CPT 99497, 99498, Same-Day Rules & Documentation
Advance Care Planning (ACP) is one of the most consistently under-billed preventive services in primary care and geriatrics. Every eligible patient conversation about end-of-life wishes, healthcare proxies, and treatment directives represents a billable encounter, and most practices capture fewer than 20% of those encounters on a claim. At $86.84 per 99497 encounter, a primary care panel having just 3 qualifying conversations a week and not billing them is leaving about $13,500 a year unclaimed (3 x 52 x $86.84).
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Advance Care Planning is a voluntary, face-to-face service in which a physician or other qualified healthcare professional discusses an individual's health care wishes regarding a potential future incapacity to make decisions. This includes explaining and discussing advance directives such as standard forms, living wills, and durable powers of attorney for healthcare.
ACP conversations are not the same as a general discussion of prognosis. They must specifically address what the patient wants to happen if they become unable to make their own healthcare decisions, and optionally involve completion or updating of advance directive documents.
In 2026, Medicare's national non-facility rate is $86.84 for CPT 99497 (first 30 minutes) and $78.16 for add-on 99498 (each additional 30 minutes). Facility rates are lower, and locality adjusts both. Patients owe cost sharing unless the ACP is billed with an annual wellness visit using modifier 33.
| Code | Description | 2026 Medicare rate (national, non-facility) | Facility |
|---|---|---|---|
| 99497 | ACP including the explanation and discussion of advance directives, first 30 minutes, face-to-face | $86.84 | $65.80 |
| 99498 | Each additional 30 minutes (add-on to 99497) | $78.16 | $63.46 |
Key rule: 99497 is a standalone code for the first 30 minutes. 99498 is an add-on code for each additional 30-minute block. A 65-minute conversation = 99497 + one unit of 99498. A 95-minute conversation = 99497 + two units of 99498.
ACP can be billed by:
The conversation doesn't have to be with the patient alone, a family member or surrogate decision-maker can be present and the service can still be billed, provided the patient or their legal representative has consented.
Under Medicare, ACP is covered as a voluntary preventive service. This means:
This is where most billing confusion occurs. ACP can be billed on the same day as:
ACP billed same-day as an AWV has patient cost-sharing waived for Medicare when you append modifier 33 to 99497 and 99498 (details below). This is the most common and highest-value combination. The ACP discussion must be distinct from the AWV components and documented separately.
ACP can be billed on the same day as a medically necessary E/M visit with modifier 25 on the E/M code (or, depending on payer, no modifier, verify by payer contract). The two services must be separately documented. Commercial payers vary significantly: some require that ACP be on a different date from E/M visits.
ACP can also be billed alongside TCM codes when the ACP conversation occurs during the TCM period and is separately documented.
Important: When ACP is billed on the same day as an E/M visit that's NOT the AWV, Medicare patient cost-sharing (deductible and coinsurance) applies to the ACP service. Only the AWV combination triggers the cost-sharing waiver.
Append modifier 33 to 99497 and 99498 when you bill them with a covered annual wellness visit (G0438 or G0439) by the same provider, and Medicare waives the patient's deductible and coinsurance. With a separate E/M visit, modifier 25 goes on the E/M instead, and cost sharing applies.
| Total ACP minutes | Codes |
|---|---|
| 16 to 45 | 99497 |
| 46 to 75 | 99497 + 99498 x1 |
| 76 to 105 | 99497 + 99498 x2 |
Those thresholds follow CPT's midpoint rule. Confirm that each commercial payer uses the same ones.
Documentation must include all of the following to support ACP billing:
Time is the key driver: 99497 requires the ACP discussion to be at least 16 minutes to bill the first 30-minute block (per CMS time-rounding rules). 99498 requires at least 16 additional minutes beyond the first 30. Document total ACP time clearly and separately from E/M or AWV time.
ACP is included on the Medicare telehealth services list, meaning it can be billed via synchronous audio-video telehealth using the same 99497/99498 codes with Place of Service 02 (telehealth, patient not at home) or POS 10 (telehealth, patient at home). CMS lists 99497 and 99498 on the 2026 Medicare telehealth services list. Audio-only is allowed with modifier 93 when the patient is at home and can't use video or doesn't agree to it, and the record should say so. Check each commercial payer's rules separately.
ACP looks harmless on a claim, but it's the kind of service auditors pull when the pattern looks too smooth. A practice that bills 99497 on nearly every Medicare patient over 65, always for the same length of time, invites questions. Reviewers compare the time you documented against the length of the visit, and they check whether the ACP conversation was separate from the problem-oriented visit rather than folded into it.
Medicare contractors and recovery auditors can look back three years, which means 36 months of ACP claims can be reopened if the documentation doesn't hold up. On a practice billing 99497 a few times a week, a 3-year lookback with a pattern of unsupported time documentation can put real recoupment at stake, small compared to a hospital-scale audit but still real money and real compliance exposure. If you find a problem yourself, the 60-day overpayment rule applies: once you've identified and quantified an overpayment, you have 60 days to report and return it. That's why a quarterly sample of your own ACP notes is cheaper than an outside audit.
Front desk and clinical staff can flag patients who might benefit from a conversation, such as those with a new diagnosis or a recent hospitalization. A brief note in the visit prep gives providers the opening.
Take a primary care practice that has 15 advance care planning conversations a month and bills none of them. At the 2026 national non-facility rate, a 30-minute conversation under 99497 pays $86.84, so that's $1,303 a month and $15,631 a year left behind. If half of those conversations run past 45 minutes and qualify for 99498 as well, the add-on brings another $586.20 a month.
The money isn't the only reason to get this right. Patients pay no deductible or coinsurance when ACP happens during an annual wellness visit, and the same service billed separately is subject to cost sharing. That difference decides whether a patient says yes to the conversation, which is why your front desk script matters as much as your coding.
In 2026, Medicare's national non-facility rate is $86.84 for CPT 99497 (first 30 minutes) and $78.16 for add-on 99498 (each additional 30 minutes). Facility rates are lower, and locality adjusts both. Patients owe cost sharing unless the ACP is billed with an annual wellness visit using modifier 33.
Append modifier 33 to 99497 and 99498 when you bill them with a covered annual wellness visit (G0438 or G0439) by the same provider, and Medicare waives the patient's deductible and coinsurance. With a separate E/M visit, modifier 25 goes on the E/M instead, and cost sharing applies.
Under CPT's midpoint rule, 99497 starts at 16 minutes and the first unit of 99498 starts at 46 minutes. A second unit starts at 76 minutes. Document start and stop times for the ACP discussion alone, and confirm your payer follows the same thresholds.
Yes. The article covers the same-day rule: ACP can be billed with an Annual Wellness Visit (G0438 or G0439), and when it is, the patient's cost-sharing is waived for Medicare. The ACP time still has to be documented as its own block, separate from the wellness visit.
The descriptor reads first 30 minutes, and under CPT's time rules you can report 99497 once you've passed the midpoint, which is 16 minutes. 99498 is the add-on for each additional 30 minutes, so document start and stop times, not just a total.
The service is a face-to-face discussion, and it doesn't have to be with the patient alone. A family member or surrogate can take part. What matters is that the record shows who was there, what was discussed, and that the conversation was voluntary.
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