CPT 99497 Billing in 2026: Advance Care Planning, Medicare Rules & Denial Preventions

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Advance care planning conversations already happen in geriatric practices constantly. The revenue cycle fails not because the conversation didn't happen, but because it wasn't documented and coded in a way that survives a claim. This guide follows the actual chain that determines whether ACP gets paid: the conversation, the documentation, the code, the claim, and what happens if a payer pushes back.

Quick Answer:  CPT 99497 reports the first 16–30 minutes of a face-to-face advance care planning discussion between a physician or qualified provider and the patient, family member, or surrogate covering advance directives, goals of care, and treatment preferences, with or without completing a form. Add-on code 99498 reports each additional 30 minutes.

2026 CPT 99497 At a Glance

Element	2026 Guidance
CPT	99497, base code; 99498, add-on for each additional 30 minutes
Qualifying time	16 minutes minimum — CMS's midpoint rule, not a full 30-minute requirement
Participants	Patient, family member(s), and/or surrogate, as applicable
Setting	Office, outpatient, inpatient, and telehealth (modifier 95), depending on payer policy
Medicare coverage	Covered as an optional AWV element or as a separately billable Part B service
Documentation	Time, substance of the discussion, and relevant clinical detail — not just a completed form
Cost sharing	Waived when furnished as part of an AWV with modifier 33; standard Part B cost-sharing otherwise
Payer variation	Commercial and Medicaid rules can differ meaningfully from Medicare verify individually

What CPT 99497 Actually Covers

99497 covers the explanation and discussion of advance directives living wills, healthcare power of attorney, POLST/MOLST forms along with goals of care, patient values, and future treatment preferences, including decision-making capacity and surrogate involvement where relevant. Completing a form is part of the service when it happens, but the form isn't the service. A conversation with no form signed still qualifies; a form handed to a patient with no substantive discussion does not.

CPT 99497 vs. CPT 99498

Code	Purpose	Time	Billing Role
99497	Initial ACP service	16–30 minutes (billable once the 16-minute midpoint is passed)	Base code
99498	Additional ACP time	Each additional 30 minutes, billed once the next midpoint is passed	Add-on to 99497, never billed alone

Does CPT 99497 Require a Full 30 Minutes?

No — this is one of the most commonly misapplied rules in ACP billing. CMS uses a midpoint rule: a time-based unit becomes billable once the midpoint of that unit is passed, not once it's fully complete. For 99497, that midpoint is 16 minutes into the first 30-minute unit.

Documented Time	Coding
15 minutes or less	Do not bill an ACP code
16–45 minutes	99497 (one unit)
46–75 minutes	99497 + 99498 × 1
76–105 minutes	99497 + 99498 × 2

Compliance Alert:  This midpoint structure reflects current CMS guidance for Medicare. CPT time-reporting conventions and payer-specific policy can differ — confirm current requirements before billing, especially for non-Medicare payers.

Documentation Requirements

☐  Patient identity and date of service

☐  Provider identity and credential

☐  Clinical reason or context prompting the ACP discussion

☐  Participants present — patient, family member(s), and/or surrogate

☐  Goals, values, and treatment preferences actually discussed

☐  Advance directives discussed, including relevant forms

☐  Decision-maker or surrogate discussion, when applicable

☐  Total ACP discussion time, supporting the code billed

☐  Decisions or outcomes reached during the conversation

☐  Forms completed, when performed

☐  Provider signature and authentication

Documentation standards can vary by payer beyond this core list — verify payer-specific expectations, particularly for Medicaid and commercial plans.

Want your ACP documentation templates checked against current requirements? Request a Revenue Cycle Assessment.

CPT 99497 With Annual Wellness Visits

ACP can be furnished two ways under Medicare: as an optional element of an Annual Wellness Visit (G0438 initial, G0439 subsequent), or as a separately medically necessary Part B service outside the AWV context. When furnished as part of the AWV, modifier 33 signals that ACP cost-sharing is waived because it's tied to a preventive service it is not a modifier required on every 99497 claim, only when the AWV-linked cost-sharing waiver actually applies. When ACP is billed as a stand-alone, medically necessary service unrelated to an AWV, modifier 33 does not apply and standard Part B cost-sharing rules govern instead.

CPT 99497 With E/M Services

A separate E/M service can be billed alongside 99497 when the E/M addresses a distinct problem, with its own supporting documentation — modifier 25 should reflect that genuine distinctness, not be appended automatically. 99497 should not be treated as an add-on to every office visit; if the required minimum time and discussion content for ACP aren't met, the encounter may still support a standard E/M service on its own, without an ACP code attached.

Most Common CPT 99497 Billing Errors

 Medicare, Medicare Advantage, Commercial & Medicaid

Medicare Part B follows CMS's national guidance directly, including the midpoint timing rule and the AWV/modifier 33 distinction. Medicare Advantage plans generally follow Medicare's coding framework but can layer plan-specific prior authorization or documentation requirements on top. Commercial insurance coverage, edits, and documentation standards vary by payer and should never be assumed to mirror Medicare. Medicaid coverage of ACP varies by state program, including whether it's covered at all — verify current state policy directly.

Common Mistake: Don't Bill 99497 Just Because...

Common Mistake:  An advance directive exists in the chart, a form was handed to the patient, a staff member briefly mentioned paperwork, the patient referenced end-of-life wishes in passing, or a templated checkbox was completed — none of these alone support billing 99497 without a documented, substantive, qualifying discussion.

