CPT code 99497: Advance care planning billing guide (2026)

CPT code 99497 is the billing code for the first 30 minutes of face-to-face advance care planning (ACP). This covers a discussion of advance directives, such as living wills, healthcare proxies, and MOLST forms. Despite the “first 30 minutes” wording, CPT’s midpoint rule means a practice can bill 99497 once the discussion passes 15 minutes. Many practices still leave reimbursement unclaimed because time documentation and modifier rules trip up billing teams at the point of submission. This guide covers the code description, eligible providers, 2026 Medicare reimbursement rates, documentation requirements, co-billing scenarios, and the errors that trigger denials most often.

Advance care planning is a Medicare-covered service under Part B. Standard cost-sharing applies unless billed with a covered Annual Wellness Visit (AWV) under modifier 33. Billing it alongside evaluation and management (E/M) visits, AWVs, and telehealth sessions each carries its own modifier and documentation rules.

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Key Takeaways

CPT code 99497 covers the first 30 minutes of face-to-face advance care planning. CPT’s midpoint rule makes it billable once the discussion passes 15 minutes.

Add-on code 99498 covers each additional 30-minute increment past 45 minutes total, and always requires 99497 on the same claim.

Medicare only waives the Part B deductible and coinsurance for 99497 when it’s billed with a covered Annual Wellness Visit under modifier 33.

Start/stop time documentation in the medical record is required; missing time notation is the leading cause of ACP claim denials.

Pabau’s claims management software and digital forms help practices capture required ACP documentation elements and submit clean claims.

What is CPT code 99497?

CPT code 99497 is the procedure code for advance care planning, defined by the American Medical Association as a face-to-face service. It covers the explanation and discussion of advance directives with the patient and/or a surrogate, including completion of such forms when performed. Unlike evaluation and management codes, 99497 is time-based from the start. The provider must document both the start and stop time of the encounter.

The official CPT descriptor covers the explanation and discussion of advance directives. Examples include a health care proxy, durable power of attorney, living will, or MOLST, with the patient and/or surrogate. It applies to the first 30 minutes, face-to-face with the physician or other qualified health care professional.

CPT applies a midpoint rule to time-based codes like this one: a unit of time counts once the midpoint is passed. For a 30-minute code, that midpoint is 15 minutes, so 99497 is billable once the face-to-face discussion reaches 16 minutes. A 10-minute discussion falls short of that threshold and can’t be billed as 99497. The provider may still bill a different E/M service if its requirements are met.

CPT 99498: The add-on code for additional time

CPT 99498 is an add-on code billed for each additional 30-minute increment of advance care planning. It applies beyond the first 30 minutes covered by CPT code 99497. It cannot be reported alone: 99498 always requires 99497 on the same claim. A 75-minute ACP session, for example, would support billing 99497 plus one unit of 99498. That covers 60 minutes documented in full 30-minute increments, with 15 minutes left over in the final, partial increment.

The same face-to-face and time documentation rules apply to 99498 as to 99497. Each unit of 99498 requires documentation of the additional time increment in the medical record. There is no published maximum number of 99498 units per encounter, but payers may flag claims with multiple units for review.

Medicare reimbursement for CPT code 99497 in 2026

Medicare pays for CPT code 99497 under the CMS Physician Fee Schedule, with rates varying by place of service. The non-facility rate (office setting) is generally higher than the facility rate (hospital outpatient, critical access hospital) because the practice bears overhead costs directly. Rates below reflect approximate 2026 national Medicare rates. Actual payment varies by geographic locality using the geographic practice cost index (GPCI).

Verify current rates using the CMS Physician Fee Schedule lookup tool before billing, since CMS’s proposed CY2027 rule could adjust the conversion factor once finalized. Real-time eligibility verification confirms Medicare coverage before the encounter.

Medicare only waives the Part B deductible and coinsurance for CPT 99497 in one scenario. It must be billed with modifier 33 on the same claim, day, and provider as a covered Annual Wellness Visit, per CMS ACP guidance. Standalone ACP, or ACP billed alongside an E/M visit, is subject to the standard Part B deductible and coinsurance.

Who can bill CPT code 99497?

