The 99498 CPT code reflects additional 30 minutes of advance care planning services, followed by an initial 30 minutes billed under CPT Code 99497. The 30 minute session involves a face-to-face discussion with patient or family members, regarding patient health status, future decisions and the treatment goals.
This detailed guide will cover important details about this advance care planning ad-on code such as the reimbursement rate, billing requirements and the difference between 99498 vs 99497.
Medicare Rules for 99498 ACP 2026
- Patient Eligibility: All beneficiaries of Medicare Part B
- Coinsurance: falls under the Medicare Part B cost sharing rule for standalone ACP. It is fully waived off when billed with AWV and the modifier 33 is used.
- Frequency: There is no limit for the treatment. However, repeated billing should have documents that support the necessity of the care.
- Diagnosis: There are no such ICD-10 diagnosis code requirements in case of advance care planning.
- Same Day Pairings: Should not be billed on same day same provider with 99291-99292, 99468-99469, 99471-99472, 99475-99480, or 99483
Understanding Advance Care Planning Ad-on Code
In medical billing, the advance care planning is a conversation between the patient regarding his future medical care advance directives, healthcare power of attorney and objectives of care preferences. In addition, a standard ACP form is also filled if a patient feels difficulty in speaking.
Here the healthcare provider does not need to fill the form when assigning 99498 CPT Code. The whole discussion is itself a billable service. Even if the discussion time is 25 minutes that involves information related to patient health, the provider will get reimbursement.
From 2016 through Q3 2018, 5.66% of continuously enrolled Medicare beneficiaries had a billed 99497 claim, while only 0.17% had a billed 99498 claim.
What Does 99498 Cover?
The code covers additional qualifying ACP discussion time. It does not represent a separate office visit. Instead, it extends the primary ACP service.
The basic structure is simple:
- 99497: First 30 minutes of ACP
- 99498: Each additional 30 minutes
- 99498: Add-on code, not the primary code
This distinction is important for claim review. Billing teams should confirm 99497 first. They can then determine additional 99498 CPT Code units.
99498 vs 99497
The easiest way to understand 99498 vs 99497 is time. The two codes cover different portions of ACP services. Code 99497 covers the initial 30 minutes. Code 99498 covers additional qualifying time.
| ACP Time | Medicare Coding |
| 15 minutes or less | Do not report ACP codes |
| 16–45 minutes | 99497 |
| 46–75 minutes | 99497 + 99498 |
| 76–105 minutes | 99497 + 99498 × 2 |
CMS uses the midpoint rule for these time-based services. A unit becomes reportable after its midpoint passes. CMS’s current 2026 fact sheet provides these time ranges.
For example, consider a 60-minute ACP discussion. The first 30 minutes support 99497. The additional qualifying time supports one 99498 CPT Code unit.
Now consider a 90-minute discussion. The first 30 minutes support 99497. The additional qualifying time supports two 99498 units.
However, the entire appointment length does not equal ACP time. Providers must count only qualifying ACP discussion time.
When Can Providers Bill 99498?
Providers can report 99498 when ACP continues beyond 99497’s initial period. The underlying discussion must meet Medicare’s ACP requirements. The documented time must also support the additional unit.
Billing teams should review the actual ACP discussion time. They should not rely only on the appointment’s scheduled length.
For example, an appointment lasts 90 minutes. The provider spends 55 minutes discussing ACP. The remaining time involves medication management. Only the qualifying ACP time counts toward ACP billing.
CMS specifically says not to include other active management time. It also excludes concurrent time-based services from ACP time.
This rule prevents double-counting provider time.
A Simple Billing Example
Suppose a patient discusses future treatment preferences. The provider spends 70 minutes on that discussion. The billing team should review the documented ACP time.
The first 30 minutes support 99497. The additional qualifying period supports one 99498 cpt code unit. The remaining minutes do not automatically create another unit.
This is why accurate time documentation matters.
ACP Additional Time Billing
ACP additional time billing depends on documented qualifying minutes. The billing team should calculate ACP time before adding units. This helps prevent both underbilling and overbilling.
Use this simple process:
- Confirm the discussion qualifies as ACP.
- Identify the total ACP discussion time.
- Exclude unrelated management time.
- Confirm 99497 is supported.
- Calculate additional 99498 units.
- Review the documentation.
- Verify current payer requirements.
This process makes time-based billing easier to manage.
Documentation Requirements
Strong documentation supports accurate ACP billing. It also gives billing teams better claim support. The medical record should clearly describe the ACP discussion.
