EM Coding Alert

Question: Our provider recently counseled an established patient on end-of-life (EOL) directives during an E/M visit. We billed 99215-25 and 99497-59; +99498-59, but the payer denied the claim with the response “The procedure code is inconsistent with the modifier used or a required modifier is missing.” Can you advise us as to what we did wrong?

Michigan Subscriber

Answer: The issue here is likely the use of modifiers on the 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) and +99498 (… each additional 30 minutes (List separately in addition to code for primary procedure).

First, as +99498 is an add-on, it does not require a modifier. Then, it is not appropriate to append modifier 59 (Distinct procedural service) to the 99497. Per Appendix A of CPT^®, “Modifier 59 should not be appended to an E/M service,” and code 99497 is an E/M service. Appending modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) on the 99215 (Office or other outpatient visit for the evaluation and management of an established patient …) is sufficient to indicate that the services are significant and separate.