Guide

99497: paying for the goals-of-care conversation

Summary

99497 pays for the first 30 minutes a physician or other qualified provider spends face-to-face with a patient, family member, or surrogate explaining and discussing advance directives, with or without completing the actual forms; 99498 is the add-on for each additional 30 minutes. It is a distinct CPT code from an E/M visit and can be reported alongside one on the same date. Coverage specifics — whether it's bundled into a wellness visit that day, and any local documentation expectations — are worth confirming before the conversation.

By Gale Editorial · Updated 2026-07-26. Every figure cited to a dated source. How we write.

How do I bill advance care planning conversations?

Bill the conversation itself using 99497 for the first 30 minutes and 99498 for each additional 30 minutes, both governed by the CPT code set the AMA maintains and updates annually 1Ref 1American Medical Association (2026).CPT® (Current Procedural Terminology).That CPT, including the advance care planning codes 99497 and 99498, is maintained by the AMA and updated annually, and that CPT is the HIPAA-named procedure code set for professional services.. The codes cover a physician or other qualified health care professional spending face-to-face time with the patient, a family member, or a surrogate decision-maker, explaining and discussing advance directives, whether or not the actual forms get completed at that visit.

Because the codes are time-based rather than MDM-based, the note has to state how much time was spent on the conversation specifically, the same discipline that any time-based CPT code requires. A conversation that runs under 30 minutes still bills 99497 once that threshold's substance is genuinely covered; 99498 only applies once a second full 30-minute block is reached.

What the code actually covers

99497 covers the conversation about goals of care and advance directives — what the patient would want if they couldn't speak for themselves, who should make decisions on their behalf, and whether documents like a healthcare proxy or living will should be completed 1Ref 1American Medical Association (2026).CPT® (Current Procedural Terminology).That CPT, including the advance care planning codes 99497 and 99498, is maintained by the AMA and updated annually, and that CPT is the HIPAA-named procedure code set for professional services.. It is not limited to any particular diagnosis or stage of illness; the conversation itself, not a prognosis, is what the code pays for.

Completing the actual legal forms during the visit isn't required to bill the code, since the conversation and the paperwork are separable — a practice can have the discussion and bill 99497 even when the patient takes the forms home to finalize with family or an attorney. What has to be documented is that the substantive conversation happened and roughly what it covered, not that a signed document resulted from it.

Same-day billing: pairing it with an office visit or the wellness visit

99497 is a distinct CPT code from an E/M office visit, and practices commonly report it alongside a same-day E/M encounter when both a medical visit and a genuine advance-care-planning conversation happen at the same appointment. Whether your payer expects a modifier on the E/M line in that situation isn't perfectly uniform across payers, so it's worth confirming rather than assuming either way.

Medicare also allows 99497 to be furnished as an optional part of the Annual Wellness Visit, which is a separate billing scenario from reporting it as a stand-alone Part B service on an ordinary office day. Which of those two paths applies changes how the visit is billed, which is one more reason to check the specifics before the appointment rather than after the claim is submitted.

99497 vs the Advance Beneficiary Notice — two different "advance" documents

99497 has nothing to do with an Advance Beneficiary Notice of Noncoverage, even though both carry the word "advance" in Medicare paperwork. An ABN is the notice a practice gives a Medicare patient before a service that's likely to be denied, so the patient can decide whether to proceed knowing they may owe the full cost 2Ref 2Centers for Medicare & Medicaid Services (2026).Beneficiary Notices Initiative (BNI).That the Advance Beneficiary Notice of Noncoverage is the notice given before a likely-denied service so a Medicare patient can decide whether to proceed, a distinct financial-disclosure mechanism from advance care planning despite the shared word "advance.".

Advance care planning is a clinical conversation about future medical decisions, billed under its own CPT code; an ABN is a financial-disclosure form tied to a specific service Medicare might not cover. The two only share a word, not a function, and confusing them is an easy mistake for a solo practice juggling both kinds of "advance" paperwork in the same chart.

Confirming coverage specifics before the conversation

Whether a MAC has published anything narrowing who may bill 99497, how it should be documented locally, or how it interacts with the wellness visit that day is the kind of jurisdiction-specific question the Medicare Coverage Database answers directly, since it indexes both national coverage decisions and every MAC's own local coverage determinations and articles 3Ref 3Centers for Medicare & Medicaid Services (2026).Medicare Coverage Database (MCD) Search.That NCDs and every MAC's LCDs and articles are searchable in the public Medicare Coverage Database, supporting the lookup method for whether a jurisdiction has published guidance narrowing or documenting advance care planning billing.. Checking it before a pattern of visits, rather than after a denial, is the efficient order to do this in.