Documentation should support several important elements:
- The nature of the ACP discussion
- The patient’s future care preferences
- Participants in the discussion
- Relevant advance directive discussions
- Total qualifying ACP time
- Any forms completed during the service
Time documentation deserves special attention. Additional units require sufficient documented time. A vague statement may create problems during review.
For example, “ACP discussed with patient” provides limited detail. A stronger note identifies the discussion and its duration. It should also show that the discussion involved qualifying ACP topics.
CMS allows the discussion to involve family members or surrogates.
Do Patients Need Completed Forms?
No, form completion is not always required.
The ACP service includes discussion of advance directives. Forms may be completed when performed. The service therefore focuses on the qualifying ACP conversation.
Billing teams should avoid creating unsupported documentation requirements. They should follow the actual Medicare requirements instead.
99498 Reimbursement Rate
The 99498 reimbursement rate is not identical nationwide. Medicare reimbursement can vary by locality and setting. Payer policies can also affect the final allowed amount.
CMS data shows different allowed amounts across providers. For example, current CMS data lists 99498 amounts that vary by provider and setting.
One CMS facility example shows an average Medicare allowed amount of $78. Another provider example shows $70. These figures demonstrate why one national rate can mislead readers.
For billing teams, the better approach is verification. Check the applicable Medicare fee schedule and locality. Also review the payer’s specific contract or policy.
This is especially important when publishing reimbursement information. A single dollar figure should not be presented as universal.
ACP and Annual Wellness Visits
Medicare treats ACP as an optional AWV element. A patient can choose to receive ACP during an AWV. The provider can report qualifying ACP separately.
When ACP is furnished with an AWV, Medicare has specific cost-sharing rules. CMS states that ACP cost-sharing is waived when billed properly. The ACP service must meet the applicable AWV requirements.
Billing teams should therefore review the complete claim. They should confirm the AWV code and ACP codes. They should also check same-day billing requirements.
Common Billing Mistakes
Several mistakes can affect ACP claim accuracy.
Billing 99498 Alone
The first mistake is treating 99498 as a standalone code. It is an add-on code. The primary ACP service must support its use.
Ignoring Time Requirements
Another mistake is adding units without enough qualifying time. Appointment length alone does not establish ACP time.
Counting Unrelated Services
Medication management should not inflate ACP minutes. Other concurrent services should also remain separate.
Weak Documentation
A short note may not support additional units. The record should support the service and reported time.
Using an Old Rate
Medicare rates can change over time. Billing teams should verify current reimbursement data before submitting claims.
Missing Payer Rules
Commercial payers may apply different requirements. Always check the applicable payer policy before billing.
Final Takeaway
99498 CPT Code helps report extended advance care planning services. It covers each additional qualifying 30-minute period. The primary ACP service is reported with 99497.
Accurate billing depends on three key areas.
- ACP discussion must qualify.
- Documented time must support the units.
- Records must support the submitted codes.
Billing teams should also verify current reimbursement information. Medicare amounts can vary by locality and setting. Payer-specific requirements should receive the same attention.
For medical billing providers, careful review is essential. Accurate time tracking supports proper coding and reimbursement. Clear documentation also helps reduce claim disputes and audit risks.
MediRemote helps healthcare organizations manage medical billing efficiently. Its billing support can help providers improve claim accuracy and streamline revenue cycle workflows. This allows providers to focus more on patient care while billing teams handle complex reimbursement requirements.
Frequently Asked Questions
Can 99498 Be Billed Alone?
No. 99498 is an add-on code for additional ACP time. It is reported with the primary ACP service, 99497.
How Much Time Does 99498 Represent?
99498 represents each additional 30 minutes. The applicable midpoint rule determines when units become reportable.
Can 99498 Be Billed With 99497?
Yes. 99498 is specifically designed to accompany 99497. Additional qualifying ACP time supports the add-on units.
Is 99498 a Face-to-Face Service?
Yes. Medicare’s ACP description requires face-to-face interaction. The discussion can include the patient, family, or surrogate.
Do Advance Directive Forms Need Completion?
No. Forms may be completed when performed. The qualifying ACP discussion remains central to the service.
Can ACP Be Billed During an AWV?
Yes. ACP can be an optional element of an AWV. Qualifying services may use 99497 and 99498.
Does 99498 Have One National Reimbursement Rate?
Not necessarily. Medicare allowed amounts can vary by provider and setting. Locality and payer rules can also affect reimbursement.
What Should Documentation Include?
Documentation should support the ACP discussion and time. It should also identify relevant participants and decisions. Any completed forms should be documented when applicable.