Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services (99497-33 and 99483) provided from 
January 20, 2023, to January 22, 2023. 
 
You asked the Plan to pay for 99497 and 99483. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says code 99497 is not supported and code 99483 is inconsistent with the 
place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of 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. The CPT Code Manual definition of code 99483 is assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other 
outpatient, home or domiciliary or rest home, with all of the following required elements: Cognition-focused 
evaluation including a pertinent history and examination, Medical decision making of moderate or high 
complexity, Functional assessment (eg, basic and instrumental activities of daily living), including decision-
making capacity, Use of standardized instruments for staging of dementia (eg, functional assessment staging 
test [FAST], clinical dementia rating [CDR]), Medication reconciliation and review for high-risk medications, 
Evaluation for neuropsychiatric and behavioral symptoms, including depression, including use of standardized 
screening instrument(s), Evaluation of safety (eg, home), including motor vehicle operation, Identification of 
caregiver(s), caregiver knowledge, caregiver needs, social supports, and the willingness of caregiver to take on 
caregiving tasks, Development, updating or revision, or review of an Advance Care Plan, Creation of a written 
care plan, including initial plans to address any neuropsychiatric symptoms, neuro-cognitive symptoms, 
functional limitations, and referral to community resources as needed (eg, rehabilitation services, adult day 
programs, support groups) shared with the patient and/or caregiver with initial education and support. 
Typically, 60 minutes of total time is spent on the date of the encounter. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for 99497 and 99483. Our reviewer says that these codes do not 
meet criteria for payment. For code 99497 our reviewer found that the documentation notes advanced care 
planning was reviewed. The procedure and time spent are not documented and therefore code 99497 cannot be 
verified. For code 99483 our reviewer found that the procedure and time spent are not documented and 
therefore code 99483 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99497 and 99483 have not been met. Therefore, we decided that the Plan does 
not have to pay for practitioner services (99497-33 and 99483) provided from January 20, 2023, to January 22, 
2023.