CPT Code 99497: Advance Care Planning Billing Guide

CPT code 99497 reports advance care planning (ACP), including the explanation and discussion of advance directives, by a physician or other qualified health care professional for the first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. ACP involves discussing and documenting a patient’s preferences for future medical care, particularly in scenarios where they may be unable to make decisions for themselves.

ACP is a critical yet often under-utilized component of patient-centered healthcare. This article provides healthcare professionals with essential guidance on billing ACP services, including CPT codes, documentation requirements, and Medicare reimbursement considerations.

Why does advance care planning matter?

While many patients express a desire to have these conversations, there is often a significant gap between personal discussions and formalized medical documentation. A survey by Howard et al. found that while 92.1% of patients had spoken with family members about their end-of-life care preferences, only 17.5% had engaged in similar discussions with their clinician. This gap underscores the need for billable ACP services to ensure that patient preferences are accurately recorded in their medical records and honored in clinical decision-making.

The growing aging population makes ACP discussions increasingly important. According to the Urban Institute, by 2040 the number of adults aged 65 and older is projected to reach 80 million, with 15 million aged 85 and older, more than twice the number in 2020.

Older adults, particularly those with chronic conditions, are considered high-risk and high-cost patients. According to the National Institute on Aging, approximately 85% live with at least one chronic illness. Over half of those with serious health conditions are aged 80 or older. These individuals often experience increased healthcare utilization and lower quality of life, making proactive ACP discussions essential for ensuring their care aligns with personal values while also helping to reduce unnecessary hospitalizations.

When should advance care planning be addressed?

ACP is a structured conversation between patients, their families, and clinicians regarding future medical care preferences. These discussions are particularly important in the following scenarios:

• Routine cognitive assessments: Patients with early signs of cognitive decline, such as mild cognitive impairment or dementia, should engage in ACP discussions before their decision-making capacity diminishes.
• Annual Wellness Visits (AWV): Medicare includes ACP as an optional component of the AWV, allowing clinicians to integrate these discussions into routine preventive care.
• Medicare & V28 requirements: With the latest risk adjustment updates, accurate documentation of ACP discussions is essential for Healthcare Effectiveness Data and Information Set (HEDIS) compliance and Medicare’s value-based care initiatives, according to ACP Decisions. Proper documentation ensures that patient care preferences are formally recorded while supporting comprehensive care planning.

Addressing ACP proactively strengthens patient-clinician trust, enhances care coordination, and aligns with broader healthcare initiatives aimed at improving outcomes for high-risk populations.

Key components of advance care planning

According to advance care planning guidance from the Centers for Medicare & Medicaid Services (CMS), ACP discussions often lead to the completion of essential legal and medical documents that guide future healthcare decisions, including:

• Advance directives: Legal documents outlining a patient’s medical treatment preferences. These will vary from state to state, and can be found on your state attorney general’s website.
• Living wills: Detailed instructions specifying preferred treatments in critical situations.
• Durable power of attorney for healthcare: A designated healthcare proxy who can make medical decisions on the patient’s behalf.
• Physician Orders for Life-Sustaining Treatment (POLST) or Medical Orders for Life-Sustaining Treatment (MOLST): Physician-signed medical orders that specify a patient’s preferences for treatments such as resuscitation, ventilation, and artificial nutrition. These forms are particularly important for patients with serious illnesses.
• Do not resuscitate (DNR) orders: A medical order indicating that a patient does not wish to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest.
• Do not intubate (DNI) orders: A directive specifying that a patient does not want mechanical ventilation if they experience respiratory failure.
• Goals of care discussions: Conversations that help align medical interventions with a patient’s values, quality-of-life priorities, and long-term healthcare goals.
• Palliative and hospice care planning: Discussions about comfort-focused care options, symptom management, and end-of-life care preferences.

Is advance care planning billable?

Yes, ACP is a reimbursable service under Medicare and many private payers, according to the CMS Medicare Learning Network. Clinicians can bill for these discussions when they involve a face-to-face conversation with the patient, their family, or caregivers about future healthcare decisions, including treatment preferences and advance directives.

Proper documentation of the discussion’s content and duration is essential to ensure reimbursement and compliance with payer guidelines. The applicable Current Procedural Terminology (CPT) codes used for ACP discussions are:

• 99497: 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
• +99498: Each additional 30 minutes (List separately in addition to code for primary procedure)

Key billing guidelines

• ACP does not require a specific diagnosis and can be billed during any appropriate patient encounter.
• Documentation should support that the ACP discussion took place and was voluntary, including key discussion points.
• Accurate time documentation is essential, as ACP codes are time-based and require clear records of the discussion duration. To report CPT code 99497 for the initial 30 minutes of ACP, a minimum of 16 minutes must be documented.
• ACP can be provided in various settings, including outpatient offices, hospitals, and nursing facilities.

When does CPT 99498 apply?

