Can you bill 99497 and G0439 together?

Yes, CPT code 99497 (Advance Care Planning) and G0439 (Subsequent Annual Wellness Visit) can be billed together on the same date of service.

Key Billing Rules

• Append Modifier 33: You must attach Modifier 33 (Preventive Service) to CPT 99497 when it is performed alongside an Annual Wellness Visit (G0438 or G0439).
• Waive Cost-Sharing: Adding Modifier 33 ensures that the patient's deductible and coinsurance are waived for the advance care planning line, making it a fully covered preventive service under Medicare Part B.
• Time Requirements: CPT 99497 requires a minimum of 16 minutes of face-to-face discussion. This time must be separate from and cannot overlap with the time spent on the wellness visit (G0439).
• Documentation: Clearly document the total time spent, that the service was voluntary, who participated in the discussion, and the nature of the advance directives reviewed. You can review official guidelines via the CMS MLN Advance Care Planning Booklet.

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.

Yes, CPT code 99497 can be billed alone as a standalone service.

Key Billing Details

• Standalone or Combined: You do not need to pair 99497 with an Evaluation and Management (E/M) visit or an Annual Wellness Visit (AWV); it can be reported by itself. It can also be billed on the same day as an E/M visit if both services are distinct and properly documented.
• Time Threshold: The discussion must last a minimum of 16 minutes to report 99497 (which covers the first 30 minutes). Conversations lasting 15 minutes or less cannot be billed using this code.
• Provider Requirements: It must be performed face-to-face by a physician or other qualified healthcare professional (such as a nurse practitioner or physician assistant).
• Documentation: You must document the total time spent, voluntary consent from the patient, and the nature of the advance care planning discussion.