📌 CPT® Codes for Advance Care Planning
| Code | Description |
|---|---|
| 99497 | First 30 minutes of face-to-face advance care planning (ACP) discussion. |
| 99498 | Add-on: each additional 30 minutes of ACP (time-based, subject to midpoint rule). |
⏱️ Time Thresholds & the Midpoint Rule
ACP billing is time-based. Document total face-to-face time clearly in the note. The midpoint rule applies to reporting the add-on code 99498.
| Total Documented Time | Correct CPT Billing | Notes |
|---|---|---|
| 1–15 minutes | Not billable as ACP | Insufficient time to meet 99497 threshold |
| 16–45 minutes | 99497 | Example: 40 minutes → bill 99497 only |
| 46–75 minutes | 99497 + 99498 | Add-on allowed when ≥46 minutes total (30 + 16 minute midpoint) |
| 76–105 minutes | 99497 + 99498 x2 | Each additional 30-minute block follows midpoint rule |
❗Critical Care Bundling Rule (High-Risk for Denials)
If the same physician or qualified health professional (same NPI) performs critical care services (CPT 99291/99292) on the same date, ACP must not be billed separately — ACP is considered bundled into critical care time. ACP can be billed on the same date only when a different clinician (different NPI) provides the ACP and documentation clearly separates the ACP discussion and time.
🌟 Goals of Care (GOC) vs Advance Care Planning (ACP)
Many clinicians document “Goals of Care” while rounding. Not all GOC notes meet ACP billing criteria. Use this guidance to determine when a GOC conversation qualifies as billable ACP:
| Scenario | Billable as ACP? | Rationale |
|---|---|---|
| General goals discussion about current treatment focus (comfort vs cure) with no future-treatment preferences discussed | No | GOC alone is not ACP unless future-specific preferences or directives are discussed and time is documented |
| Discussion includes code status (DNR/DNI), ventilation, artificial nutrition, surrogate decision-maker, or POLST/Advance Directive completion | Yes (if time documented) | This meets ACP content; time threshold must be met for CPT reporting |
| Two-minute bedside statement: “We’ll focus on comfort” | No | Insufficient documented time and specificity for ACP |
📝 Documentation Requirements
- Confirmation that discussion was voluntary and who participated (patient, spouse, surrogate).
- Topics covered: CPR/DNR/DNI, mechanical ventilation, feeding tube/artificial nutrition, dialysis, POLST/Advance Directive, surrogate.
- Clear statement of decisions made or deferred.
- Total face-to-face time spent in the ACP discussion (required to support CPT time-based billing).
- Separate documentation when ACP is provided by a clinician different from the critical care provider.
Sample Compliant Documentation
Good example (billable):
“Voluntary Advance Care Planning discussion with patient and daughter. Reviewed CPR, intubation, mechanical ventilation, artificial nutrition, and POLST options. Patient elects DNR/DNI and names daughter as surrogate. 40 minutes face-to-face ACP time documented.”
Bill: CPT 99497 only (40 minutes = 99497).
Not billable example:
“Goals of care discussed; focus on comfort. Patient agreeable.” — No time documented, no specific future-treatment preferences documented → not eligible for ACP CPT billing.
🏷 ICD-10 Support Codes Often Paired with ACP
| ICD-10 Code | Description / Use |
|---|---|
| Z71.89 | Other specified counseling — commonly used to indicate counseling/ACP when relevant |
| Z51.5 | Encounter for palliative care — use when ACP is part of palliative services |
| Z66 | Do Not Resuscitate status — use when DNR is elected or confirmed |
🧪 Practical Billing Scenarios
| Scenario | Correct Billing | Notes |
|---|---|---|
| Outpatient ACP discussion — 38 minutes, code status changed to DNR | 99497 | 16–45 min = 99497 only |
| Hospital palliative clinician performs ACP 62 minutes; intensivist provided critical care same day | 99497 + 99498 (palliative clinician) and 99291/99292 (intensivist) | Different NPIs — both services may be billed if separately documented |
| Hospitalist performs 40 minutes ACP while also documenting critical care (99291) on same date | 99291 only (do not bill ACP) | Same-provider critical care bundles ACP |
✅ Quick Reference — ACP Coding at a Glance
| Item | Guidance |
|---|---|
| Primary CPTs | 99497 (first 30 min); 99498 add-on (each additional 30 min) |
| Minimum time for 99497 | 16 minutes (16–45 min = 99497) |
| When to add 99498 | Total documented time ≥46 minutes (30 + 16 midpoint) |
| Critical care conflict | If same physician provides critical care (99291/99292) same date → do NOT bill ACP |
| GOC documentation | GOC alone ≠ ACP. Must document future preferences/directives + time to bill |
💡 Best Practices for Compliance
- Use EHR templates/smart-phrases that require time and specific ACP topics.
- Train providers on the difference between Goals of Care rounds and billable ACP conversations.
- Require NPI separation when different clinicians provide critical care vs ACP on the same date.
- Audit ACP claims frequently for time documentation and critical care overlap.
- Verify payer-specific rules (telehealth allowances, Medicare Advantage variations).
📣 Closing
Accurately distinguishing Goals of Care from billable Advance Care Planning and applying the correct CPT time thresholds prevents denials and supports appropriate reimbursement for meaningful patient conversations. When in doubt, ensure the note documents who participated, what future-treatment preferences were discussed, and the total face-to-face time.
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