According to CMS guidance, CPT code 99497 may be billed by physicians or “other qualified health care professionals” as defined by CMS. This includes nurse practitioners (NPs), physician assistants (PAs), clinical nurse specialists (CNS), and certified nurse-midwives (CNMs) within their scope of practice and state law.

Eligibility differs by care setting and billing arrangement. The key distinctions are:

• Billing under own NPI: NPs and PAs can bill 99497 independently under their own NPI when practicing in states and settings that permit independent billing.
• Incident-to billing: In a physician practice, an NP or PA may furnish the ACP service incident-to the physician’s plan of care, under the physician’s NPI. The physician must be in the office suite (not necessarily the same room) during the service.
• RN exclusion: Registered nurses (RNs) who are not nurse practitioners cannot independently bill 99497. CMS does not recognize RNs as “other qualified health care professionals” for this code in most settings.
• Non-physician practitioners in hospice/palliative: Social workers and chaplains cannot independently bill 99497, though they may conduct ACP conversations as part of their broader care role.

Practices with mixed provider teams should confirm each provider’s eligibility status individually, since incident-to rules and NP/PA independent billing rights vary by state and setting.

Medicare and insurance coverage rules

Medicare Part B covers CPT code 99497 without requiring a specific diagnosis code linkage. ACP is classified as a preventive service, not treatment for an active condition. The patient only needs to be a Medicare beneficiary. No minimum age or diagnosis threshold applies.

For private (commercial) insurance, coverage is highly variable. Some commercial payers cover 99497 as a preventive benefit, while others require prior authorization or do not cover it at all. Never assume commercial payer coverage without verifying through the payer’s provider portal. Payers that do cover ACP may apply different cost-sharing rules than Medicare.

Medicare Advantage plans must cover the same services as traditional Medicare, but their billing and authorization rules may differ. Confirm ACP coverage with each Medicare Advantage plan before the encounter.

Billing CPT 99497 alongside other services

Three co-billing scenarios come up regularly in practice. Each has its own modifier and documentation requirements.

Billing with an E/M visit on the same day

CPT code 99497 can be billed on the same date of service as an evaluation and management code. The ACP discussion must be separately identifiable from the E/M service. The E/M code requires modifier 25 to signal a significant, separately identifiable service was performed. The modifier goes on the E/M code, not on 99497. Document the ACP discussion separately in the note, including the start and stop time distinct from E/M time.

Billing with the Annual Wellness Visit

ACP can be billed alongside the Medicare Annual Wellness Visit (AWV), and CMS treats both as preventive benefits. To waive the patient’s Part B deductible and coinsurance, append modifier 33 (Preventive Services) to 99497. Bill it on the same claim, same day, and by the same provider as a covered AWV (G0438 or G0439), per CMS coverage guidance. Without modifier 33, standard cost-sharing applies even when both visits are billed together. Document the AWV code, the 99497 code, and separate start/stop time for the ACP portion in the encounter note.

Billing via telehealth

Telehealth delivery of advance care planning was permitted under the COVID-19 Public Health Emergency (PHE) waivers. Post-PHE telehealth rules for specific codes remain subject to ongoing congressional and CMS action. As of the 2026 Physician Fee Schedule rulemaking, verify the current telehealth status for 99497 directly with CMS. When telehealth delivery is permitted, the place of service code changes. Use 02 for a location other than the patient’s home, or 10 for the patient’s home.

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Documentation requirements for CPT code 99497

Documentation failures are the primary reason ACP claims are denied or flagged in audits. Every element below must appear in the medical record to support a valid 99497 claim. Digital intake forms pre-populated with required ACP fields reduce the risk of incomplete records at the point of care.

• Patient identity: Name, date of birth, and patient identifier in the record.
• Date of service: The specific date the ACP discussion took place.
• Start and stop time: Both times must be documented to establish that the 30-minute threshold was met. This is the most commonly missing element.
• Provider identity: Name and credentials of the qualified health care professional who conducted the discussion.
• Participant names: Whether the discussion involved the patient, a surrogate (family member, legal representative), or both.
• Discussion content summary: A brief narrative describing what was discussed, including which directive types were explained (living will, health care proxy, DPOA, MOLST/POLST).
• Forms status: Whether advance directive forms were completed, reviewed, updated, or declined during the encounter.
• Voluntary nature: Documentation confirming that ACP participation was voluntary and patient-initiated, per CMS guidance.

