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CPT 99497 and 99498: advance care planning billing for Medicare
Code descriptors, the time rule, the AWV cost-sharing waiver and 2026 payment.
Short answer: Advance care planning is a voluntary discussion with a physician or qualified practitioner about a patient’s health care wishes if they cannot make medical decisions. Medicare uses 99497 for the initial time-based service and 99498 for additional time; the discussion, participants and qualifying minutes must be documented.
Advance care planning explains a patient’s treatment preferences before illness prevents them from speaking for themselves. CMS describes a face-to-face discussion with the patient, family member, caregiver or surrogate, as appropriate, rather than a requirement to complete a legal form.
For your practice, the billing questions are practical: who conducts the conversation, which minutes belong to it, and whether an annual wellness visit changes the patient’s cost sharing. The rules below follow CMS’s March 2026 advance care planning fact sheet; the Sources identify the CMS guidance behind these rules.
Advance care planning at a glance
Patient choice: The discussion is voluntary; completing an advance directive is optional.
Time: Use the documented ACP discussion time, excluding separately reported services.
Cost sharing: The preventive waiver depends on a covered AWV and all associated claim conditions.
What advance care planning covers
The practitioner discusses what care the patient would want if they lose the ability to make medical decisions. An advance directive may appoint someone to act for the patient and record preferences based on the patient’s values. The conversation can occur with or without helping the patient complete legal forms.
CMS lists living wills, health care powers of attorney, health care proxies and medical orders for life-sustaining treatment among examples of advance directives. Forms and legal requirements vary by state. Your practitioner should use the appropriate state materials rather than treating a billing note as a substitute for the directive itself.
ACP does not require a particular diagnosis. CMS instructs the practice to report the condition discussed using an ICD-10-CM code; when ACP is part of an AWV, the diagnosis may describe an administrative examination. A diagnosis explains the encounter, but it does not replace the discussion or time requirement.
Hospitals, physicians and non-physician practitioners may bill when their scope of practice, Medicare benefit category and independent billing authority include the service. A staff member handing out forms does not establish that the practitioner furnished the coded discussion. Confirm the responsible practitioner before building the claim.
Advance care planning CPT codes and qualifying minutes
The 99497 CPT code description concerns explaining and discussing advance directives, with forms completed when performed. The base descriptor refers to the first 30 minutes, while the additional code describes each further 30-minute unit. CMS’s reporting table applies the midpoint rule shown below.
| Documented ACP minutes | Code selection | Units |
|---|---|---|
| 15 or fewer | No ACP code | None |
| 16 to 45 | 99497 | One base unit |
| 46 to 75 | 99497 plus 99498 | One base and one additional unit |
| 76 to 105 | 99497 plus 99498 | One base and two additional units |
Count only the face-to-face ACP discussion for this service. CMS excludes active management of other medical problems from the time reported as ACP and prohibits sharing time with another concurrent time-based service. Separate the conversation from medication changes, examination work and other separately reported activity.
As an illustrative workflow, a practitioner can record the ACP portion separately from the rest of an encounter and send those minutes to billing. Your billing team then selects the applicable row, rather than using the full appointment length. If the ACP discussion is too short, another E/M service may be reportable only when its own requirements are met.
How the practice documents the ACP encounter
Step 1: Confirm the patient wants the discussion
Explain the purpose of ACP and let the patient choose whether to participate. Document that the encounter was voluntary. Do not let a scheduling label or a preselected charge stand in for the patient’s decision.
Step 2: Record the people and preferences involved
Identify who participated, including family members, caregivers or surrogates when appropriate. Record the explanation of advance directives and the patient’s wishes discussed during the encounter. If forms were completed, keep that work distinguishable from the requirement to have a qualifying conversation.
Step 3: Record the ACP time and handoff
Document time spent discussing ACP during the face-to-face encounter. A practical handoff also identifies the practitioner and separates other service time, so the billing team can apply the correct range. These suggested handoff fields support review; CMS’s stated documentation items are voluntariness, explanation of directives, participants and ACP time.
- Keep the voluntary nature of the discussion visible in the note.
- Keep the participants and discussion of directives visible in the note.
- Keep the ACP minutes separate from other reported service time.
When an annual wellness visit changes ACP cost sharing
Medicare pays for ACP as an optional AWV element or as a separate medically necessary Part B service. The patient decides whether ACP is included during the wellness visit. Review the separate annual wellness visit codes before pairing the two services on a claim.
- Confirm that the AWV is covered and identify G0438 or G0439 as appropriate.
- Confirm that the same provider furnished ACP on the same day as that covered AWV.
- Report ACP with modifier 33 on the same claim as the AWV.
- Review the AWV disposition before explaining the final ACP cost sharing to the patient.
CMS waives the ACP Part B deductible and coinsurance only when these conditions are met. If Medicare denies the AWV because its once-per-year limit was exceeded, the ACP deductible and coinsurance apply. An appointment described as preventive does not by itself establish the waiver.
