Does 99497 need a 25 modifier?
Asked by: Britney White | Last update: October 4, 2025Score: 4.1/5 (69 votes)
Does modifier 25 go on 99497?
Not typically. However, payers may require modifier 25 on the code for the office E/M service to signify that a significant and separately identifiable office E/M service was provided in addition to the advance care planning (CPT codes 99497 and 99498).
How do I bill my CPT code 99497?
Code 99497 can be billed for the first 30 minutes of the advance care planning (ACP) conversation. For an ACP conversation of less than 16 minutes, CMS suggests considering billing a different evaluation and management (E/M) service such as an office visit.
Does 99497 need a 33 modifier?
Yes. Advance care planning is a preventive service only when provided in conjunction with an annual wellness visit and reported with modifier 33 attached to the advance care planning code (e.g., 99497-33).
When should a 25 modifier be used?
Modifier 25 is used to indicate that a patient's condition required a significant, separately identifiable evaluation and management (E/M) service above and beyond that associated with another procedure or service being reported by the same physician or other qualified health care professional (QHP) on the same date.
EXAMPLES OF WHEN TO APPLY MODIFIER 25 TO EVALUATION AND MANAGEMENT LEVELS MEDICAL CODING
Can you bill an E&M with a planned procedure?
In general, E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service.
Does 99213 need a modifier 25?
If the E/M is not bundled into the stress test, then the Cardiologist's coder can use modifier 25 to indicate that these two services were separate and significant: 99213-25, 93015.
Why is Medicare denying 99497?
Billing improperly for an add-on code without billing for the primary code (99497) is a common reason for claims denials. Primary code 99497 can be billed for the first 30 minutes of the conversation. But if the conversation is less than 16 minutes then a different code (e.g., E/M code) must be used.
How do you know if a CPT code needs a modifier?
- The service or procedure has both professional and technical components.
- More than one provider performed the service or procedure.
- More than one location was involved.
- A service or procedure was increased or reduced in comparison to what the code typically requires.
Can you bill an 99497 with an AWV?
Yes, CPT 99497 and 99498 can be billed separately as long as minimum time requirements are met. Use modifier -33 to avoid co-pay and deductible. Yes, CPT 99497 and 99498 can be billed separately as long as minimum time requirements are met. Use modifier -33 to avoid co-pay and deductible.
What is the 33 modifier used for?
Current Procedural Terminology (CPT) modifier 33 can be used when billing for ACA-designated preventive services with a commercial payer. The addition of modifier 33 communicates to a commercial payer that a given service was provided as an ACA preventive service.
Can 99497 and 96372 be billed together?
Separate reimbursement will not be allowed for CPT code 96372 when billed with an Evaluation and Management (E/M) Service (CPT code 99201-99499) by the same rendering provider on the same service date.
Does G0439 need modifier 25?
Along with HCPCS G0438 or HCPCS G0439, CPT code modifier -25 must be appended to the medically necessary E&M service. CPT guidelines define the -25 modifier as "Significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service."
How do you code 99497?
CPT® codes 99497 and 99498 are time based codes (a base code and an add-on code). Practitioners should consult CPT® provisions regarding minimum time required to report timed services. Use CPT® code 99497 for the first 16 to 30 minutes. Use CPT® code 99498 for each additional 30 minutes.
How often can 99497 be billed to Medicare?
2. Are there limits on how often I can bill CPT codes 99497 and 99498? Per CPT, there are no limits on the number of times ACP can be reported for a given beneficiary in a given time period. Likewise, the Centers for Medicare & Medicaid Services has not established any frequency limits.
Can a modifier 25 be added to 99396?
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In this case, you may submit codes for both a preventive service (such as 99396) and a regular office visit (such as 99213) by attaching -25 to the office-visit code.
How do I know which modifier to use?
The correct modifier to use is determined by payor preference. There can be instances where a CPT code is further defined by an HCPCS modifier, for example, to describe the side of the body the procedure is performed on, such as left (modifier -LT) or right (modifier -RT).
What is modifier 25 in CPT coding?
Modifier 25 is used to signify that when a separate identifiable evaluation-and-management (E/M) service was performed, which can refer to two evaluation-and-management (E/M) services, or a procedure plus an E/M service.
Do anesthesia codes require modifiers?
Physicians are required to report the appropriate anesthesia modifier when reporting for anesthesia. The modifier explains whether the service was personally performed, medically directed, medically supervised, or monitored anesthesia care.
Can you bill 99497 with modifier 25?
Modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service) must be appended to CPT code 99497.
What is the reimbursement for 99497?
CPT code 99497 pays for “ACP, including the explanation and discussion of AD such as standard forms (with completion of such forms, when performed), by the physician or other qualified healthcare professional, first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate” and code 99498 reimburses ...
What is included in advance care planning?
What is advance care planning? Advance care planning involves discussing and preparing for future decisions about your medical care if you become seriously ill or unable to communicate your wishes.
When to use 25 and 59 modifiers?
Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.”
Does Medicare recognize modifier 25?
Under certain circumstances, Medicare will allow use of modifier 25 when an E/M service is reported with a global procedure.
Can you add modifier 25 to 99214?
Yes, you can add modifier 25 to CPT code 99214 if a significant, separately identifiable E/M service is performed on the same day as another procedure.