CPT 99498 is used to report each additional 16+ minute unit of advance care planning services beyond the initial 30 minutes captured under 99497.

Requirements for CPT 99498

• The billing clinician must exceed the initial 99497 time requirement (≥ 46 minutes total: 30 minutes for 99497 + 16 minutes for 99498).
• The service must be face-to-face and involve in-depth discussions on goals of care, treatment options, and patient preferences.
• Time spent must be well-documented to support the additional billing.

Considerations for CPT 99498

• Since this is an add-on code, it should only be used in conjunction with 99497; it cannot be reported alone.
• Some commercial payers may have different rules regarding coverage for additional time, so verification with the payer is recommended.
• Ensure clear documentation of total times to substantiate the additional billing.

Who can bill for advance care planning?

ACP discussions often require a team-based approach, but only certain clinicians can bill for ACP services. The following professionals are eligible to bill:

• Physicians (MD/DO)
• Nurse practitioners (NPs)
• Physician assistants (PAs)
• Clinical nurse specialists (CNS)

Other healthcare roles involved in ACP discussions

While billing eligibility is limited, other team members can support ACP discussions under physician supervision, including:

• Social workers: Facilitate discussions on patient values and preferences.
• Care coordinators: Assist in advance directive documentation.
• Registered nurses (RNs): Educate patients and provide initial ACP guidance.

Can you bill CPT code 99497 with an AWV?

Yes, CPT 99497 can be billed separately from an Annual Wellness Visit (AWV) when ACP services are provided. While ACP is an optional component of the AWV or Initial Preventive Physical Exam (IPPE), it is not mandatory. Clinicians can bill ACP as a standalone service or as part of an AWV, ensuring patients receive structured guidance on their future healthcare decisions.

Medicare & commercial payer codes for AWV

Billing requirements for CPT 99497 during an AWV

To ensure proper reimbursement, clinicians must:

• Document that the ACP discussion took place and was voluntary.
• Include key discussion points, such as advance directives, treatment preferences, and goals of care.
• Meet the minimum required time of 16 minutes for face-to-face discussion, in addition to the time spent in the AWV.
• Append Modifier 33 to indicate ACP as a preventive service when applicable.

Since ACP is voluntary, patients should be informed that Medicare may apply cost-sharing if ACP is billed outside of the AWV timeframe or exceeds the once-per-year limit.

Documentation & coverage considerations

Medicare Part B covers ACP at no cost when conducted within an AWV. However, if billed separately, standard Medicare co-pays and deductibles may apply. To ensure proper reimbursement, clinicians must document:

• That the discussion was voluntary
• An explanation of advance directives (completion of forms is optional)
• Who was present during the conversation
• Total time spent on ACP
• Any updates to the patient’s health status or medical preferences

Thorough documentation of discussion content and duration is essential for reimbursement.

Can CPT 99483 be billed with ACP services?

No, CPT 99483 for cognitive assessment and care planning considers any ACP services to be inclusive when performed alongside a cognitive assessment for patients with cognitive impairment. If both services are provided, 99483 is the appropriate code to report.

Which ICD-10-CM codes are used for advance care planning?

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes used for ACP typically reflect the patient’s medical condition, cognitive status, or overall need for ACP discussions.

The diagnosis linked to ACP services should support medical necessity and help payers determine coverage eligibility. These codes often relate to:

• Chronic conditions (e.g., heart failure, cancer, COPD)
• Neurocognitive disorders (e.g., dementia, mild cognitive impairment)
• Palliative or end-of-life care discussions

For example, if a physician is discussing advance directives with a patient diagnosed with moderate dementia and depression due to early-onset Alzheimer’s disease, they would report the following codes:

• G30.0: Alzheimer's disease with early onset
• F02.B3: Dementia in other diseases classified elsewhere, moderate, with mood disturbance

Requirements for ICD-10-CM selection

• When selecting an ICD-10 code for ACP, it must accurately reflect the patient’s clinical condition and the nature of the discussion.
• Some payers may require specific primary diagnosis codes to justify ACP reimbursement, making it essential to verify payer guidelines.
• Additionally, documentation should clearly establish a connection between the ACP discussion and the selected diagnosis to support medical necessity.

Considerations for ICD-10-CM code use

• While ICD-10 codes are necessary for billing, they do not guarantee payment unless medical necessity is clearly demonstrated through documentation.
• Medicare does not require a specific diagnosis code for ACP services, but certain commercial payers may have stricter requirements.
• To ensure compliance, clinicians should review payer policies and confirm any necessary coding specifications before submitting claims.

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Final thoughts

Incorporating advance care planning into routine care is a pivotal strategy for optimizing patient care and aligning with value-based initiatives. By documenting and respecting patients' wishes, clinicians not only ensure that care is tailored to the individual’s preferences but also enhance the overall quality of care delivery. This thoughtful approach helps guide medical decision-making, improves patient satisfaction, and fosters a more proactive, patient-centered healthcare model.