A geriatrician we work with spends 20 to 30 minutes with most new patients over 80 talking about what they want if they can no longer speak for themselves: who should decide, what a hospital stay should and should not include, whether a POLST form makes sense. She has done this for fifteen years. Until two years ago she billed all of it as part of a 99204 or 99215 and considered herself lucky if the visit fit in 45 minutes. Her billing manager finally asked why the practice had never once billed 99497.
The answer was the usual one: nobody had explained the advance care planning codes 99497 and 99498, the physician assumed they required a completed advance directive, and the biller assumed they needed a prior authorization. Neither is true. Medicare has paid for advance care planning (ACP) as a separate service since January 1, 2016, most commercial payers followed, and the codes are among the more straightforward time-based services in the fee schedule. They are also, in our audits, among the most under-billed and, where they are billed, the most often documented badly.
This article covers what the codes describe, the time thresholds, how ACP interacts with the Medicare annual wellness visit (AWV) and with a problem visit on the same day, what the note has to contain, and the mistakes that produce denials or refund letters. For readers new to the term: an advance directive is a document such as a living will or health care power of attorney in which a patient records wishes and names a decision maker; ACP is the conversation about those wishes, whether or not a form is completed.
Key takeaways
- 99497 covers the first 30 minutes of face-to-face advance care planning by a physician or other qualified health professional with the patient, family or surrogate, and is reportable once at least 16 minutes are spent; 99498 adds each further 30 minutes and is reportable at 46 minutes total.
- No form has to be completed and the patient may decline; the service is the discussion, and the note must show it was voluntary, who was present, what was discussed and how long it took.
- When ACP is furnished on the same day as an AWV by the same clinician, append modifier 33 to 99497 and Medicare waives the deductible and coinsurance; on any other day the patient owes normal Part B cost sharing.
- ACP can be billed with a problem visit on the same day, but the ACP minutes must be carved out of the E/M time and documented separately.
- There is no frequency limit, but repeat billing should be tied to a documented change in the patient's health status or wishes.
How advance care planning codes 99497 and 99498 are defined
CPT 99497 is "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." CPT 99498 is each additional 30 minutes, listed separately in addition to 99497. Three things in that descriptor matter for billing.
First, "when performed." Completing a form is not required. A 25-minute discussion in which the patient decides to think about it and take the forms home is a 99497. Second, "face-to-face with the patient, family member(s), and/or surrogate." The patient does not have to be present or able to participate; a conversation with the health care proxy of a patient with advanced dementia qualifies. Telehealth counts as face-to-face for Medicare when the service is furnished by real-time audio and video under the telehealth rules in effect for that date. Third, "physician or other qualified health care professional." Physicians, nurse practitioners, physician assistants and clinical nurse specialists bill these codes under their own numbers. Clinical staff time does not count toward 99497 time.
The time thresholds follow the CPT midpoint rule for time-based codes: a code whose descriptor says 30 minutes is reportable once more than half, meaning 16 minutes, has been spent. So 99497 needs at least 16 minutes, and 99498 needs at least 16 minutes beyond the first 30, or 46 minutes total. A 12-minute conversation is not separately reportable; it becomes part of the E/M visit's medical decision making or time. Nationally, Medicare pays roughly $87 for 99497 in the office setting in 2026; 99498 pays somewhat less, and commercial rates vary by contract.
ACP with the annual wellness visit and with a problem visit
The Medicare AWV (G0438 for the first, G0439 for subsequent visits) is the natural home for ACP; Medicare lists ACP as an optional element of the AWV and waives cost sharing when the two are furnished together. The mechanics are specific. The ACP must be on the same date, by the same clinician, and 99497 (and 99498 if reached) carries modifier 33, the preventive service modifier. With modifier 33 the Part B deductible and 20 percent coinsurance are waived. Without it, Medicare pays the claim but applies cost sharing, and the patient receives a bill for an ACP conversation they were told was part of their free wellness visit. That phone call is avoidable.
ACP alongside a problem visit works differently. A 99214 and a 99497 on the same date by the same clinician are both payable, but the time cannot overlap. If the physician spends 40 minutes total and 18 of them were the ACP conversation, the E/M is leveled on the other 22 minutes (or on medical decision making) and the 99497 is supported by its own 18. The note should state both times. CMS does not require a modifier on the E/M for Medicare, but many commercial payers and some Medicare Advantage plans want modifier 25 on the E/M when ACP is billed the same day; we load that as a payer rule rather than arguing with each remit. ACP is not reportable on the same date as critical care (99291 and 99292) by the same clinician.
