Advance care planning discussion visit template

Key Takeaways

An advance care planning discussion visit is a billable Medicare encounter (CPT 99497/99498) where clinicians facilitate conversation about patient values, goals of care, advance directives, and healthcare proxies.

Medicare Part B fully covers ACP visits with zero patient cost-sharing when billed during an Annual Wellness Visit. CPT 99497 covers the first 30 minutes, and CPT 99498 covers each additional 30 minutes.

Complete ACP documentation must include patient consent, goals-of-care narrative, advance directive status, healthcare proxy designation, POLST/MOLST form status (where applicable), and next-step action items.

Practice management software like Pabau streamlines ACP visit documentation with digital forms and customizable templates.

Most advance care planning guides teach you how to have the conversation, while the majority of billing guides just list the CPT codes.

Almost none put both in one place.

That disconnect is why a Medicare-billable advance care planning discussion visit so often becomes a strong conversation that gets under-documented and under-billed, especially in a busy primary care practice.

This guide closes the loop: a downloadable template, the exact code stack (CPT 99497 and 99498, plus same-day Annual Wellness Visit billing), and a validated step-by-step conversation framework your team can use at the next appointment.

What is an advance care planning discussion visit?

An advance care planning discussion visit is a dedicated clinical encounter where a provider and patient discuss the patient’s values, goals of care, and treatment preferences in the context of possible future health scenarios such as serious illness, decline, or end-of-life care.

• Voluntary participation: Patients initiate or agree to the conversation.
• Goals-focused: Clarifies what matters most to the patient (quality of life, symptom relief, longevity, family time, spiritual beliefs).
• Documentation-heavy: Produces a written record of preferences that guides future clinical decisions.
• Legally recognized: Informs advance directives, healthcare proxy designation, and POLST/MOLST orders.
• Medicare billable: Covered under CPT 99497 and 99498 with zero patient cost-sharing.

Unlike a routine office visit, an advance care planning discussion visit requires dedicated time, a quiet setting, and family involvement where appropriate. Many practices use digital intake forms and structured templates to reduce clinician burden and make sure no essential elements are missed.

Advance care planning CPT codes: 99497 and 99498

Medicare created two dedicated codes so this time-intensive conversation is reimbursed on its own instead of being bundled into an office visit. The advance care planning CPT code for the first block of time is 99497, and CPT 99498 is the add-on for each additional 30 minutes. The table below gives the 99497 CPT code description alongside time and reimbursement.

Both codes require documentation of time and can be billed the same day as an Annual Wellness Visit (G0438/G0439) without a bundling penalty. That’s a key claims management advantage for primary care practices.

One detail the code descriptions leave out: there is no ICD-10 code specific to advance care planning. You report the diagnosis that prompted the conversation, usually the patient’s relevant chronic or serious condition, or a general counseling code such as Z71.89 for a standalone preventive discussion. Matching the right ICD-10 code to advance care planning is what keeps a well-documented visit from being denied.

Medicare coverage and reimbursement for ACP visits

Medicare Part B covers advance care planning discussion visits as a preventive benefit with no frequency restrictions, which matters most for preventive care practices billing ACP alongside an Annual Wellness Visit. Patients aren’t required to have an ACP visit annually or on a set schedule.

It’s patient-initiated or clinician-recommended based on clinical appropriateness. The 99497 billing guidelines below hold whether the visit stands alone or rides along with another service.

• Cost-sharing waived: Patients pay $0 when billed as a preventive service during an AWV
• No frequency limits: CMS does not restrict how often a patient can have an ACP conversation
• Multi-disciplinary billing: Physicians, NPs, and PAs (per state scope-of-practice rules) can bill ACP codes
• Modifier rules: Same-day AWV and ACP billed together do not require a modifier or claim rejection
• State variation: Some states allow advanced practice clinicians to bill independently, while others require physician oversight. Verify your state’s rules

CMS preventive services guidance confirms the ACP benefit applies nationally to all Medicare beneficiaries, though state scope-of-practice laws determine who can conduct the visit.

What to include in an advance care planning discussion visit template

A compliant advance care planning discussion visit template captures six elements that together meet the advance care planning documentation requirements for billing, satisfy legal documentation standards, and reflect clinical best practice. Practices using comprehensive client records embed these as a structured form so the same fields are captured at every visit.

