The 99497 cpt code is a medical billing code used when a doctor or health worker talks with a patient about future care plans. This is not about treatment right now, but about what should be done if the patient becomes very sick in the future.
These conversations give patients an opportunity to explain their wishes before a serious illness or emergency occurs. For providers and medical billing teams, accurate time tracking and documentation are especially important because 99497 is a time-based service.
Medicare records show that around 1.35 million beneficiaries received Advance Care Planning (ACP) services in 2023, demonstrating growing use of CPT 99497 and 99498 nationwide.
CMS describes 99497 as the first 30 minutes of face-to-face ACP with the patient, family member(s), and/or surrogate. Under Medicare’s timed-service rules, 99497 is reported when at least 16 minutes are spent on the qualifying ACP discussion.
This guide explains the 99497 CPT code description, billing guidelines, time requirements, reimbursement considerations, documentation standards, modifier rules, and common claim problems.
99497 cpt code description
The 99497 CPT code is used in medical billing when a physician or qualified health professional provides Advance Care Planning. The service includes explaining and discussing advance directives and future healthcare choices with the patient, family member(s), and/or surrogate.
The main goal is to help patients understand their options and communicate their preferences before an emergency occurs. The discussion may include whether the patient wants certain treatments, comfort-focused care, hospitalization, or other forms of future medical care.
CMS states that 99497 is a face-to-face service and can include the patient, family members, and/or a surrogate.
ACP is voluntary. The patient’s agreement to participate should be documented, along with the substance of the discussion and the people who participated.
Goals of Treatment
These conversations focus on what the patient wants for future health situations.
The provider may discuss treatment preferences, advance directives, resuscitation wishes, hospitalization, comfort-focused care, or who should make decisions if the patient later loses decision-making capacity.
It is also common for billing teams to ask whether 99214 and 99497 can be billed together. Medicare allows 99497 to be reported with many E/M services when the requirements for both services are met and the services are separately identifiable. For applicable same-day E/M services, CMS guidance requires modifier 25 when the modifier’s requirements are satisfied.
End-of-life planning basics
Advance care planning can include conversations about CPR, life-sustaining treatment, hospital care, palliative care, or comfort-focused treatment.
The discussion does not require the patient to complete an advance directive before 99497 can be billed. CMS specifically notes that completion of an advance directive is not required because the CPT descriptor says “when performed.”
This distinction is important because the purpose of ACP is the meaningful discussion and planning process, not simply completing a form.
Legal and Medical Documentation
All important parts of the discussion should be recorded in the medical record.
Documentation should identify the voluntary nature of the service, the topics discussed, participants, advance directives discussed or completed when applicable, and the time spent in the face-to-face encounter.
CMS recommends documenting the content and medical necessity of the ACP discussion, who participated, and the time spent.
CPT 99497 Billing Guidelines
The CPT 99497 billing guidelines explain how providers should report this time-based Advance Care Planning service.
For Medicare, 99497 covers the first 30 minutes of qualifying ACP. The minimum time threshold is 16 minutes. Therefore, a qualifying discussion lasting 16–30 minutes may support 99497 when all other requirements are met.
The notes must show the purpose of the discussion, the relevant topics, participants, and time spent. Weak documentation can make an otherwise appropriate claim difficult to support.
Minimum Time Requirement
The provider must spend at least 16 minutes on the qualifying ACP discussion to report 99497 under Medicare’s timed-service rules.
A discussion lasting 15 minutes or less should not be reported as 99497 under Medicare guidance. CMS indicates that a different E/M service may be considered when its own requirements are met.
For example, a documented 18-minute ACP discussion may fall within the 16–30 minute range for 99497. A discussion lasting 28 minutes remains within the same initial 99497 time block.
Time should be supported in the medical record. Using start and end times is a practical way to make the record easier to audit.
First 30 min Payment frame
99497 represents the initial 30-minute ACP service.
The code is not automatically limited to a full 30 minutes. Under Medicare’s timed-service rules, the 16-minute minimum allows the first 30-minute code to be reported when the qualifying discussion reaches the required threshold.
When the ACP discussion continues beyond the initial time period, 99498 may be reported for additional qualifying time when its requirements are met.
When used on its own
99497 may be reported as a standalone service when the provider performs a qualifying ACP discussion and all billing requirements are met.
The medical record should still clearly establish why the ACP discussion occurred, what was discussed, who participated, and how much qualifying time was spent.
The fact that no other service was billed on the same date does not remove the documentation requirements.
When used with E/M or year check visit
99497 may be reported on the same date as many E/M services when the requirements for both services are met.
The E/M service and ACP service must represent separately identifiable work. Time spent on another active service should not be counted again as ACP time.
For applicable E/M services performed on the same date, CMS guidance states that modifier 25 should be used when the requirements for that modifier are met.
This is why billing teams should review the provider’s documentation rather than automatically adding a modifier whenever two codes appear on the same claim.
Can 99497 Be Billed With an Annual Wellness Visit?