CMS also requires that the discussion be “voluntary,” meaning the patient (or surrogate) initiated or consented to the conversation. Documenting this explicitly in the note protects the practice during post-payment review.

ICD-10 codes to use with CPT 99497

Advance care planning does not require a specific ICD-10-CM diagnosis code because it is a preventive service under Medicare. However, pairing a relevant diagnosis or encounter code strengthens the claim and satisfies payer edits that require at least one diagnosis code on the claim. The most commonly accepted ICD-10 codes used alongside 99497 are listed below.

Some commercial payers do require a linked diagnosis code, so always verify individual payer requirements before claim submission. Check payer-specific LCD and NCD policies before assuming the Medicare standard applies to all payers.

Common billing errors for advance care planning claims

Advance care planning claims have a high denial rate relative to their complexity. Most failures come from a small set of recurring mistakes. Understanding common medical billing denial codes helps billing teams catch these before they reach the payer.

• Missing start/stop time: Documenting only “30 minutes of ACP discussed” without specifying start and stop time does not satisfy the documentation standard. Payers require both timestamps.
• Billing 99497 for a discussion under 16 minutes: A 10-minute ACP conversation falls short of CPT’s midpoint threshold and can’t be billed as 99497. Consider a different E/M service if its requirements are met.
• Billing 99498 without 99497: 99498 is an add-on code and cannot appear on a claim without 99497. Claims submitted with 99498 alone will be rejected.
• Omitting modifier 25 on the E/M code: When ACP and an E/M visit occur on the same date, the E/M code needs modifier 25. Without it, the payer may deny the E/M as a duplicate service.
• Missing modifier 33 on an AWV-day claim: Leaving it off 99497 billed with a covered Annual Wellness Visit triggers standard cost-sharing instead of a waiver.
• Billing for non-face-to-face discussions: Phone calls, patient education handouts, or asynchronous messaging cannot be billed as 99497. The service requires face-to-face contact (in-person or, where permitted, live interactive video).
• Insufficient narrative documentation: A brief note stating “ACP discussed” with no content summary does not support the claim. The record must describe what directives were discussed and whether forms were completed or declined.

Submitting a clean claim for CPT code 99497 depends on having complete documentation before the claim leaves the practice. A pre-submission audit checklist, built from the required elements above, catches most of these errors at the source rather than after denial.

Using practice management software to streamline ACP billing

Most revenue leaks occur where practices know the ACP billing rules but struggle to apply them consistently in a busy day. Static reference guides describe what to document. The claims management software within Pabau enforces those requirements at the point of care. It embeds required fields into the encounter template and flags incomplete records before submission.

Structured ACP note templates in Pabau capture start/stop time, participant names, directive types discussed, and form completion status as discrete fields. That structured data flows directly into the claim, reducing the manual re-entry that introduces errors. Pabau’s reporting dashboards then track 99497 claim acceptance rates and denial reasons by provider. Billing managers can use this to spot systematic issues versus one-off clinician errors.

Pabau’s claims management software handles the full claim lifecycle for complex billing arrangements, such as AWV plus ACP or E/M plus ACP with modifier 25. That means eligibility checks, electronic submission, remittance processing, and payment posting, closing the loop on revenue cycle management for ACP services.

Conclusion

Advance care planning is among the most frequently underbilled Medicare preventive services. Time documentation and co-billing rules create friction that leaves claims incomplete or unsubmitted. CPT code 99497 rewards practices that get the documentation right. A face-to-face ACP conversation of 16 minutes or more captures roughly $87 in Medicare reimbursement at non-facility rates. Billing it correctly with a covered Annual Wellness Visit under modifier 33 also waives the deductible and coinsurance.

Pabau’s claims management software embeds the required ACP documentation fields into the encounter workflow and routes completed claims to payers electronically. This reduces denial rates and recaptures revenue that would otherwise be written off. Book a demo to see how Pabau can streamline ACP billing for your practice.

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