Ultimate Guide to CPT 99497 & 99498: Advance Care Planning Billing
- Sirius solutions global
- Aug 3
- 7 min read
⏱️ 16 min Minimum Time to Bill 99497 | 💰 Mod 33 Waives Coinsurance When Paired With AWV | 🏆 98% |
⚡ Quick Answer: What Are CPT 99497 & 99498?
CPT 99497 covers the first 30 minutes of face-to-face advance care planning a conversation about advance directives, healthcare proxies, and end-of-life wishes between a physician or qualified provider and the patient, family, or surrogate. CPT 99498 is the add-on code for each additional 30 minutes. Medicare covers both with no diagnosis requirement, and waives coinsurance entirely when billed alongside the Annual Wellness Visit with modifier 33. |
Why ACP Billing Trips Up Internal Medicine Practices
Advance care planning conversations are some of the most valuable time a physician spends with a patient and some of the most inconsistently billed. Many internal medicine and primary care practices either skip billing 99497 entirely, unsure whether the conversation "counts," or bill it without the one modifier that determines whether the patient owes anything out of pocket.
Sirius Solutions Global's healthcare billing experts review E/M and preventive-service coding for internal medicine practices nationwide, and CPT 99497/99498 sit in a specific blind spot: the codes themselves are simple, but the Medicare coverage rules around coinsurance, timing, and same-day billing trip up even experienced coders. This guide breaks down exactly what CMS requires in 2026 and what changes the moment ACP is billed alongside an Annual Wellness Visit.
CPT Code Overview
Code | Description | Time | Documentation Needed |
99497 | ACP: explanation and discussion of advance directives, first 30 minutes, face-to-face | 16-30+ min | Time, participants, topics discussed, decisions made |
99498 | ACP add-on: each additional 30 minutes (list separately with 99497) | 16+ min into the additional period | Same as above, tied to the additional time block |
What Is Advance Care Planning?
Advance care planning is a face-to-face conversation about a patient's future medical care advance directives, living wills, healthcare power of attorney, and goals-of-care preferences if the patient can no longer speak for themselves. Completing a standard form is part of ACP "when performed," but it's not required to bill the code; the conversation itself is the billable service. A physician spending 25 minutes discussing a patient's wishes around resuscitation and long-term care, with no form signed that day, still supports 99497 if the discussion and time are documented.
CPT 99497 Explained
✓ Any Medicare beneficiary qualifies — ACP is not restricted to terminally ill or seriously ill patients ✓ Billable by the physician or other qualified health care professional personally, face-to-face with the patient, family member(s), or surrogate ✓ Minimum 16 minutes required to bill the first 30-minute unit; CMS suggests billing a different E/M service for conversations under 16 minutes ✓ No specific ICD-10 diagnosis is required to support the code ✓ Can be billed as a stand-alone service or alongside many other E/M visits, on the same day or a different day |
CPT 99498 Explained
✓ Add-on code only — 99498 should never be billed without 99497 on the same claim ✓ Requires at least 16 minutes into the additional 30-minute block to bill that unit ✓ No CMS-stated cap on the number of 99498 units, but documentation must support the additional time as genuine ACP discussion ✓ If a second ACP conversation happens on a different day, 99497 is billed again for that day's first 30 minutes, not 99498 |
Medicare Rules for ACP in 2026
Factor | Detail |
Covered patients | All Medicare Part B beneficiaries; not limited to any specific diagnosis or prognosis |
Coinsurance/deductible | Standard Part B cost-sharing applies for stand-alone ACP; fully waived when billed with the AWV using modifier 33 |
Frequency | No CPT-stated limit; repeat billing should reflect a documented change in health status or patient wishes |
Diagnosis requirement | None — ACP does not require a specific ICD-10 code to be billable |
Excluded same-day pairings | Should not be billed same day, same provider, with 99291-99292, 99468-99469, 99471-99472, 99475-99480, or 99483 |
💰 The Modifier That Matters Most The single most valuable rule in this entire guide: ACP is only free to the patient when billed on the same claim, same day, and by the same provider as the Annual Wellness Visit (G0438 or G0439), with modifier 33 attached to 99497/99498. Miss the modifier, and standard coinsurance and deductible apply even though the visit context was identical. |
Time Requirement at a Glance
0-15 min | Below minimum — consider a standard E/M code instead |
16-30 min | 99497 (first unit) |
31-45 min | 99497 + 99498 requires 16+ min into the second block (46+ min total) |
46-60+ min | 99497 + 99498, additional units as time and documentation support |
Documentation Checklist
✓ Patient consent to have the conversation, noted in the record ✓ Topics discussed: advance directives, healthcare proxy, goals of care, treatment preferences ✓ Participants present: patient, family member(s), surrogate ✓ Total face-to-face time, stated explicitly ✓ Decisions made or forms completed, if any ✓ Provider signature ✓ For repeat billing: what changed since the last ACP conversation |
📝 Sample Documentation Sample documentation language: "Spent 32 minutes face-to-face with patient and daughter (healthcare proxy) discussing advance directives, goals of care, and preferences regarding resuscitation and long-term treatment. Patient expressed wish to avoid prolonged mechanical ventilation. Advance directive form reviewed but not completed today; patient will return with a signed copy. Time: 32 minutes." |
Modifiers That Actually Matter for ACP
Modifiers GW and GV are hospice-specific (attending physician relationship to a hospice election) and generally aren't relevant to routine ACP billing outside a hospice context — don't add them by default.
