CPT 99497 | Advance Care Planning Billing Guide ACP Coding, Documentation & Reimbursement for Geriatric Practices

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The Conversation That Pays — And the Revenue Most Practices Aren't Collecting

Advance Care Planning conversations happen in geriatric practices every day. A physician sits with a patient and their family, discusses goals of care, explores what the patient wants if they can no longer speak for themselves, and helps them think through their values, their fears, and their wishes. It is among the most important clinical conversations in medicine.

It is also billable. Medicare created CPT 99497 specifically to reimburse this service and added CPT 99498 as an add-on for extended sessions. No prior authorization is required. The code can be billed on the same day as an office visit with correct modifier usage. And yet, at MedCloudMD, our geriatrics billing audits consistently find that ACP billing is one of the most systematically missed revenue streams in geriatric practice.

Most providers either don't know they can bill for it, aren't sure what documentation is required, or have had previous claims denied and stopped trying. All three problems are correctable and this guide addresses each of them with the 2026 standards your practice needs to capture this revenue.

2026 CPT 99497 Billing: The Numbers That Matter

< 15% of Medicare Geriatric Patients Receive a Billed ACP Service Annually

$72–$90 Estimated 2026 Medicare Rate for CPT 99497 (Non-Facility)

30 min Minimum Face-to-Face Time Required for CPT 99497

$0 Prior Authorization Required for CPT 99497 Under Medicare

Less than 15% of eligible Medicare geriatric patients receive a billed ACP service annually. The clinical conversations are happening far more frequently than the billing reflects. That gap represents significant uncaptured revenue across every geriatric practice in the country.

What Is Advance Care Planning? The Clinical and Billing Context

Advance Care Planning (ACP) is a structured conversation between a physician or qualified non-physician practitioner and a patient (and/or their surrogate decision-maker) about the patient's values, goals, and preferences for future medical care particularly in the context of serious illness or loss of decision-making capacity.

ACP discussions typically cover topics including: what constitutes an acceptable quality of life for the patient, which life-sustaining treatments the patient would or would not want, how the patient wants to be cared for at the end of life, who they designate as their healthcare proxy, and whether they have or wish to complete advance directive documents.

From a billing perspective, ACP is a time-based service that is separately reimbursable from E/M visits when conducted as a distinct clinical activity. The 2026 Medicare coverage rules are clear: ACP is a preventive service for all Medicare beneficiaries and a billable clinical service when provided outside the Annual Wellness Visit context.

📋  As Part of the Annual Wellness Visit ACP can be performed and documented as part of the Annual Wellness Visit (G0438/G0439) without billing CPT 99497 separately. However, when ACP is conducted as a distinct, separately documented service, CPT 99497 is separately billable — even on the same day as the AWV.

🏥  As a Standalone Billable Service When ACP is performed as a dedicated encounter or as a distinct service on the same day as an E/M visit, CPT 99497 is billed separately. On same-day E/M encounters, the E/M code must carry Modifier -25. The ACP service itself does not require a modifier.

CPT 99497 Code Breakdown: What the Code Covers and How It Works

CPT 99497 vs CPT 99498: The Complete Comparison

Understanding the relationship between CPT 99497 (the base ACP code) and CPT 99498 (the add-on code for additional time) is essential for accurate billing in extended conversations. Here is the complete 2026 comparison:

Feature	CPT 99497 (Base Code)	CPT 99498 (Add-On Code)
Official Description	Advance care planning including the explanation and discussion of advance directives, first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate	Each additional 30 minutes of advance care planning (list separately in addition to code for primary procedure)
Time Requirement	Minimum 30 minutes face-to-face	Each additional 30-minute block beyond first 30 min
Billing Relationship	Standalone base code	Add-on — cannot be billed without 99497 on same claim
2026 Medicare Rate (Est.)	~$72–$90 non-facility	~$72–$88 per additional 30 min (similar rate)
Frequency Limit	No annual frequency limit specified	No limit; billed per each additional 30-min block
Same-Day E/M	Billable same day with -25 on E/M	Billable same day; follows same rules as 99497
Prior Authorization	None required for Medicare	None required for Medicare
Place of Service	Office, hospital outpatient, SNF, home, telehealth	Same as 99497 — follows base code POS
Provider Types	MD, DO, NP, PA, CNS within scope	Same as 99497
Documentation Required	Time documented with specific minute count; content of ACP discussion described	Additional time documented; extended discussion content described

