Denials for Advanced Care Planning with mod 25

JennRT929

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Hello! We are receiving denials for Advanced Care Planning CPT 99497 from Cahaba Medicare stating that modifier 25 is an invalid modifier. I am at a loss. We are billing this on the same day as a PFT test and they are bundled but per CCI edits a modifier is allowed. Since ACP is under the E/M section I would think that modifier 25 would be most appropriate.

We are also receiving the same "modifier is inappropriate" when 99497 is billed on the same day as a preventive. Our MAC doesn't require modifier 33 so again, I would think that for two E/M services on the same day modifier 25 would apply.

Is anyone else having trouble billing 99497-99498 with modifier 25?

Thanks in advance!
 

StacyGalloway

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Try a modifier 59 on the 99497. This might un-bundle it from the procedure that was done on the same day.

Stacy - CFPC
 

JennRT929

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Cahaba updated their edit

Thanks for the suggestion. Adding modifier 59 was initially Cahaba's suggestion as well but since 99497-99498 are E/M Services modifier 59 is not appropriate. After much discussion with Cahaba and validation from the AMA, Cahaba has agreed that modifier 25 is appropriate and they have updated their edits to reflect this and asked us to resubmit claims. Thanks!
 
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does 99497 need a Modifier for medicare why and why not

does 99497 need a Modifier when billed with 20610 and 99348 for medicare why and why not
 

jhendrix08

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99497 for Advance Care Planning requires modifier 33 for Medicare; this modifier means that copay and deductibles do not apply. (This is allowed when done in conjunction with another visit, for example Medicare Wellness Exam)
 

eorthaus

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Billing 99497 with procedures

Can a procedure and ACP be billed together; i.e., 99497 with 11720? We been getting denials. What modifier is necessary? We have gotten denials when billing 11720 with 99497-33. Any insight would be much appreciated. Thank you!
 

des7010

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We billed 99349, 99497, G0008, 90472, 90715 & 90686. Which E & M gets modifier 25? Coder light points to the Advanced Care Planning code, stating code 99497 is a column 2 code for 90472, my coding manager disagrees. What is the correct answer?
 

jhendrix08

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I would add modifier 25 to the visit itself, so 99349-25 and also add modifier 33 to 99497 for the Advance Care Planning.
 
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