• Patient demographics and consent: Full name, date of birth, date of visit, and a signed consent form confirming the patient agrees voluntarily to discuss advance care planning
• Patient values and goals of care: Narrative of what matters most to the patient (relief from suffering, time with family, maintaining independence, religious/spiritual beliefs) and overarching health goals
• Advance directive status: Whether the patient has a living will or advance healthcare directive. If not, offer to discuss it or provide resources
• Healthcare proxy or power of attorney: Designated surrogate decision-maker, including name, relationship, contact information, and confirmation that the proxy understands their role
• POLST/MOLST form status (where applicable): Whether the patient has a Physician Orders for Life-Sustaining Treatment form (state-specific). If not, assess appropriateness and offer completion
• Next steps and follow-up: Action items (e.g., patient to review advance directive template, schedule appointment with legal counsel, bring proxy to next visit)

Pabau’s automated workflows route ACP templates to patients before the visit, collect responses through a secure intake form, and populate the clinician’s note at appointment time, so much of the documentation is done before the patient sits down.

Step-by-step: How to conduct an advance care planning discussion visit

A structured framework helps clinicians lead a goals of care conversation with confidence. The Serious Illness Conversation Guide from Ariadne Labs at Harvard provides validated language and example scripts, adapted below for primary care. Not sure who to offer it to? Use the “surprise question” clinicians rely on to prioritize: would you be surprised if this patient died within the next year? If the answer is no, book the visit.

1. Set the stage: Schedule 30-60 minutes in a quiet room. Invite family/healthcare proxy if present. Say: “I’d like to spend time today talking about what matters most to you if your health were to change significantly. Is now a good time?”
2. Ask open-ended questions about values: “What does a good day look like for you?” “What activities or roles are most important?” “If time were limited, what would you want to focus on?” Listen more than you speak.
3. Explore worries and fears: “What concerns you most about the future?” “What would you want to avoid?” Document specific concerns (pain, loss of independence, burden on family) and address them directly.
4. Introduce advance directives and proxy: “Have you thought about who should make decisions if you were unable to communicate?” Offer templates and a timeline for completion, and clarify that this is about planning, not about imminent illness.
5. Discuss POLST/MOLST (if appropriate for age/illness): “This form tells EMS and hospitals your wishes about life-sustaining treatments like CPR or breathing machines.” Complete only if the patient requests it or the clinical condition warrants it. It isn’t routine for all ages.
6. Summarize and document: Reflect back what you heard (“So what I’m hearing is…”) and document verbatim. Offer written summary and resources. Schedule follow-up.

Clinicians new to ACP conversations often worry about time burden. AI-assisted clinical documentation can reduce note-writing time by recording key points and structuring them into your EHR format, leaving the clinical conversation itself uninterrupted.

Advance care planning checklist for compliant documentation

Use this checklist before, during, and after the visit to ensure billing compliance and documentation completeness.

• Pre-visit: Schedule 30-60 minutes, identify if the patient has a family member or proxy to involve, and prepare advance directive templates and POLST forms (if applicable to your state or setting)
• During visit: Document patient consent, time in/out, chief values and goals, advance directive status, healthcare proxy name and contact, POLST form status, and any referrals made
• Document specific goals using patient language, not clinical jargon (e.g., “wants to be at home,” not “refuses ICU”)
• Billing: Confirm your time documentation supports the CPT code you’re billing (≥16 minutes for 99497, ≥46 minutes cumulative for 99498), then link the visit to the Annual Wellness Visit if billed the same day
• Post-visit: Share a written summary with the patient, schedule a proxy appointment to discuss their role, and flag the advance directive or POLST for follow-up at the next visit
• File all documents in the patient chart, and note completion in the clinical note and care plan

Compliance management workflows help practices track ACP conversation completion and flag overdue discussions in high-risk populations (age >75, serious chronic illness).

How Pabau supports advance care planning visit documentation

Pabau’s practice management platform simplifies ACP visit workflows through customizable templates, automated patient intake, and structured note generation. Practices use Pabau to streamline the administrative burden while clinicians focus on the conversation.

• Pre-visit patient intake: Send patients a digital form collecting basic demographics, current medications, and advance directive status before the appointment, so clinicians start with complete information
• Customizable visit template: Build your practice’s ACP visit note template within Pabau with your specific fields (values, proxy, POLST), ensuring consistent documentation
• Billing code integration: Link ACP visits to CPT 99497/99498 codes. Pabau flags time requirements and same-day AWV co-billing rules to prevent claim rejections
• Automated follow-up: Trigger reminder workflows (e.g., “Advance directive not yet signed: schedule legal review”) to ensure conversations convert to completed documents

Make advance care planning visits routine and reimbursable

Advance care planning discussion visits are a high-value, billable service that respects patient autonomy and reduces crisis decision-making. By using a structured template, scheduling dedicated time, and documenting comprehensively, practices can ensure that conversations are clinically sound and reimbursable. Download the template above and begin integrating ACP into your preventive care visits today.

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