Wiki Advanced Care Planning 99497

[SSingler]

I'm new to In-Patient Palliative billing. I have noticed denials for ACP when billed with E/M code from Humana Medicare & Aetna Medicare. E/M code is billed with 25 modifier. Anyone else experiencing this? Any advice would be appreciated.

 

[janetrose]

Use a 33 modifier on 99497

 

[mezaelizabeth33@yahoo.com]

We've been adding modifier 25 to the ACP codes 99497/99498 when billing alongside an E/M visit, and they've been getting paid. We only add modifier 33 to the ACP codes during annual wellness visits, since modifier 33 is only for preventative services. Here's a presentation from Center to Advance Palliative Care in regard to billing ACP. https://media.capc.org/recorded-webinars/slides/ACP_Webinar-final-1.pdf

 

[SSingler]

Thank you for your response. I have read that modifier 25 should be on both the ACP and E/M. Do you bill with modifier 25 only on the ACP or on both?

 

[Deb LaVancher]

We only put the 25 modifier on the E/M code not the ACP code. Some insurances don't pay for the 99497/99498 because they say its inclusive to the visit code even if the 25 modifier is added. I wonder if for the insurances that don't cover the ACP codes if we could bill based on time so then you would probably be billing a higher E/M code for the visit. Any thoughts?

 

[jkyles]

We only put the 25 modifier on the E/M code not the ACP code. Some insurances don't pay for the 99497/99498 because they say its inclusive to the visit code even if the 25 modifier is added. I wonder if for the insurances that don't cover the ACP codes if we could bill based on time so then you would probably be billing a higher E/M code for the visit. Any thoughts?

Wouldn't that fit under activities described in the E/M guidelines as "counseling and educating the patient/family/caregiver"?

 

[SSingler]

Humana stated that 99497 is a billable code. Resubmitted claim with 25 modifier on 99497 was denied for "THIS SERVICE IS INCLUDED IN ANOTHER SERVICE PROVIDED AT THE SAME TIME AND ISN'T ALLOWED SEPARATELY." It was difficult to get some clarity. I asked to speak with a provider rep and was told they don't have someone like that. Advised to file an appeal. Anyone else having issues?

 

[Deb LaVancher]

Wouldn't that fit under activities described in the E/M guidelines as "counseling and educating the patient/family/caregiver"?

ACP is Advanced Care Planning and can include education and counseling but is more specifically about advance directives and recording and determining the wishes of the patient, Living Will ,Healthcare Proxy, Power of Attorney and Medical Orders for life sustaining treatment and is based on time spent.