Make the distinction clear when scheduling: an ACP discussion can be covered without qualifying for the preventive cost-sharing waiver. Your staff should avoid promising the waiver before confirming the wellness benefit and the claim arrangement. The annual limit described here concerns the AWV-related waiver, rather than an absolute annual limit on ACP discussions.
How follow-up ACP fits beside ongoing care management
ACP is not a monthly enrollment service. CMS places no numerical limit on how often it may be reported for a patient or within a period, but repeated billing requires documentation of changes in health status, end-of-life wishes or both. A standing monthly charge without a new qualifying discussion would miss that distinction.
At a later encounter, the practitioner should identify what changed before repeating the service. A revised preference after a health change belongs in the new note; simply copying the prior directive does not explain the reason for another discussion. The practice then applies the time and documentation requirements to that encounter.
Chronic care management addresses qualifying chronic conditions through a comprehensive care plan and ongoing services. An AWV can serve as the CCM initiating visit when one is required, but CCM also has separate consent and service requirements. The CCM requirements guide explains that handoff without treating ACP as CCM enrollment.
For patients with cognitive impairment, CMS identifies advance care planning among the elements considered in cognitive assessment and care planning. CMS also lists 99497 and 99498 among codes that cannot be billed on the same day as 99483. Your billing team should review that specific service combination before assigning a separate ACP charge.
ACP misreadings to catch before the claim leaves
Four checks for the billing lead
Forms alone: A completed directive does not replace the voluntary, documented discussion.
Appointment length: Only qualifying ACP discussion minutes belong to the ACP time total.
Preventive label: An ACP cost-sharing waiver requires the covered AWV and all claim conditions.
Repeat service: Another billable discussion needs the documented change CMS requires for repeat ACP.
Moving from visit planning to chronic care management
Companian does not offer advance care planning. Practices evaluating support between visits can review chronic care management for CCM codes 99490 and 99439, or principal care management for codes 99426 and 99427.
For those supported care-management workflows, Companian describes the handoff this way: Your team refers; we handle enrollment, outreach and documentation. You bill monthly under your license. Which team members’ time counts toward each code is set in your services agreement.
Key takeaways
- ACP is a voluntary discussion of the patient’s future health care wishes.
- Completing an advance directive form is optional.
- Code selection follows qualifying ACP minutes, excluding other service time.
- The AWV-related waiver requires the same day, same provider, same claim and modifier 33.
- Repeated ACP billing requires documentation of changes in health status, wishes or both.
Frequently asked questions about advance care planning
Does Medicare require a signed directive before 99497 can be reported?
No. CMS allows the discussion with or without completion of legal forms, provided the ACP service and its documentation requirements are met.
Can a 15-minute ACP discussion support the base code?
No. CMS’s table assigns no ACP code to 15 minutes or fewer; a different E/M service is reportable only if its own requirements are met.
What is the role of 99498 in an ACP claim?
It describes additional ACP time and is reported with the base service. Your billing team should apply CMS’s time ranges to the documented ACP minutes.
Is ACP limited to patients with a terminal diagnosis?
CMS does not require a specific diagnosis for ACP billing. The practice reports the condition discussed and documents the voluntary conversation.
Why can ACP cost sharing apply after a wellness visit denial?
The waiver depends on a covered AWV. CMS applies the ACP deductible and coinsurance when the paired AWV is denied for exceeding its annual limit.
What should a practice document before reporting ACP again?
CMS requires documentation of changes in the patient’s health status, end-of-life wishes or both. The new encounter still needs its own qualifying discussion, participants and time record.
Companian does not offer advance care planning; physician practices distinguish its Medicare Part B codes 99497 and 99498 from supported chronic care management codes 99490 and 99439. Your team refers; we handle enrollment, outreach and documentation. You bill monthly under your license.
Read more: Annual wellness visit codes · CCM requirements
Add staffed care management between visits
See how Companian runs care management for your primary care practice. Your practice bills Medicare under its own NPI.
Rates & disclosures
National amounts are 2026 Medicare Physician Fee Schedule non-facility payments at the non-QP conversion factor of $33.4009, computed from CMS RVUs. Your amount depends on your Medicare payment locality; see it in the CCM/PCM revenue calculator. Actual payment depends on participation status, place of service and cost-sharing.
Companian supplies Care Advocates and documentation to physician practices nationwide. Companian is not a medical practice and does not bill Medicare. The billing practitioner keeps the care plan, every clinical decision and the claim. Patients pay the usual Medicare Part B deductible and coinsurance for these services unless other coverage pays it.
Sources:
- CMS MLN909289, Advance Care Planning (March 2026)
- CMS, Annual Wellness Visit (provider page)
- CMS fact sheet, CY 2027 PFS proposed rule (proposed)
- Federal Register 2026-14327, CY 2027 PFS proposed rule
- CMS 2026 Physician Fee Schedule relative value files (RVU26D)
Disclosures
This guide summarizes CMS information for physician practices. It is not legal or billing advice.