BILLING TIP 💡

CPT 99498 is one of the most consistently missed add-on opportunities in geriatric ACP billing. A meaningful ACP conversation with a patient who has advanced dementia, multiple comorbidities, and complex family dynamics routinely takes 60–90 minutes. That supports CPT 99497 + one or two units of CPT 99498. At MedCloudMD, our audits find that most practices performing 60+ minute ACP sessions are billing only 99497 — leaving the add-on revenue completely uncaptured.

CPT 99497 Quick Snapshot: 2026 Reference Card

⚡ Featured Snippet — CPT 99497 at a Glance (2026)

▶  Code:  CPT 99497 — Advance Care Planning, first 30 minutes, face-to-face

▶  Add-on:  CPT 99498 — Each additional 30-minute block (billed alongside 99497)

▶  Time required:  Minimum 30 minutes face-to-face with patient and/or family/surrogate

▶  2026 Medicare:  ~$72–$90 non-facility for 99497 | ~$72–$88 per 99498 unit

▶  No prior auth:  Medicare does NOT require prior authorization for ACP services

▶  Same-day rules:  Billable same day as E/M (Modifier -25 on E/M) or AWV (as distinct additional service)

▶  Documentation:  Specific minute count, content of discussion, patient/surrogate participation, and advance directive status required

▶  2026 Update:  CMS confirmed telehealth eligibility for ACP in 2026 — CPT 99497/99498 can be billed for audio-video encounters following standard telehealth rules

Is Your Practice Billing CPT 99497 for Every ACP Conversation?

MedCloudMD identifies ACP billing gaps, audits documentation compliance, and ensures every eligible session is accurately captured and submitted.

[ Schedule a Free Billing Assessment → medcloudmd.com/specialties/geriatrics-billing-services ]

Medicare Reimbursement Rules for CPT 99497 in 2026

Coverage & Frequency Rules

Medicare Part B covers CPT 99497 and 99498 without prior authorization for all Medicare beneficiaries, regardless of diagnosis. There is no annual frequency limit explicitly stated in Medicare coverage policy — ACP can be billed multiple times per year when clinically appropriate, provided each session is separately documented.

Telehealth Coverage in 2026

CMS confirmed telehealth eligibility for ACP services in 2026. CPT 99497 and 99498 can be billed for audio-video telehealth encounters under standard Medicare telehealth rules. Audio-only telehealth for ACP requires patient consent and documentation of inability to conduct video visit.

Place of Service Considerations

2026 MEDICARE UPDATE 💡

ACP via telehealth carries the non-facility rate in 2026 — the same as an in-person office visit. This is significant for geriatric practices with homebound or mobility-limited patients. A 30-minute audio-video ACP discussion conducted via telehealth can be billed at the full CPT 99497 non-facility rate. Ensure your telehealth documentation includes patient location, technology platform used, and patient consent.

Documentation Requirements for CPT 99497: What Every Note Must Include

Documentation failures are the primary reason CPT 99497 claims are denied. Unlike E/M coding, ACP billing is almost entirely time-based which means the note must establish time explicitly, not imply it. Here is the complete 2026 documentation standard:

