Primary Care Coding Alert

Question: Medicare just denied our bill for 99497, 99498, and 99498, saying that the second 99498 is duplicate even though the codes are appropriate for the time documented, which was 80 minutes. Do we need a modifier for the second 99498, such as modifier 52 to indicate that the planning did not last for a full 90 minutes? And if not, how else should we bill this?

Answer: The issue here does not seem to be your time calculation, but it may well lie in the way your bill was presented. To arrive at 80 minutes, you would use one unit of 99497 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate) along with 2 units of +99498 (… each additional 30 minutes (List separately in addition to code for primary procedure)).

This appears to give you a total of 90 minutes, but using modifier 52 (Reduced Services) on the second unit of +99498 to represent the 80 minutes your provider documented for the service is not only unnecessary but also incorrect. It is incorrect because an add-on code, particularly one that is time-based, does not take a modifier, and it is unnecessary because the second unit satisfies CPT^®’s typical requirement that a time-based code can be used when the total time accumulated passes the mid-point of the time listed in the code descriptor. So, the three codes together would represent a minimum of 76 minutes and a maximum of 105 minutes, which accurately describes the 80 minutes your provider has documented.

In your case, your best bet is to resubmit the claim with one unit of 99497 on the first line, and two units of +99498 on the second rather than one unit of 99497 on the first line, one unit of +99498 on the second, and one unit of +99498 on the third, which may have been the problem with the way you presented the bill originally.