Wiki Diag codes to be used with 99497 and 99498

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Diag codes to be used with 99497 and 99498

Members suggest Z00.00/01 but report no payment.
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Does anyone know what ICD-10 code can be used with the new End of Life Care CPT codes 99497 and 99498? I believe the HCPCS code might be S0257. For non-medicare patients Z02.89 looked like it might be suitable, but I'm not sure. Does anyone have advice? I have also received mixed messages on whether or not the half rule applies to 99497. Does a physician need to spend at least 16 minutes with the patient planning or does anytime with the first 30 minutes apply?
 

cknc174

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I used Z71.89 family counseling and all my claims were denied as non-covered services because this is a routine exam. I am going to call Medicare today to see if they give me any info since this is a newly payable code by Medicare. I will respond with hopefully a good dx to use :)
 

annielou

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Acp

I looked around quite a bit yesterday for guidance on these codes, but found none. There is no guidance as to whether 99497 has to be 30 minutes or up to 30 minutes, and not one article addresses the ICD10 coding for this service. The "feeling" I got was that since Medicare is just starting to pay for this, CMS is waiting for the local carriers to develop LCD policies. I wonder if you could use any comorbid codes. The transmittal number is R216BP and the implementation date is 01/04/2016, but that is all the guidance there is.
 

jlewis142

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We are using Z00.00, and have not rec'd any denials or payments yet. We should know in a few days and I will let you know.
 
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99497 denials

I've billed 99497 using Z00.00 since there is no guidance from Medicare on what code to use. All my claims have been denied. Medicare does not know what code should be used, they say I billed it correctly with modifier 33 in conjunction with a Wellness code, but they don't know what ICD10 I should use. They told me to contact the AMA. The AMA told be to contact AHA Coding Clinic Advisor on line. I tried to submit a question but you have to join the organization to do so. Has anyone figured out the right ICD10?? Sure would help make up for all the 'dings' we're getting on payments.

Thanks!
 
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We are experiencing issues getting this paid as well. We have been linking it with the Z00.00/Z00.01 as we were advised; however, all of our claims that we submitted with this code AND the mod 33 are being bundled. Has anyone found the answer to this problem? Should we be linking it to a critical DX?

Thanks,
Sarah
 
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does anyone know what icd-10 code can be used with the new end of life care cpt codes 99497 and 99498? I believe the hcpcs code might be s0257. For non-medicare patients z02.89 looked like it might be suitable, but i'm not sure. Does anyone have advice? I have also received mixed messages on whether or not the half rule applies to 99497. Does a physician need to spend at least 16 minutes with the patient planning or does anytime with the first 30 minutes apply?
i've billed g0439 and 99497 with no modifier and medicare did not make any payments, but allowed us to bill the patient for it.
 
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Hi everyone,

I thought I was the only one going crazy trying to figure out what ICD-10 code to use! I'm glad I stumbled upon this forum. Has anyone figured out or have gotten any response from Medicare as to what dx code needs to be used for ACP? We are just about to start to bill for it. I've tried reading around the internet and I could not find any information as to what ICD-10 code to be used. Any response would be greatly appreciated.
 

pclaybaugh

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Please read the following article, in particularly the comments. While this information is not official, there is some good discussion. I read that the diagnosis codes should be the patients problems. As far as time is concerned, CMS says they are abiding by the CPT time threshold.

http://nicolettinotes.com/2015/12/02/advance-care-planning-99497-99498/

There is an official CMS transmittal as well as MLN Matters on line. I have contacted my MAC in hopes that they will hurry and provide further guidance. As of today, they have nothing on their site. CMS has indicated that they are waiting for provider implementation prior to instituting any further official guidance.
 

ttspoon

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Dx

All the discussions I have read seem to talk about using a counseling Dx when billing for ACP. I was wondering if anyone had tried Z51.5? Description reads "Encounter for palliative care" which includes "Dying/death measures"
 

Stroyer1

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If the patient has a chronic condition ie: hypertension, diabetes ect.. you can use those dx codes to bill the ACP. Our office has had some success with that:)
 

mmonak

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According to the FAQ sheet on Advance Care Planning from CMS...
9. What diagnosis must be used?
No specific diagnosis is required for the ACP codes to be billed. It would be appropriate to report a condition for which you are counseling the beneficiary, an ICD-10-CM code to reflect an administrative examination, or a well exam diagnosis when furnished as part of the Medicare Annual Wellness Visit (AWV) (see #11, 12).
 