☐	Total face-to-face time documented  Specific minute count required. "Approximately 35 minutes" is insufficient. "Total ACP discussion time: 38 minutes" is compliant.
☐	Participants identified  Who was present: patient, family member(s), surrogate, caregiver. Each participant should be named or identified by relationship.
☐	Content of ACP discussion documented  What was discussed: the patient's values and goals, specific care preferences, life-sustaining treatment preferences, and end-of-life care wishes.
☐	Advance directive status documented  Does the patient have existing advance directives? Were they reviewed and updated? If not completed, was the process discussed and initiated?
☐	Surrogate/healthcare proxy discussion  Was a healthcare proxy or surrogate decision-maker identified? Document the name and relationship if disclosed.
☐	Patient decision-making capacity assessed  Document that the patient has or lacks decision-making capacity. If lacking, document the surrogate's role and basis for involvement.
☐	Voluntariness of discussion confirmed  Document that the patient and/or family willingly participated and that participation was not coerced.
☐	Provider identity and attestation  The qualified provider who conducted the ACP session must be identified. Resident or medical student involvement must be documented per applicable rules.
☐	ACP separate from standard E/M (if same day)  When billed same day as an office visit, the note must clearly distinguish the ACP discussion from the clinical E/M content.

COMPLIANCE ALERT ⚠

2026: "ACP discussed" in a single sentence is not sufficient documentation for CPT 99497. Payers reviewing ACP claims in 2026 — including several CMS-contracted Medicare Administrative Contractors — are looking for substantive documentation of what was discussed, not just that a discussion occurred. A note that says "advance directives discussed with patient and family, patient verbalized understanding" does not establish the content, time, or specificity required for compliant billing.

Common CPT 99497 Denial Reasons: What's Driving the Rejections in 2026

Denial Reason	Root Cause	Prevention Strategy
Time not documented or vague	Note doesn't include specific minute count or says "approximately"	Build mandatory time entry into ACP note template. Require specific minutes, not estimates.
ACP content not described	Note says "discussed" without documenting what was discussed	Template should prompt for: goals of care, life-sustaining treatment preferences, advance directive review, proxy identification.
Missing Modifier -25 on E/M	Same-day E/M billed without Modifier -25 on E/M code	Charge capture rule: any 99497 claim with same-day E/M requires -25 on the E/M automatically.
Non-qualified provider	ACP billed under medical assistant, RN, or unlicensed staff NPI	Restrict CPT 99497 billing to MD, DO, NP, PA, or CNS only. Audit provider NPI before submission.
AWV bundling error	ACP billed separately when conducted as part of AWV without documentation of distinct additional service	If ACP is an extension beyond AWV content, document separately with distinct time tracking.
99498 without 99497	Add-on code submitted on claim without base code	Billing system rule: CPT 99498 cannot be processed without CPT 99497 on the same claim.

Are Your ACP Sessions Generating the Revenue They Should?

MedCloudMD reviews CPT 99497 and 99498 billing patterns and quantifies the ACP revenue your practice is currently leaving uncaptured.

[ Request a Revenue Analysis → medcloudmd.com/specialties/geriatrics-billing-services ]

CPT 99497 Revenue Opportunity: 2026 Estimates

These estimates illustrate the annual revenue opportunity at different ACP session volumes. The figures assume approximately 50% of sessions qualify for CPT 99498 (extended sessions > 60 minutes):

ACP Sessions/Month	Monthly Revenue*	Annual Revenue*	+ Add-On 99498	Full Annual Potential*
5 sessions	~$360–$440	~$4,320–$5,280	~$1,440–$1,760	~$5,760–$7,040
10 sessions	~$720–$880	~$8,640–$10,560	~$2,880–$3,520	~$11,520–$14,080
20 sessions	~$1,440–$1,760	~$17,280–$21,120	~$5,760–$7,040	~$23,040–$28,160
40 sessions	~$2,880–$3,520	~$34,560–$42,240	~$11,520–$14,080	~$46,080–$56,320

*Estimates based on ~$72–$90 non-facility Medicare rate for CPT 99497 and similar rate for CPT 99498. Actual reimbursement varies by geographic locality, payer mix, and contracted rates.

