How To Use CPT Code 99497

CPT 99497 is a code used for advance care planning, including the explanation and discussion of advance directives with patients, family members, or surrogates. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 99497.

1. What is CPT 99497?

CPT 99497 is a code used by healthcare providers to bill for advance care planning services. These services involve discussing and explaining advance directives, such as standard forms, with patients, their family members, or surrogates. The code is used for the first 30 minutes of face-to-face time spent on this process. Advance care planning is essential for patients to make informed decisions about their future healthcare needs and preferences, depending on their current and anticipated health status and available treatment options.

2. 99497 CPT code description

The official description of CPT code 99497 is: “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.”

3. Procedure

  1. The healthcare provider schedules a face-to-face meeting with the patient, family members, or surrogate to discuss advance care planning.
  2. The provider explains the concept of advance directives and their importance in guiding future healthcare decisions.
  3. The provider presents and discusses standard forms used for documenting advance directives, such as living wills and healthcare power of attorney documents.
  4. The patient, family members, or surrogate ask questions and engage in a discussion about the patient’s preferences and values related to future healthcare decisions.
  5. If the patient decides to complete an advance directive form, the provider assists with the completion of the form, ensuring that it accurately reflects the patient’s wishes.
  6. The provider documents the discussion and any completed forms in the patient’s medical record.

4. Qualifying circumstances

Patients eligible to receive CPT code 99497 services are those who have not previously completed advance directives or who wish to review and update their existing advance directives. This may include patients with chronic or life-limiting illnesses, elderly patients, or patients undergoing high-risk medical procedures. The healthcare provider must be a physician or another qualified healthcare professional, such as a nurse practitioner or physician assistant, to bill for CPT 99497 services.

5. When to use CPT code 99497

It is appropriate to bill the 99497 CPT code when a healthcare provider spends at least 30 minutes in a face-to-face meeting with a patient, their family members, or surrogate discussing advance care planning and advance directives. This may occur during a routine office visit, a hospital stay, or a separate appointment specifically scheduled for advance care planning. If the provider spends additional time beyond the initial 30 minutes, CPT code 99498 should be used for each additional 30-minute increment.

6. Documentation requirements

To support a claim for CPT 99497, the healthcare provider must document the following information in the patient’s medical record:

  • Date and duration of the face-to-face meeting
  • Names and relationships of any family members or surrogates present during the discussion
  • A summary of the topics discussed, including the explanation of advance directives and the patient’s preferences and values related to future healthcare decisions
  • Any completed advance directive forms, or a notation that the patient declined to complete a form
  • The provider’s signature and credentials

7. Billing guidelines

When billing for CPT code 99497, healthcare providers should ensure that they have met the documentation requirements and that the service was medically necessary and appropriate for the patient’s circumstances. Providers should also be aware of any payer-specific guidelines or requirements related to billing for advance care planning services. If the provider spends more than 30 minutes on advance care planning, they should bill CPT code 99498 for each additional 30-minute increment, in addition to CPT 99497 for the initial 30 minutes.

8. Historical information

CPT 99497 was added to the Current Procedural Terminology system on January 1, 2015. There have been no updates to the code since its addition.

9. Similar codes to CPT 99497

Five similar codes to CPT 99497 include:

  1. CPT 99498: This code is used for additional 30-minute increments of advance care planning beyond the initial 30 minutes billed with CPT 99497.
  2. CPT 99201-99205: These codes are used for new patient office or other outpatient visits, which may include discussions of advance care planning as part of the visit.
  3. CPT 99211-99215: These codes are used for established patient office or other outpatient visits, which may also include advance care planning discussions.
  4. CPT 99304-99306: These codes are used for initial nursing facility care visits, during which advance care planning may be addressed.
  5. CPT 99334-99337: These codes are used for domiciliary, rest home, or custodial care services, which may involve advance care planning discussions.

10. Examples

Here are 10 detailed examples of CPT code 99497 procedures:

  1. A 65-year-old patient with a history of heart disease meets with their primary care physician to discuss their preferences for future healthcare decisions, including the use of life-sustaining treatments.
  2. A patient with advanced cancer meets with their oncologist and family members to discuss their goals of care and complete a healthcare power of attorney form.
  3. A patient with end-stage renal disease meets with their nephrologist and surrogate to review and update their existing advance directive, reflecting their current health status and treatment options.
  4. An elderly patient with dementia meets with their geriatrician and adult children to discuss their preferences for future healthcare decisions, including the use of artificial nutrition and hydration.
  5. A patient scheduled for high-risk surgery meets with their surgeon and spouse to discuss their values and preferences related to postoperative care and potential complications.
  6. A patient with a progressive neurological disorder meets with their neurologist and designated healthcare agent to discuss their goals of care and complete a living will.
  7. A patient with chronic obstructive pulmonary disease meets with their pulmonologist and family members to discuss their preferences for future healthcare decisions, including the use of mechanical ventilation.
  8. A patient with a history of stroke meets with their primary care physician and spouse to review their existing advance directive and discuss any changes in their preferences or health status.
  9. A patient with a terminal illness meets with their hospice care team and family members to discuss their goals of care and complete an advance directive, if not already in place.
  10. An elderly patient with multiple chronic conditions meets with their geriatrician and designated healthcare agent to discuss their preferences for future healthcare decisions, including the use of hospitalization and aggressive treatments.

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