Billing ACP With Other Visit Types
Common Billing Mistakes
Denial Prevention Guide
Most 99497/99498 denials trace back to one of four things: a missing modifier 33 on an AWV day, insufficient time documentation, billing 99498 as a stand-alone line, or same-day conflicts with excluded E/M codes. None of these require guessing they're all confirmable before the claim goes out. A pre-submission check against the AWV date, the documented time, and the CMS exclusion list catches the overwhelming majority of preventable ACP denials.
Revenue Optimization Tips
📈 Flag every AWV visit for a potential ACP conversation and modifier 33 pairing this is the most commonly missed revenue opportunity in this code family
📈 Train front-desk and clinical staff to recognize when a visit's actual content supports 99497, even if it wasn't scheduled as an ACP visit
📈 Audit a sample of ACP claims quarterly against actual documented time, not just code frequency
📈 Coordinate with your EHR templates so time and participant documentation are captured consistently, not reconstructed after the visit
Internal Medicine Billing Support From Sirius Solutions Global
Advance care planning is one piece of a much larger internal medicine billing picture — chronic care management, annual wellness visits, and E/M coding all intersect the same way. Sirius Solutions Global helps practices get all of it right, combining AI-powered claim scrubbing with human coding review.
🚀 Explore Internal Medicine Billing Services siriussolutionsglobal.com/specialties/internal-medicine-billing 📞 Contact Sirius Solutions Global |
Frequently Asked Questions — CPT 99497 & 99498
▼ Q: What is CPT 99497?
CPT 99497 bills the first 30 minutes of a face-to-face advance care planning conversation between a physician or qualified provider and the patient, family member, or surrogate, covering advance directives and end-of-life care preferences.
▼ Q: What is CPT 99498?
99498 is the add-on code for each additional 30 minutes of ACP beyond the first 30 minutes billed under 99497. It's never billed alone.
▼ Q: When should CPT 99497 and 99498 be billed?
Whenever a genuine, documented advance care planning conversation of at least 16 minutes occurs, whether as a stand-alone visit or alongside another qualifying E/M or preventive visit.
▼ Q: Who can bill CPT 99497 and 99498?
Only the physician or qualified health care professional personally conducting the conversation may bill these codes — they can't be delegated entirely to clinical staff the way some other care management codes can.
▼ Q: What documentation is required for ACP billing?
Time spent, participants present, topics discussed, any decisions or forms completed, and — for repeat billing — what changed since the last ACP conversation.
▼ Q: How many minutes are required for CPT 99497?
A minimum of 16 minutes of face-to-face time is required to bill the first 30-minute unit; CMS suggests a standard E/M code for shorter conversations.
▼ Q: Can CPT 99497 be billed with an E/M visit?
Yes, on the same day as most E/M visits, with modifier 25 on the E/M code if it represents a significant, separately identifiable service.
▼ Q: Does Medicare cover Advance Care Planning?
Yes. Medicare Part B covers ACP for all beneficiaries. It's fully covered with no coinsurance or deductible when billed the same day as the Annual Wellness Visit with modifier 33; standard cost-sharing applies otherwise.
▼ Q: Which modifier should be used for ACP with an Annual Wellness Visit?
Modifier 33, appended to 99497 (and 99498 if applicable), on the same claim as the AWV, same day, same provider — this is what waives the patient's coinsurance and deductible.
▼ Q: Which diagnosis codes support ACP billing?
None are required. CMS does not mandate a specific ICD-10 code for CPT 99497 or 99498 to be billable.
▼ Q: What causes CPT 99497/99498 denials?
The most common causes are a missing modifier 33 on an AWV-day visit, billing 99498 without 99497, insufficient documented time, and same-day billing with excluded codes like critical care services.
▼ Q: Can ACP be billed via telehealth?
Yes, when payer telehealth policy includes ACP on its covered list, using modifier 95 to indicate synchronous audio-video delivery — verify current payer-specific telehealth rules before billing.
Final Takeaway
CPT 99497 and 99498 reward practices that treat advance care planning as a billable, documentable service rather than an informal conversation folded into a longer visit. The clinical work is often already happening — the revenue and patient cost-sharing outcome depends entirely on whether the time, participants, and modifier 33 pairing are captured correctly.
Sirius Solutions Global's healthcare billing experts help internal medicine practices build that habit into their workflow, so ACP conversations translate into accurate, fully supported claims every time.
⚠️ Important Disclaimer
Disclaimer This content is for educational purposes only and does not replace official CPT guidelines, CMS policy, or payer-specific rules. This article reflects CMS guidance and AMA CPT principles understood to be current as of 2026, including CMS Medicare Coverage Database Article A58664. Reimbursement varies by payer, locality, and plan type; verify current rates and policy using the CMS Physician Fee Schedule Look-Up Tool and payer-specific guidance. Coding decisions should be based on the complete medical record and reviewed by a certified professional coder (CPC) or compliance officer before claims are submitted. |
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