REVENUE OPPORTUNITY 💰

A geriatric practice conducting 20 ACP sessions per month can generate $23,000–$28,000 annually from CPT 99497 and 99498 combined. When ACP billing is integrated with same-day E/M optimization, Annual Wellness Visit scheduling, and CCM enrollment from the care goals documented during ACP sessions, the downstream revenue impact per ACP patient significantly exceeds the initial session reimbursement.

Step-by-Step CPT 99497 Billing Workflow: From Conversation to Payment

At MedCloudMD, we implement this 6-step workflow for ACP billing across every geriatric practice we support. Each step has a compliance checkpoint built in.

1

Patient Eligibility & Session Planning Identify patients appropriate for ACP discussion: advanced age, serious illness, recent hospitalization, cognitive decline, or patient/family request. Confirm Medicare coverage and ensure no duplicate ACP billing in recent encounters.

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2

ACP Session Conduct (30+ Minutes) Conduct a structured, voluntary ACP conversation with the patient and/or their surrogate. Cover goals of care, life-sustaining treatment preferences, advance directive status, and healthcare proxy designation. Track clock time from start.

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3

Real-Time Time Tracking Document start and end time of ACP discussion in the note or log. If extended beyond 60 minutes, flag for CPT 99498 add-on billing. Separate ACP time from any concurrent E/M time if applicable.

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4

Documentation Completion Complete the ACP note with all required elements: participants, specific discussion content, advance directive status, proxy identification, capacity assessment, voluntariness, and total face-to-face time in minutes.

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5

Charge Capture & Coding Apply CPT 99497 as the primary ACP code. Add CPT 99498 for each additional 30-minute block if total time exceeded 60 minutes. If same-day E/M is billed, apply Modifier -25 to the E/M code.

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6

Claim Submission, Tracking & Denial Management Submit claim through Medicare or commercial payer. Track adjudication status. If denied, work denial within 24–48 hours with documentation support. Appeal with specific Medicare ACP coverage policy citations.

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Best Practices for Higher CPT 99497 Reimbursement in 2026

1

Build a Dedicated ACP Note Template With All Required Fields Create an EHR template specifically for CPT 99497 encounters that includes required documentation fields: time start/end, participants, discussion topics (each as a separate prompted entry), advance directive status, and provider attestation. Make all fields mandatory before the note can be finalized.

2

Train Clinical Staff to Recognize ACP Billing Opportunities Every provider who conducts goals-of-care conversations should know when those conversations qualify for CPT 99497 billing. The most common missed opportunity: a physician spends 40 minutes in a serious illness conversation but charges nothing because they don't recognize it as billable.

3

Implement a Same-Day Modifier -25 Check in Your Billing Workflow Build an automatic flag in your billing system that identifies any claim with CPT 99497 and a same-day E/M code, and confirms Modifier -25 is present on the E/M before submission. This one rule prevents the most common ACP claim pairing error.

4

Track ACP Sessions by Patient to Avoid Duplicate Billing Maintain a log of ACP billing dates per patient. There is no strict annual limit — but submitting multiple ACP claims in a short period without documented clinical rationale for repeat discussions attracts payer scrutiny. Space sessions appropriately and document the clinical reason when ACP is conducted more than once in a 6-month period.

5

Use Telehealth for ACP With Homebound Patients In 2026, CPT 99497 is fully billable via audio-video telehealth at the non-facility rate. This is particularly valuable for geriatric patients who have difficulty traveling to the office. Telehealth ACP sessions require standard documentation plus patient location, technology platform, and consent.

6

Leverage ACP Documentation as a CCM and AWV Integration Point The goals of care and care preferences documented during a CPT 99497 session are directly valuable for CCM care plan development and AWV personalized prevention planning. Practices that integrate ACP documentation into CCM and AWV workflows maximize both clinical value and downstream billing from each ACP encounter.

How MedCloudMD Helps Geriatric Practices Maximize CPT 99497 Revenue

At MedCloudMD, we approach ACP billing as part of a comprehensive geriatrics revenue cycle strategy — not as an isolated code. Here's what that means in practice:

🔍  ACP Billing Opportunity Analysis We review your patient panel and billing history to identify how many ACP-eligible encounters are occurring without CPT 99497 being billed. Most practices are surprised by the volume — and the uncaptured revenue figure.

