Physician Practice

Q&A: You've got questions! We've got answers!

Physician Practice Insider, March 22, 2016

Submit your questions to Associate Editor Nicole Votta at nvotta@hcpro.com and we will work with our experts to provide you with the information you need.


Q: I am in need of clarification on advance care planning (ACP) CPT® codes 99497 and 99498.

Code 99497 covers the first 30 minutes. Does that mean the MD/NPP must provide at least 30 minutes of ACP, or is there a halfway mark that can be met? For example, if the MD/NPP provided 16 minutes of ACP services, which is past the halfway mark to 30 minutes could they bill the 99497?

If they provided 15 minutes or less, which would be less than the halfway mark, then they would not be able to bill for these services?


A: Throughout the CPT Manual, you will find codes that include a time component in the code descriptor. Often the subsection guidelines will contain explicit instructions on how to report time for the code in question. For example, the subsection guidelines for critical care (99291-99292) state not to report critical care unless 30 minutes or more of critical care have been provided. Similarly, for prolonged services (99354-99357), the guidelines explicitly state not to report the prolonged service code if less than 30 minutes of prolonged service has been provided. In the absence of explicit guidance, it is generally understood that once you exceed the midpoint of the time specified in the CPT code descriptor, you may report the applicable CPT code.

Editor’s note: Peggy S. Blue, MPH, CCS-P, CPC, CEMC, answered this question. This information does not constitute legal advice. Consult legal counsel for answers to specific questions.

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