Yes. Medicare allows ACP to be provided as an optional element of an Annual Wellness Visit (AWV). When ACP is furnished on the same day by the same provider as a covered AWV, modifier 33 is used to identify the preventive-service circumstances under Medicare’s rules.
When the applicable requirements are met, Medicare waives the Part B deductible and coinsurance for ACP furnished with the covered AWV.
For example, if an AWV and qualifying ACP are performed together, the claim should reflect both services and follow the applicable modifier and billing instructions.
The cost-sharing waiver does not apply in the same way when ACP is furnished separately from the covered AWV.
CPT 99497 Reimbursement Rules
The CPT 99497 reimbursement rules determine how the service is paid after the claim meets the applicable billing requirements.
Medicare payment is based on the applicable Physician Fee Schedule and can vary by locality and other payment factors. Commercial payers may use their own contracted rates and policies.
For 2026, CMS publishes Physician Fee Schedule payment files that billing teams can use when checking current Medicare payment information.
Medicare Payment Criteria
Medicare pays for ACP when the applicable service and billing requirements are met.
The discussion must be voluntary, involve the appropriate participants, satisfy the time requirement, and be supported by documentation.
Facility vs Non-Facility Payment
ACP services can be furnished in both facility and non-facility settings.
CMS states that there are no general place-of-service limitations for ACP codes. Services may be furnished in settings such as an office, hospital, skilled nursing facility, or home, subject to applicable billing requirements.
The place of service should be reported correctly on the claim.
Key Payment Factors
Reimbursement can depend on:
- Payer.
- Geographic locality.
- Place of service.
- Medicare or commercial payer rules.
- Modifier requirements.
- Documentation.
- Time reported.
- Whether another service was billed on the same date.
A billing team should verify the current fee schedule rather than using an old reimbursement amount copied from a previous year.
Key Payment Factors
Different insurance plans may reimburse the same CPT code differently.
Medicare and commercial plans can have different payment policies, claim edits, and documentation requirements. A clean claim therefore depends on more than selecting the correct CPT code.
Reimbursement Gaps
Different insurance plans may reimburse the same CPT code differently.
Medicare and commercial plans can have different payment policies, claim edits, and documentation requirements. A clean claim therefore depends on more than selecting the correct CPT code.
Strong documentation helps support the reported service and gives the billing team evidence if the claim is reviewed.
Documentation Requirements for CPT 99497
Good documentation requirements for CPT 99497 are essential for accurate billing and claim support.
CMS recommends documenting the content and medical necessity of the ACP discussion, its voluntary nature, any advance directives discussed or completed, the participants, and the time spent in the face-to-face encounter.
- Detailed Clinical Notes Requirement
The provider should document.- Why ACP was discussed.
- The patient’s care preferences.
- Major topics covered.
- Advance directives discussed.
- Decisions or preferences expressed.
- Any relevant follow-up plan.
Avoid vague statements such as “ACP discussed” without explaining what the discussion covered.
- Patient and Family Participation Proof
Notes should show whether the patient, family member(s), or surrogate participated. This is especially important when a surrogate participates because the record should make the participants and their role clear. - CPR and Resuscitation Decision Documentation
If CPR or resuscitation preferences are discussed, the relevant discussion should be documented. The note should describe the patient’s expressed preferences rather than simply listing a form or checkbox without supporting discussion. - DPOA / Surrogate Decision-Maker Assignment
The record may identify who the patient wants to involve in future healthcare decisions. If a healthcare proxy, surrogate, or other decision-maker is discussed, document the person’s role and any relevant decisions made during the conversation. - Living Will and POLST Discussion Records
Advance directives and other planning documents may be discussed during ACP. Completion of a form is not required for billing 99497, but if a form is completed or discussed, the documentation should reflect what occurred. - Exact Time Tracking for Billing Validation
Time documentation is one of the most important parts of a 99497 claim. CMS notes that start and end times are a useful way to document the face-to-face discussion. Billing staff should ensure that time counted toward ACP was actually spent on qualifying ACP activities. Do not combine time spent on another time-based service with the ACP time.
Who Can Bill CPT 99497?
Medicare allows physicians and other qualified practitioners whose scope of practice and Medicare benefit category include the service to report ACP codes. CMS specifically identifies physicians and qualified providers such as nurse practitioners and physician assistants.
Other team members may participate in ACP under applicable supervision and medical management arrangements, but they do not independently report 99497 unless they meet the applicable requirements to bill Medicare.
The billing practitioner must meaningfully participate in the ACP service.
This distinction matters for medical billing companies because the person participating in the conversation and the practitioner reporting the code should be consistent with the applicable Medicare rules.