📋  Documentation Template Development We work with your clinical team to build compliant ACP note templates that capture all required elements systematically — ensuring every ACP session is documentation-ready for billing on the same day it occurs.

⚡  Pre-Submission Claim Review Every CPT 99497 and 99498 claim is reviewed before submission: time documentation verified, modifier logic checked, provider eligibility confirmed, and same-day code pairing validated.

🛡  Denial Management & Appeals ACP denials are worked within 24–48 hours with Medicare-specific appeal letters citing CMS coverage guidelines, ACP policy documentation, and clinical record support. Our ACP appeal overturn rate exceeds 85%.

“A geriatric practice we work with was conducting ACP discussions in roughly 60 encounters per month but billing CPT 99497 for fewer than 10. After documentation training and billing workflow implementation, they went from < $900/month in ACP revenue to over $4,200/month in 90 days — from the same clinical work they were already performing.” — MedCloudMD Geriatrics Billing Team

CPT 99497 Implementation Checklist: Get Your Practice ACP-Billing Ready

☐	Identify all providers who conduct ACP conversations  Map which physicians, NPs, and PAs regularly have goals-of-care discussions with patients — all of these individuals may be eligible billers for 99497
☐	Build a CPT 99497-specific EHR note template  Template must prompt for all required documentation elements as mandatory fields
☐	Add time tracking to every ACP encounter  Clock start time, clock end time, and total minutes must appear in every ACP note
☐	Implement Modifier -25 check for same-day E/M billing  Automatic flag before claim submission when 99497 and E/M code appear on same date
☐	Set up CPT 99498 billing for extended sessions  Establish 60-minute threshold flag — any ACP session > 60 minutes triggers 99498 review
☐	Verify provider NPI eligibility before billing  Confirm each billing provider type is eligible under Medicare and commercial payer rules
☐	Track ACP sessions per patient in billing log  Prevent duplicate billing; document clinical rationale when multiple sessions per year
☐	Enable telehealth ACP billing per 2026 CMS rules  Configure telehealth billing with correct POS code (02) and modifier requirements for audio-video ACP
☐	Connect ACP documentation to CCM care plan workflow  Use ACP goals-of-care notes to inform and update CCM care plans for enrolled patients
☐	Review denied ACP claims before write-off  No CPT 99497 or 99498 denial should be written off without documentation review and at least one appeal attempt

Frequently Asked Questions: CPT 99497 ACP Billing in 2026

❓ Is CPT 99497 covered by Medicare?

✔  Yes. Medicare Part B covers CPT 99497 and 99498 for all Medicare beneficiaries, regardless of diagnosis. No prior authorization is required. The service can be billed at any Medicare-covered place of service, including office, hospital outpatient, SNF, home, and via telehealth (audio-video) in 2026.

❓ Can CPT 99497 be billed multiple times per year for the same patient?

✔  Yes. There is no explicit annual frequency limit in CMS coverage policy for CPT 99497. ACP can be billed multiple times per year when clinically appropriate — such as after a significant change in health status, following a hospitalization, or when the patient requests a renewed discussion. Document the clinical rationale for repeat sessions, especially when billed more than once within a 6-month period.

❓ What is the difference between CPT 99497 and CPT 99498?

✔  CPT 99497 covers the first 30 minutes of advance care planning face-to-face time with the patient and/or family or surrogate. CPT 99498 is an add-on code for each additional 30-minute block beyond the first. CPT 99498 cannot be billed without CPT 99497 on the same claim. A 65-minute ACP session would support 99497 + one unit of 99498.

❓ What documentation is required for CPT 99497?

✔  Required documentation includes: (1) total face-to-face time as a specific minute count; (2) participants identified (patient, family, surrogate); (3) content of the discussion described in substantive detail; (4) advance directive status — existing, reviewed, or initiated; (5) surrogate/healthcare proxy identification if disclosed; (6) voluntariness of participation; and (7) provider identity and attestation.

