Pulmonology Coding Alert

Question: Our physician saw a patient for advance care planning and reported 99497 for the service. We waived the deductible and coinsurance per Medicare rules, but then our payer said that the patient should have paid the coinsurance. We are a pulmonology practice and we don’t commonly bill this code, so we aren’t sure what we’re doing wrong.

Codify Subscriber

Answer: It’s likely that you administered the advance care planning by itself or with a problem-based E/M service (e.g., 99213) and not with an annual wellness visit (G0438 or G0439). Medicare only waives the deductible and coinsurance for advance care planning (99497-99498) if you bill it on the same claim as an annual wellness visit and that the same provider performs both.

In addition, you can collect for 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) as often as required by the patient’s condition, level of understanding, or inability to make an expedited decision.