waive cost-sharing.
• Provider type mismatch: Services must be furnished personally by a physician, nurse practitioner, physician assistant, or clinical nurse specialist.
• Unbundled add-on usage: Submitting add-on code 99498 without meeting the 46-minute threshold or pairing it properly with a primary 99497 claim triggers rejections.