❓ Can CPT 99497 be billed on the same day as a regular office visit?

✔  Yes. CPT 99497 can be billed on the same day as an E/M visit (99212–99215) when ACP was conducted as a separately identifiable service beyond the standard clinical encounter. The E/M code must carry Modifier -25 to indicate that a significant, separately identifiable evaluation and management service was also performed. The ACP code itself does not require a modifier.

❓ Who is eligible to bill CPT 99497?

✔  CPT 99497 can be billed by physicians (MD/DO), nurse practitioners, physician assistants, and clinical nurse specialists when acting within their scope of practice and meeting Medicare conditions. Social workers, chaplains, and non-licensed clinical staff cannot bill 99497 under Medicare. Services provided by NPPs may also be billable incident-to a physician under applicable Medicare incident-to rules.

❓ Can CPT 99497 be billed via telehealth in 2026?

✔  Yes. CMS confirmed in the 2026 Physician Fee Schedule that CPT 99497 and 99498 qualify for audio-video telehealth billing. The service must meet standard telehealth documentation requirements: patient location, technology platform, patient consent, and real-time audio-video connection. Audio-only telehealth requires additional documentation of why video was not feasible.

❓ Why are CPT 99497 claims frequently denied?

✔  The most common denial causes are: (1) time documented vaguely without a specific minute count; (2) ACP content described in a single sentence without substantive detail about what was discussed; (3) missing Modifier -25 on same-day E/M code; and (4) ACP billed by a non-eligible provider type. All four causes are preventable with the right documentation template and billing workflow.

❓ How does CPT 99497 relate to the Annual Wellness Visit?

✔  ACP can be conducted as part of the Annual Wellness Visit (G0438/G0439) without separately billing CPT 99497. However, when ACP goes beyond the AWV context — such as an extended family meeting for a patient with advanced dementia that occurs on the same day as the AWV — the additional ACP time can be separately documented and billed as CPT 99497, with Modifier -25 on the AWV code.

Key Takeaways: CPT 99497 ACP Billing in 2026

📋 Summary — What Every Geriatric Practice Needs to Know

▶  CPT 99497 covers the first 30 minutes of advance care planning — fully covered by Medicare, no prior authorization required.

▶  CPT 99498 adds reimbursement for each additional 30-minute block. Extended sessions > 60 minutes should include 99498.

▶  Time must be documented as a specific minute count — not an approximation or general range.

▶  Discussion content must be described substantively — not summarized in one sentence.

▶  ACP is billable on the same day as an E/M visit with Modifier -25 on the E/M code.

▶  ACP is fully billable via audio-video telehealth at non-facility rates in 2026.

▶  Most geriatric practices are conducting ACP conversations without billing for them. The revenue is already being earned.

▶  Connecting ACP documentation to CCM care plans and AWV personalized prevention plans creates downstream billing value from every session.

Your Advance Care Planning Work Deserves Full Reimbursement

The conversations you have with your patients about their values, their goals, and their wishes at the end of life are among the most meaningful clinical services in medicine. They are also fully reimbursable and most practices are not collecting on them.

At MedCloudMD, we specialize in geriatrics billing and CPT 99497 is one of the first billing gaps we close for every new geriatric practice we work with.

The documentation framework, the workflow implementation, the modifier logic, and the denial management infrastructure are all in place. The only missing piece is the billing. And that's exactly what we do.

Speak with a Geriatrics Billing Expert About CPT 99497

MedCloudMD specializes in geriatrics billing services — including ACP billing, CCM, AWV, CPT 99483, and the full geriatric code set.

Schedule a free billing assessment and find out exactly what your ACP sessions should be generating.

→  medcloudmd.com/specialties/geriatrics-billing-services

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Content reflects 2026 CMS Physician Fee Schedule, Medicare ACP coverage guidelines, and current payer policies. Revenue estimates are illustrative. Individual results vary by locality, payer mix, and practice volume.