Geriatrics & Care Management, coding reference.

Use G0438 for a Medicare beneficiary's first AWV. Eligibility window: the patient must be past 12 months from their IPPE eligibility, OR has been on Medicare more than 12 months. Once-per-lifetime; year two and onward use G0439 (subsequent AWV). The AWV is a structured preventive service, not a problem-oriented visit. If you also performed problem-oriented E/M work, bill 99213 through 99215 with modifier 25 in addition to G0438 and document the two services separately.

For subsequent AWV eligibility, confirm the payer-reported next eligible date. Medicare uses month-based frequency guidance; do not apply a calendar-year reset or a blanket 365-day calculation. See the G0439 frequency guide and CMS eligibility instructions.

Use 99490 for monthly chronic care management of a patient with two or more chronic conditions expected to last 12 or more months or until the patient's death, and at significant risk of death, acute exacerbation, or functional decline. The 20-minute threshold is cumulative across the calendar month and covers clinical staff time (medical assistant, RN, LPN) directed by the billing provider. Activities counted: care plan review, care coordination with other providers, medication reconciliation, prescription refills, patient or family phone calls, lab and imaging review, social work coordination, behavioral health coordination. The work is non-face-to-face; do not count the time of any face-to-face encounter with the patient that month.

Use 99439 when documented clinical staff CCM time for the month exceeds the 20 minutes covered by 99490. The first unit applies at 40 cumulative minutes, the second at 60; two units is the monthly ceiling, so staff-time CCM tops out at 60 billable minutes (99490 + 2 x 99439). The patients who routinely reach add-on territory are the ones with active care plans in motion: a heart failure patient with weekly diuretic titration calls, a poorly controlled diabetic getting structured glucose-log review and coaching, a frail elder whose care involves repeated coordination with home health, pharmacy, and family. Time counts when clinical staff (MA, LPN, RN, care manager) perform care plan activities under the billing clinician's general supervision: phone calls, medication reconciliation, coordinating referrals and DME, arranging community services, reviewing remote data, and documenting against the care plan. If the billing clinician personally performs the work instead, use the 99491/99437 track; the staff and clinician code families cannot be mixed for the same patient in the same month.

For an eligible transition from a qualifying facility to a community setting, with the complete 30-day TCM service. A follow-up visit alone is insufficient.

For an eligible transition from a qualifying facility to a community setting, with the complete 30-day TCM service. A follow-up visit alone is insufficient.

99497 captures the time spent in a structured conversation about advance directives, healthcare proxy designation, code status, MOLST or POLST forms, hospice eligibility, and goals of care. The patient must be present at the start of the conversation unless the entire visit is with a designated surrogate (which is independently billable but requires explicit documentation). Common scenarios: ACP as a same-day add-on to an AWV (cost-share is waived with modifier 33); ACP at a primary-care continuity visit for a patient with advanced chronic disease; ACP at an oncology visit for a patient at end of treatment options; ACP during a geriatric assessment.

Use 99498 when a face-to-face advance care planning discussion runs past the first 30 minutes covered by 99497. The CMS time bands follow the midpoint rule: 99497 alone covers 16 to 45 minutes of ACP time, 99497 plus one unit of 99498 covers 46 to 75 minutes, and 99497 plus two units covers 76 to 105 minutes. The discussion covers the explanation and discussion of advance directives (health care proxy, living will, MOLST/POLST), with or without completing the forms, by the physician or QHP face-to-face with the patient, a family member, or a surrogate. Long ACP conversations that earn the add-on are common in newly diagnosed serious illness (metastatic cancer, advanced heart failure, ALS), at transitions like starting dialysis or considering hospice, and in family meetings where the patient lacks capacity and multiple decision makers need to align. ACP is time-based and separately billable on the same day as an E/M visit, an AWV, or monthly care management, provided the ACP minutes are carved out and documented separately.

A detailed assessment and written care plan, not a brief cognitive screen. CMS describes a typical 60-minute visit with an independent historian; confirm the complete current requirements.

Use the current physical activity and nutrition assessment definition for 2026 dates of service. An older social-needs screening template does not establish eligibility.