CPT 99497 vs CPT 99498
CPT 99497 is used for the first 30 min talk on care plans. CPT 99498 is for extra time after that. 99497 starts the care talk, and 99498 adds more time when talk is long. Both help record full care plans and support correct pay by insurance rules.
| Point | CPT 99497 | CPT 99498 |
| Time usage | Initial 30-minute session | Additional time beyond 30 minutes |
| Code type | Primary billing code | Add-on billing code |
| Usage stage | Start of advance care planning | Extended discussion time |
| Billing rule | Can be used alone | Must be used with 99497 |
| Purpose | Begin care planning discussion | Extend detailed conversation time |
| Insurance | Base reimbursement code | Extra reimbursement support |
For Medicare, 99497 may be reported for the first 16–30 minutes. Once the discussion continues into additional qualifying time, 99498 may be reported according to the applicable timed-service rules.
Can 99497 and 99498 Be Billed Together?
Yes. 99498 is specifically designed as an add-on code for additional ACP time after the initial 99497 service.
The provider must document enough qualifying time to support the additional service.
Billing staff should not add 99498 simply because the appointment lasted longer. The additional time must represent qualifying ACP work and must be properly documented.
Can 99214 and 99497 Be Billed Together?
Yes, Medicare permits 99497 to be separately reported with many E/M services when the services are separately identifiable and the applicable requirements are met.
For certain same-day E/M services, modifier 25 is required when the E/M service is significant and separately identifiable from the ACP service.
The provider should clearly document the separate E/M work and ACP discussion. Time used for the E/M service should not also be counted toward 99497.
What Diagnosis Code Should Be Billed With 99497?
There is not one universal diagnosis code that applies to every 99497 claim.
CMS’s current Advance Care Planning fact sheet states that the condition discussed with the patient should be reported using an appropriate ICD-10-CM code. When ACP is provided as part of an AWV, an administrative examination or well-exam diagnosis may be used according to the applicable guidance.
The diagnosis should therefore reflect the patient’s documented condition or the applicable reason for the encounter rather than using one diagnosis code for every ACP claim.
Common CPT 99497 Billing Problems
Missing Time
The provider documents that ACP occurred but does not record enough time to support the code.
A 15-minute discussion does not meet Medicare’s 16-minute minimum for 99497. A qualifying 18-minute discussion can meet the initial timed-service threshold when the other requirements are satisfied.
Vague Documentation
A short note such as “discussed advance care planning” may not adequately explain the service.
Document the discussion content, participants, voluntary nature, and time spent.
Double-Counting Time
Time spent on another time-based service should not also be counted toward ACP.
This is particularly important when 99497 is billed alongside an E/M service.
Incorrect Modifier Use
Modifier requirements depend on the services billed and the circumstances of the encounter. Modifier 25 may apply when 99497 is reported with certain E/M services, while modifier 33 has a specific role when qualifying ACP is furnished with an AWV.
Billing Without a Meaningful ACP Discussion
The presence of an advance directive form alone does not establish that 99497 was performed. The service is based on the qualifying ACP discussion.
99497 CPT Reimbursement Challenges
The main issues with CPT 99497 payment come when the write up is not full or not clear. Many claims get cut when the time is not shown in the note. This code needs proof of time, so no time log can make the claim weak. Some claims also fail when bill codes are mixed in one visit and the discussion is not split in a clear way.
If the healthcare provider does not show what was said in the talk, who was there, and what plan was made, the pay may be cut. No clear proof of the care talk is a big cause of loss.
Sometimes the note is too short and does not show key facts like care wish or end care plan. This makes the claim hard to trust for the pay group. Good notes with clear time, clear plan, and clear talk help the claim pass fast. Bad or weak notes can slow pay or stop pay.
Final Thoughts
The CPT 99497 code helps plan for care in the near and far time. It lets the provider talk with the person and their kin about care wishes for bad health days. Good notes help the claim get paid with no cut or delay. The provider must show clear time, clear talk, and clear plan in each case.
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If the write up is weak, the pay may stop or slow. Good care talk helps the man and kin feel safe and sure. This type of talk also helps in hard days when quick care must be set by the team.
Frequently Asked Questions
1) Can 99214 and 99497 be billed together?
Yes. Medicare allows 99497 to be reported with many E/M services when both services are separately identifiable and their individual requirements are met. Modifier 25 may be required for applicable same-day E/M services.
2) Does 99497 need a modifier?
It depends on how the service is billed. Modifier 25 may apply when 99497 is reported with certain E/M services, while modifier 33 is used in specific Medicare AWV circumstances to identify qualifying preventive services.
3) What diagnosis code should be billed with 99497?
There is no single diagnosis code for every 99497 claim. The diagnosis should reflect the condition discussed during ACP or the applicable AWV diagnosis when ACP is provided as part of the wellness visit.
4) Who can take part in the 99497 talk?
The discussion may include the patient, family member(s), and/or surrogate.
The billing practitioner must meet the applicable Medicare requirements and meaningfully participate in the ACP service.
5) How long must 99497 talk be?
For Medicare, 99497 is reported for the first 30 minutes of ACP, with a minimum of 16 minutes under the applicable timed-service rules. A discussion of 15 minutes or less does not support 99497.
6) Is completing an advance directive required to bill 99497?
No. CMS states that completion of an advance directive is not required because the CPT descriptor includes completion of forms “when performed.” The qualifying ACP discussion and documentation remain important.