If you're unsure which MAC serves your jurisdiction at all, CMS publishes the list of which contractor administers Medicare claims in each region, which is the starting point for finding that MAC's own published guidance 4Ref 4Centers for Medicare & Medicaid Services (2026).Medicare Administrative Contractors.That Medicare claims administration is regionalized across MACs and that CMS publishes which MAC serves each jurisdiction, supporting the find-your-MAC lookup method before checking that contractor's own published guidance.. This matters more for a code like 99497, where documentation expectations can vary by contractor, than it does for a flat, uniformly defined CPT code.

What it pays, and why tracking time matters

The current national and locality payment for 99497 and the 99498 add-on is available directly in the Physician Fee Schedule search tool, which is updated as CMS sets rates annually through rulemaking, rather than assumed from a flat figure 5Ref 5Centers for Medicare & Medicaid Services (2026).Physician Fee Schedule Search.That CMS publishes a public Physician Fee Schedule look-up tool where any clinician can find the national and locality payment amount for a CPT code, so the current payment for 99497 and 99498 is checked directly rather than assumed.. Checking it directly also shows the add-on's incremental value, which is what makes tracking whether a conversation crossed into a second 30-minute block worth the effort.

For a solo practice already having these conversations informally, the gap between billing nothing for the time and billing 99497 or 99498 accurately is real, recurring revenue for work that's already happening. The only cost is the same documentation habit any time-based code requires: stating the time spent and what the conversation substantively covered.

Documenting the conversation itself

The note should state who was present — the patient, a family member, a surrogate, or some combination — how much time was spent, and a brief description of what was discussed: goals of care, whether an advance directive exists or needs updating, and who the patient wants to make decisions if they can't. That level of detail is what distinguishes a billed 99497 from a passing mention of advance directives inside an unrelated visit.

A short line on the outcome — a form completed, a decision to revisit the conversation later, or a surrogate identified — rounds out the note without requiring a finished legal document to justify the code. The conversation is what's being paid for; the paperwork, when it happens, is a byproduct of it, not a precondition.

Common questions

No. The code pays for the conversation about goals of care and advance directives, whether or not the actual legal forms get completed during that visit. A patient can take the forms home to finish with family or an attorney, and the conversation is still billable as long as it substantively covered the required content.

Yes, practices commonly report it alongside a same-day E/M encounter when both a genuine medical visit and a substantive advance-care-planning conversation occur. Whether your payer expects a modifier on the E/M line varies, so it's worth confirming with that specific payer rather than assuming the same rule applies everywhere.

No, and confusing the two is an easy mistake. 99497 bills a clinical conversation about future care decisions. An Advance Beneficiary Notice is a financial-disclosure form given before a service Medicare might not cover, so the patient can decide whether to proceed. They share a word, not a function.

The conversation itself isn't restricted to any particular diagnosis or prognosis in the code's own definition; it's the discussion of goals of care and advance directives regardless of current health status. If a specific MAC has published anything narrowing this further, that's the kind of local policy worth checking in the Medicare Coverage Database.

99497 covers the first 30 minutes of the conversation. 99498 is the add-on code for each additional 30 minutes beyond that, reported alongside 99497 rather than on its own. Both are time-based, so the note needs to state the actual time spent to support billing either one.

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References

1.American Medical Association (2026). CPT® (Current Procedural Terminology). American Medical Association (AMA). link ✓That CPT, including the advance care planning codes 99497 and 99498, is maintained by the AMA and updated annually, and that CPT is the HIPAA-named procedure code set for professional services.
2.Centers for Medicare & Medicaid Services (2026). Beneficiary Notices Initiative (BNI). Centers for Medicare & Medicaid Services (CMS). link ✓That the Advance Beneficiary Notice of Noncoverage is the notice given before a likely-denied service so a Medicare patient can decide whether to proceed, a distinct financial-disclosure mechanism from advance care planning despite the shared word "advance."
3.Centers for Medicare & Medicaid Services (2026). Medicare Coverage Database (MCD) Search. Centers for Medicare & Medicaid Services (CMS). link ✓That NCDs and every MAC's LCDs and articles are searchable in the public Medicare Coverage Database, supporting the lookup method for whether a jurisdiction has published guidance narrowing or documenting advance care planning billing.
4.Centers for Medicare & Medicaid Services (2026). Medicare Administrative Contractors. Centers for Medicare & Medicaid Services (CMS). link ✓That Medicare claims administration is regionalized across MACs and that CMS publishes which MAC serves each jurisdiction, supporting the find-your-MAC lookup method before checking that contractor's own published guidance.
5.Centers for Medicare & Medicaid Services (2026). Physician Fee Schedule Search. Centers for Medicare & Medicaid Services (CMS). link ✓That CMS publishes a public Physician Fee Schedule look-up tool where any clinician can find the national and locality payment amount for a CPT code, so the current payment for 99497 and 99498 is checked directly rather than assumed.

https://www.gale.care/for-providers/em-advance-care-planning-99497 · 5 sources. Competitor details are cited to dated public sources and maintained as they change; figures are estimates, not commitments. Synthetic demonstration.

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