What are the guidelines for CPT code 99497?

CPT code 99497 covers the first 30 minutes (with a minimum requirement of 16 minutes) of voluntary, face-to-face advance care planning.

Code Definition and Time Rules

• 99497: Reports the first 30 minutes of advance care planning (ACP), including the explanation and discussion of advance directives.
• Time Threshold: You must document and provide at least 16 minutes of direct service time to report 99497. 15 minutes or less cannot be billed.
• +99498: Use this add-on code for each additional 30 minutes, which requires exceeding the initial block and reaching at least 46 total minutes.

Eligible Providers and Participants

• Qualified Providers: Physicians, nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs). Clinical staff time or medical assistants cannot bill this independently.
• Participants: Discussions can take place face-to-face with the patient, family members, and/or a legal surrogate.

Documentation Requirements

To meet compliance standards per the Centers for Medicare & Medicaid Services (CMS) guidelines, your medical record must record:

• The voluntary nature of the encounter.
• The exact total time spent (or start and end times).
• The names and relationships of the attendees present.
• The content and explanation of advance directives or care goals discussed (actual completion of a physical form is optional).

Billing and Coverage

• Setting & Frequency: Billable in any care setting with no strict annual limit, though subsequent sessions require a documented change in the patient's health status or end-of-life wishes.
• Annual Wellness Visit (AWV): Can be paired with an AWV using modifier -33 to waive patient coinsurance and deductibles under traditional Medicare.

Medicare denies CPT code 99497 (Advance Care Planning) most frequently due to documentation gaps, time-threshold failures, or missing modifier errors during joint billing.

⏱️ Time-Threshold Failures

• Under 16 minutes: Conversations lasting 15 minutes or less cannot be billed under 99497.
• Missing total time: Medical records must explicitly state the start time, end time, and total face-to-face duration.

📝 Incomplete Documentation

• Voluntary status omitted: Charts must explicitly note that the advance care planning discussion was voluntary.
• Missing participant details: Documentation fails if it omits the names and relationships of family members or surrogates present.
• Unclear content: Notes must describe the specific advance directives or forms discussed, not just state "ACP performed".

🧩 Billing and Modifier Errors

• Missing Modifier -33: When billed on the same day as an Annual Wellness Visit (AWV), modifier -33 must be appended to waive cost-sharing.
• Provider type mismatch: Services must be furnished personally by a physician, nurse practitioner, physician assistant, or clinical nurse specialist.
• Unbundled add-on usage: Submitting add-on code 99498 without meeting the 46-minute threshold or pairing it properly with a primary 99497 claim triggers rejections.

Yes, you can bill CPT code 99497 (Advance Care Planning) on the same day as an Evaluation and Management (E/M) office visit like 99214, but you must append modifier -25 to the E/M code to indicate that the office visit was a separate and distinct service.

Key Requirements for Co-Billing

• Separate Times & Documentation: The time spent on the advance care planning (ACP) discussion must be completely separate from the time or work counted toward the 99214 office visit.
• Minimum Duration for 99497: The ACP discussion must last a minimum of 16 minutes to report 99497 (which covers the first 30 minutes under the midpoint rule).
• Provider Qualification: The service must be personally performed and documented by a physician or other qualified health care professional (QHP).
• Content: Documentation must clearly note the total duration of the ACP conversation, who was present, and that the discussion was voluntary.

The minimum time required to bill CPT code 99497 is 16 minutes of face-to-face advance care planning.

Key Details for Billing 99497

• Time Threshold: Under standard CPT midpoint rules for time-based codes, you can bill a 30-minute code once you pass the 15-minute mark (16 to 45 minutes total).
• Service Type: Face-to-face discussion regarding Advance Care Planning (ACP) with the patient, family, or surrogate.
• Additional Time: CPT code 99498 can be added for each extra 30 minutes, which requires reaching at least 46 total minutes.
• Documentation: Must include the exact duration, voluntary nature of the conversation, and topics discussed.

No, modifier 25 is placed on the accompanying Evaluation and Management (E/M) code, not on the Advance Care Planning (ACP) code 99497.

Key Billing Rules for 99497 and Modifier 25

• Placement of Modifier 25: When you perform a separate problem-oriented E/M service (like an office visit) and an ACP discussion (99497) on the same day, append modifier 25 to the E/M service to indicate a significant, separately identifiable service.
• Do Not Add to 99497: Modifier 25 does not go on code 99497 itself.
• Preventive Services Exception: If billing 99497 during a Medicare Annual Wellness Visit (AWV), use modifier 33 instead of modifier 25 to waive coinsurance and deductibles.
• Documentation Requirements: Ensure the medical record separates the time spent on the E/M service from the time spent on 99497, as ACP time cannot be counted toward the total time of the standard E/M visit. A minimum of 16 minutes of face-to-face time is required to bill 99497.