CPT Code 99497: Advance Care Planning, First 30 Minutes

What is advance care planning (ACP)?

Advance care planning (ACP) is a structured conversation between healthcare providers and patients about future healthcare preferences, especially in case the patient becomes unable to make decisions later. It involves discussing values, goals of care, and treatment options like life-sustaining interventions.

The health care professional spends time helping patients make informed decisions and formally document them, often in an advance directive or similar form. ACP is typically used for patients with serious illness, chronic conditions, or those facing complex health decisions.

CPT 99497 refers to 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.

As a healthcare professional, you can bill CPT code 99497 when you spend at least 16 minutes in a face-to-face ACP discussion, with or without completing legal documents. An advance care planning patient may also qualify for ACP services under Medicare or private insurance depending on their plan and clinical situation.

CPT code 99497 documentation requirements

CPT code 99497 supports providers in billing for time spent having meaningful conversations with patients about their future healthcare wishes. Under the physician fee schedule, proper documentation ensures eligibility for ACP payment and accurate Medicare payment.

Here are the requirements for CPT code 99497:

• Time spent (at least 16 of 30 minutes)
• Participants (patient and/or surrogate)
• Proof that the visit was voluntary
• Topics discussed (e.g., living will, do not resuscitate orders or DNR, goals of care)
• Decision aids or forms used (if applicable)
• Outcome (form completion, plan documentation)

Billing requires documentation of medical necessity and time.

CPT code 99497 billing guidelines

CPT code 99497 is what you’d use to bill for having a conversation with a patient about their future healthcare wishes. To get paid for it, you just need to follow a few rules:

• Remember that ACP services are time based. Bill per 30-minute interval. Use 99497 for the first 30 minutes and 99498 for each additional 30 minutes. This should be listed as an add-on code for primary procedure.
• ACP services can be billed multiple times per year, but each instance must reflect a documented change in the patient’s health or end-of-life preferences. Frequency depends on the patient's condition, some may need it often, others not at all.
• ACP can be provided and billed by physicians from any specialty, as well as clinical nurse specialists (CNSs), nurse practitioners (NPs), and physician assistants (PAs).
• Medicare advance care planning pays in two ways. It can be included as an optional part of a Medicare Wellness Visit, like the Annual Wellness Visit (AWV), or billed separately as a medically necessary service under Medicare Part B.
• Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) get paid for ACP a bit differently. They’re reimbursed through a bundled payment system or all-inclusive rate, which means ACP is just one part of the overall services covered.