99497
Advncd care plan 30 min
Advance care planning (ACP) discussion with the patient, family member, or surrogate, first 30 minutes of face-to-face conversation. CMS 2026 wRVU 1.50. Use 99498 for each additional 30 minutes beyond the first.
When to use it
99497 captures the time spent in a structured conversation about advance directives, healthcare proxy designation, code status, MOLST or POLST forms, hospice eligibility, and goals of care. The patient must be present at the start of the conversation unless the entire visit is with a designated surrogate (which is independently billable but requires explicit documentation).
Full guidance
Common scenarios: ACP as a same-day add-on to an AWV (cost-share is waived with modifier 33); ACP at a primary-care continuity visit for a patient with advanced chronic disease; ACP at an oncology visit for a patient at end of treatment options; ACP during a geriatric assessment.
Documentation checklist
- ✓Document time spent in the discussion. Minimum threshold is 16 minutes for the first 99497 unit (must reach at least half of 30 minutes).
- ✓List topics discussed. Examples: advance directives, healthcare proxy designation, MOLST or POLST completion, code status preferences, hospice eligibility, dialysis preferences, artificial nutrition preferences.
- ✓Identify who participated: patient alone, patient with family, surrogate only.
- ✓Documentation does not require that a directive be completed. The discussion alone qualifies for billing.
- ✓Time spent in prep (chart review before the visit, time spent after the patient leaves) does not count.
- ✓If billed with an AWV (G0438 or G0439) on the same day, append modifier 33 to 99497 to waive patient cost share.
Common pitfalls
- !Counting prep time toward the discussion threshold. Only face-to-face time with the patient or surrogate counts.
- !Billing on the same day as 99490 (CCM) without separately documenting the ACP discussion. The two services can coexist but require distinct documentation.
- !Forgetting modifier 33 on the AWV-paired visit. Without it, the patient pays a copay; with it, the visit is free to the patient and a strong continuity gesture.
- !Billing 99498 for an additional 30 minutes when the second 30-minute block was not actually reached. The half-time rule applies to additional units too (need at least 16 more minutes).
- !Missing 99497 entirely on AWV visits where ACP was discussed in passing. If you spent 16 or more minutes in directives or goals-of-care talk, the code is billable.
Payer notes
Medicare and Medicare Advantage plans pay 99497 with no cost share when billed with modifier 33 on the same day as an AWV; otherwise standard cost share applies. Commercial payers including BCBS and Aetna typically reimburse 99497 with their standard E/M fee schedule. Some commercial plans require documentation of the patient's expressed wish to discuss ACP; routine documentation should record patient request or clinician initiation.