Real-World Scenarios

Scenario	Coding Outcome
12-minute discussion of a POLST form	No ACP code — falls under the 16-minute threshold
22-minute documented ACP conversation	99497 only
52-minute conversation covering goals of care and a healthcare proxy	99497 + 99498 × 1
ACP conducted during an Annual Wellness Visit	99497 with modifier 33, cost-sharing waived under the AWV
Form given to patient with minimal discussion	Documentation likely doesn't support 99497 — review before billing

2026 CPT 99497 Revenue Cycle Workflow

Stage	Billing Action	Risk
Encounter	Identify that an ACP conversation occurred	Missed charge
Documentation	Validate the service against the core checklist	Unsupported claim
Coding	Assign 99497 and 99498 per documented time	Coding error
Modifier Review	Confirm modifier 33 or 95 applicability	Denial
Claim Scrub	Check against current payer edits	Rejection
Submission	File the claim	Delay
Adjudication	Monitor the payer response	Underpayment
Denial	Analyze root cause by category	Lost revenue
Appeal	Submit supporting documentation	Unrecovered revenue
Reporting	Track denial and missed-charge trends	Repeated errors

KPIs to Monitor for ACP Billing

☐  ACP services identified vs. actually billed

☐  First-pass acceptance rate on ACP claims specifically

☐  Denial rate, tracked by category — time, documentation, modifier, or payer policy

☐  Days in AR for ACP claims

☐  Appeal overturn rate

☐  Documentation-related denial share

Establish your own baseline for each metric rather than assuming a universal benchmark applies.

Why CPT 99497 Denials Keep Happening

Most recurring 99497 denials trace back to one of five distinct root causes: a coding problem (wrong unit count), a documentation problem (thin or templated notes), a payer-policy problem (Medicare rules assumed to apply to a commercial claim), a workflow problem (ACP conversations that happen but never reach billing), or a training problem (staff unaware of the 16-minute threshold). Diagnosing which one is driving a given denial pattern determines the fix a documentation problem and a payer-policy problem require completely different corrections.

Expert Insight:  Federal oversight reviews have specifically flagged ACP claims for undocumented time and undocumented discussion content exactly the two elements a defensible 99497 note has to show clearly, independent of everything else on the claim.

How MedCloudMD Can Help

Our billing specialists support geriatric and primary care practices with ACP charge capture, coding review, documentation audits, claim scrubbing, and denial management across Medicare and commercial payers helping identify where ACP conversations are happening but not reaching a clean claim, and correcting the pattern going forward.

Are your geriatric ACP services being fully captured? Request a Revenue Cycle Assessment or explore our geriatrics billing services.

Frequently Asked Questions

What is CPT 99497?

The base code for advance care planning — a face-to-face discussion of advance directives, goals of care, and treatment preferences with a patient, family member, or surrogate, covering the first 16–30 minutes.

How many minutes are required for CPT 99497?

A minimum of 16 minutes, under Medicare's midpoint rule — not a full 30 minutes as sometimes assumed.

Can 99497 be billed with an Annual Wellness Visit?

Yes, as an optional AWV element, with modifier 33 applied to waive cost-sharing under that specific pairing.

What modifier is used with CPT 99497?

Modifier 33 when ACP is furnished as part of an AWV; modifier 95 for telehealth delivery. Neither applies universally — use them based on the actual circumstances of the visit.

Can 99497 be billed with an E/M visit?

Yes, when the E/M addresses a genuinely distinct problem with its own documentation, using modifier 25 to reflect that distinctness rather than applying it automatically.

What documentation is required for 99497?

Participants, discussion content, time, decisions reached, and provider authentication, at minimum — a completed form alone doesn't satisfy the requirement.

What's the difference between 99497 and 99498?

99497 is the base code for the first 16–30 minutes; 99498 is an add-on for each additional 30-minute increment, never billed without 99497.

Can Medicare pay for advance care planning?

Yes, either as part of an Annual Wellness Visit or as a separately billable Part B service, depending on how it was furnished.

Why is CPT 99497 denied?

Most often insufficient documented time, thin discussion documentation, incorrect modifier use, or applying Medicare-specific rules to a non-Medicare payer without verification.

Can commercial insurance cover CPT 99497?

Often, but coverage, documentation standards, and edits vary by payer — verify current policy rather than assuming Medicare rules apply.

The Bottom Line

CPT 99497 success depends on three things: a qualifying service, defensible documentation, and payer-specific correct billing. Confirm time against the midpoint rule, document the conversation itself rather than just a completed form, apply modifier 33 only when AWV cost-sharing rules actually apply, verify payer-specific policy before assuming Medicare rules transfer, and track denials by root cause to fix the actual workflow gap, not just the individual claim.

 Disclaimer

This content is provided for educational and informational purposes only and should not be considered legal, coding, reimbursement, or medical advice. Billing regulations, CPT® coding, CMS policies, and payer requirements may change over time and can vary by payer and location. Healthcare providers should verify current coding guidelines and reimbursement policies with the appropriate payer, CMS, AMA CPT® resources, or qualified coding professionals before submitting claims. MedCloudMD provides professional medical billing and revenue cycle management services to support healthcare organizations but does not guarantee reimbursement outcomes.