wynonna

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Advanced Care Directives: 99497 and 99498

Does anyone know what ICD-10 code can be used with the new End of Life Care CPT codes 99497 and 99498? I believe the HCPCS code might be S0257. For non-medicare patients Z02.89 looked like it might be suitable, but I'm not sure. Does anyone have advice? I have also received mixed messages on whether or not the half rule applies to 99497. Does a physician need to spend at least 16 minutes with the patient planning or does anytime with the first 30 minutes apply?
We have been using Z75.8 ("other problems related to medical facilities and other health care"). It was the first choice of one of our providers out of the 4 or 5 I presented him with, and as far as I know, this ICD10 is not denying.
Hope that helps.
 
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The point of advance care planning is to discuss and inform a patient about the rights they have as far as "do not treat" and "do not resuscitate" choices. Additionally, the provider would instruct the patient how to go about getting their wishes put into writing, ensuring the documentation is legal and can be upheld should the need arise. (Keeping in mind that a provider should never offer legal advice unless they are also a licensed attorney).

One of the primary reasons ACP services are done is because, generally speaking, most patients are unaware that there are multiple types of advance directives, each with a different purpose. Living Wills and Durable Medical POA aka Durable POA for Health Care are the biggies - some states require a person have some sort of advance directive. Some states also have mandatory forms to use, versus a document drafted by an attorney. Ideally, a person would have both a Living Will and a Durable Medical POA, at minimum. Additionally, if a person wants to be an organ donor, there is a separate form/document for that. If a person does carry a legally binding document for organ donation, it trumps a "do not treat" order and also forbids the medical proxy from ceasing life support until the organs are harvested.

If the ACP is stemming from a patient's current condition, potentially terminal or actually terminal, you would use the appropriate DX for that condition. If the ACP is not attributable to any specific condition and is being done proactively, that would occur during an AWV and the AWV DX would be appropriate. For non-Medicare patients, this would be a preventive visit code.

Although CMS does not provide specific DX codes, aside from the AWV, it's common sense that a patient wouldn't normally be discussing ACP during an encounter for illnesses that aren't potentially life-threatening. If you are billing for ACP, you need a medically necessary reason for that service; if an otherwise healthy patient comes in with a runny nose and the provider does ACP during that visit, with no other complaints, it would likely be denied for this reason. Because of the volume of possible payable medical diagnosis codes, there's no way CMS could specify them all.
 
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ttspoon

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Successfully paid!

I've billed 99497 using Z00.00 since there is no guidance from Medicare on what code to use. All my claims have been denied. Medicare does not know what code should be used, they say I billed it correctly with modifier 33 in conjunction with a Wellness code, but they don't know what ICD10 I should use. They told me to contact the AMA. The AMA told be to contact AHA Coding Clinic Advisor on line. I tried to submit a question but you have to join the organization to do so. Has anyone figured out the right ICD10?? Sure would help make up for all the 'dings' we're getting on payments.

Thanks!
Our internal medicine practice is seeing payments on 99497 when billed with G0438-25 or G0439-25. Dx used is Z00.00 for the G-code and Z78.9 with Z66 for 99497-33.
When not billed on the same day as the AWV we use the same dx Z78.9 with Z66 or Z78.9 with Z71.89 depending on the patients ACP decisions. No modifier and getting paid.

Hope this helps!
 

bmdrive

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99497 I got paid too.

Our internal medicine practice is seeing payments on 99497 when billed with G0438-25 or G0439-25. Dx used is Z00.00 for the G-code and Z78.9 with Z66 for 99497-33.
When not billed on the same day as the AWV we use the same dx Z78.9 with Z66 or Z78.9 with Z71.89 depending on the patients ACP decisions. No modifier and getting paid.

Hope this helps!
I am at a Family Practice. I billed and office visit of 99213 with modifer 25 and then 99497 with modifer 59. For the dx code I used the same code for both, in this case it was COPD in end stage. I was paid for both e/m codes!
 

Trex1959

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99497

We use Z71.89 if not in an AWV or IPPE and if used with office visit we use Z71.89 and have been paid.
 
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