| Situation | Codes | Modifiers | Patient cost sharing for the ACP |
|---|---|---|---|
| Subsequent AWV plus 22 minutes of ACP, same clinician, same day | G0439, 99497 | 33 on 99497 | None |
| AWV plus 50 minutes of ACP with patient and daughter | G0439, 99497, 99498 | 33 on both ACP codes | None |
| Problem visit plus 18 minutes of ACP, times documented separately | 99214, 99497 | 25 on 99214 if the payer requires it | Deductible and 20 percent |
| Stand-alone ACP visit, 35 minutes with the health care proxy of a patient with dementia | 99497 | None | Deductible and 20 percent |
| 12 minutes of ACP during a 99213 | 99213 only | None | Not separately billed |
| ACP at a hospital discharge visit in the office, 20 minutes | 99495 or 99496 plus 99497 | None for Medicare | Deductible and 20 percent |
What the note has to contain
The documentation elements come from CMS's guidance and from what auditors have asked us for. The note should record that the discussion was voluntary and the patient (or surrogate) agreed to it; who was present and their relationship to the patient; the content, in enough detail to show it was ACP rather than a general conversation (explanation of advance directives, discussion of the patient's goals and values, identification of a decision maker, discussion of specific interventions such as resuscitation, ventilation or feeding tubes where they came up); any forms explained, completed or declined, with the form name (health care power of attorney, living will, POLST or the state's equivalent); the total face-to-face time spent on ACP; and, when ACP was billed with an E/M, the statement that the ACP time was separate from the visit time.
A template sentence we like: "Advance care planning discussion, voluntary, patient and spouse present, 24 minutes face-to-face separate from the problem-oriented visit. Explained health care power of attorney and living will; patient named spouse as agent and wishes to avoid prolonged mechanical ventilation; forms provided, patient will complete with family; Z66 not applicable." The specifics change every time, which is the point: a cloned ACP paragraph that appears identically in 40 charts is what a payer's analytics flag first.
Diagnosis coding is flexible. Medicare does not require a specific diagnosis for ACP; most practices report the chronic condition that prompted the conversation, with Z66 (do not resuscitate status) when the patient has documented that choice and Z71.89 (other specified counseling) as a supporting code where the payer accepts it. Check Medicare Advantage plan policies, because a few list acceptable diagnoses.
Frequency, repeat conversations and the mistakes we see
Medicare imposes no frequency limit on ACP. CMS has said repeat ACP is appropriate when there is a change in health status or in the patient's wishes, and auditors read that as a documentation requirement: the second and third ACP in a year should say why. A new diagnosis of metastatic disease, a hospitalization, a move to assisted living, a spouse's death that changes the proxy, all are reasons. "Annual ACP review" with no change is a weaker reason and a common audit finding.
The errors that cost practices money run in both directions. Under-billing: the geriatrician who folds 25 minutes of ACP into an E/M every day, or the practice that discusses code status at every AWV and never adds 99497-33. Over-billing: ACP billed for a five-minute mention that the patient should think about a living will; 99497 billed by a nurse or social worker who led the conversation without the billing clinician present; ACP time double-counted inside the E/M time on the same claim; 99498 billed at 35 minutes. And the modifier 33 omission, which is not an overpayment but produces patient complaints and refunds of collected coinsurance.
A worked example of the stakes. A five-clinician primary care practice with 1,800 Medicare patients completes about 1,400 AWVs a year. If ACP is offered and accepted at 30 percent of those and averages 20 minutes, that is 420 conversations that qualify for 99497-33, roughly $36,000 a year at national rates for work the clinicians were mostly already doing inside the wellness visit. If the practice is also carving out ACP correctly from problem visits, the number grows. Our revenue leakage audits compare AWV volume to 99497 volume for exactly this reason, and the gaps-in-care workflow can prompt the conversation at the right visits.
Questions we hear
Can a nurse or social worker do the ACP conversation and the physician bill it?
Not as 99497 time. The codes describe the physician's or qualified health professional's own face-to-face time. Clinical staff can prepare the patient, hand out and explain forms, and document the patient's questions, but only the minutes the billing clinician spends in the conversation count. If your care team model relies on a social worker leading these discussions, that work is valuable and it supports the visit; it is not a separately billable 99497.
The patient completed a POLST at the hospital last month. Can we bill ACP for reviewing it?
Yes, if a discussion actually happens and meets the 16-minute threshold: reviewing the form with the patient, confirming it still reflects their wishes, explaining what it does and does not cover in the outpatient setting, and updating the record. Reviewing a scanned document without the patient is chart review, not ACP.
Do we need the patient's written consent to bill ACP?
No written consent is required, but the service must be voluntary and the note should say the patient agreed to the discussion. Because cost sharing applies outside the AWV, it is good practice, and in some Medicare Advantage plans required, to tell the patient before the conversation that it is a billable service with a copay. A one-sentence script for the clinician avoids the surprise.
What to do this week
- Count last year's AWVs (G0438 and G0439) and last year's 99497 claims; if the ratio is under one in ten, the conversations are probably happening and not being billed.
- Add modifier 33 as an automatic edit whenever 99497 or 99498 shares a claim date with G0438 or G0439 for the same clinician.
- Give each clinician the template sentence above and the 16-minute and 46-minute thresholds on one card.
- Check your top Medicare Advantage and commercial payers for modifier 25 requirements on the E/M when ACP is billed the same day, and load those as payer rules.
- Pull ten billed 99497s and confirm each note shows voluntary participation, attendees, content, forms discussed and time.
