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    v1.0.30
    OpenPayerBilling CodesAdvance Care PlanningCPT cpt-99498-advanced-care-planning-additional-30-minutes
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    CPT 99498: Advance Care Planning, Each Additional 30 Minutes

    Medicare pays $80 and commercial payers pay $96 on average nationally for this procedure.

    CPT code 99498 describes advanced care planning services beyond the initial 30 minutes, used when a provider spends each additional 30 minutes in face-to-face discussion and documentation of future health care preferences and advance directives; service type: advanced care planning counseling, typical site of service: office or other outpatient face-to-face clinical setting.

    For related coverage guidance, see recent payer policy updates: Percutaneous Electrical Nerve Field Stimulation for Functional Abdominal Pain Disorders, Esophagogastroduodenoscopy (EGD) Coverage Policy, Radiofrequency Therapy for Fecal Incontinence.

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    National Reimbursement Benchmarks

    Medicare’s national mean of $80.4 sits below BUCA’s average commercial mean of $95.7, indicating that commercial contracting through BUCA generally pays more than the Medicare baseline for CPT 99498. This gap of $15.3 highlights a modest commercial premium versus Medicare, with Medicare showing a very tight central tendency (P25 $77 to P75 $82) that suggests limited variation across localities.

    Dispersion measured by the IQR (P75 minus P25) is widest for UnitedHealth Group (IQR $63.3) and Cigna (IQR $59.5), signaling broader negotiated outcomes, while Blue Cross Blue Shield (IQR $34.6) and Aetna (IQR $36.4) exhibit tighter central ranges. BUCA’s IQR is $46.7 and Medicare’s IQR is just $5, making Medicare the tightest and UnitedHealth Group the most dispersed among these payers.

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    National Payer Mean Reimbursement Rates

    State Reimbursement Rates

    State: Alaska1 / 51

    Rate by payer

    Clinical & Coding Specifications

    Clinical Context

    A 78-year-old patient with multiple chronic conditions (congestive heart failure, chronic obstructive pulmonary disease, and early-stage dementia) presents for a planned face-to-face visit in the primary care clinic. The primary care physician or family medicine clinician conducts an extended advance care planning session following an initial 30-minute discussion. During the additional 30-minute segment billed with 99498, the clinician reviews previously documented advance directives, discusses goals of care and likely illness trajectories, clarifies patient and surrogate decision-maker preferences for life-sustaining treatments (including CPR and mechanical ventilation), documents designation of a health care proxy, and completes or updates an advance directive form. The workflow includes direct, face-to-face time with the patient and/or their surrogate, documented total time spent on advance care planning beyond the first 30 minutes, informed consent and shared decision-making elements, and placement of the updated directive in the medical record. The visit typically occurs in an outpatient clinic or primary care office; it may also occur in a skilled nursing facility or during a home visit when performed by eligible clinicians under their taxonomy. Time-based documentation and a distinct note describing the content of conversations are required to support billing of 99498 for each additional 30 minutes of face-to-face advance care planning time.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure

    Related Modifiers

    6 rows

    ModifierDescriptionWhen to Use
    25CPT modifier 25 indicates that on the same day as another procedure or service, the same physician or other qualified health care professional provided a significant, separately identifiable…- When to apply: Use modifier 25 only on an E/M code to indicate the same provider delivered a significant, separately identifiable E/M service on the same day as another procedure or service — i.e.,…
    22Modifier –22 (Increased Procedural Services) is used when a reported procedure is substantially more extensive than normally required. The CPT Manual and CMS state it may be appended only when the…- When to use: Append modifier -22 to a procedural CPT code when the service performed is substantially more extensive than the usual service described by that code — i.e., the procedure required…
    52Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
    53Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…
    57CPT® modifier -57 (“Decision for Surgery”) is appended to an Evaluation and Management (E/M) service when that encounter results in the initial decision to perform a major surgery (a procedure with a…- Use modifier 57 when an E/M service provided by the same provider (or same tax ID) on the day of or the day before a major surgical procedure (90‑day global period) results in the initial decision…
    95Modifier 95 indicates that a service was provided via synchronous, real‑time audio‑video telehealth rather than in‑person. Per CMS, AAPC and professional associations, append modifier 95 to claim…- Use modifier 95 to indicate a service was furnished via synchronous, real‑time audiovisual telehealth (a live audio‑video conference between patient and provider) rather than in‑person. - Pair…

    Related Provider Taxonomies

    8 rows

    Taxonomy Code
    207R00000X
    207Q00000X
    208D00000X
    2251S0007X
    247200000X
    363LS0200X
    3336I0012X
    208100000X

    Related Payer Policy Updates

    Specialty: Gastroenterology1 / 2

    10 rows

    PolicyPayerEffective Date
    Percutaneous Electrical Nerve Field Stimulation for Functional Abdominal Pain Disordersbcbsvermont2026-12-01
    Esophagogastroduodenoscopy (EGD) Coverage Policyevicore2026-11-05
    Radiofrequency Therapy for Fecal IncontinenceCigna2026-10-15
    Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD)univerahealthcare2026-10-15
    High-Resolution Anoscopy (HRA)Premera Bluecross2026-10-01
    Gastroesophageal and Gastrointestinal (GI) Services and ProceduresColorado Rocky Mountain Health Plans2026-10-01
    Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver DiseaseOscar Health2026-10-01
    Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant TestingOscar Health2026-10-01
    Pancreatic Enzyme Testing for Acute PancreatitisOscar Health2026-10-01
    Helicobacter pylori TestingOscar Health2026-10-01

    Related Codes

    CPT-99497-ADVANCE-CARE-PLANNING-30-MINUTE-FACE-TO-FACE

    CPT 99497: Advance Care Planning, First 30 Minutes

    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
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    Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

    99497
    Advance care planning first 30 minutes (face-to-face time that the provider spends).
    Primary code for the initial 30 minutes; 99498 is billed for each additional 30 minutes beyond 99497.
    99291Critical care, evaluation and management of the critically ill or critically injured patient; first 30–74 minutes.Unrelated in typical outpatient advance care planning but listed as related for time-based critical care billing context; ensure services are not concurrently billed for the same time.
    99292Critical care… each additional 30 minutes.As above for additional critical care time; not typically billed with advance care planning on the same time basis.
    99468Neonatal critical care, per day, for the evaluation and management of a neonate (critically ill newborn).Related only as part of the time‑based family of codes; not clinically used for adult advance care planning.
    99469Subsequent neonatal critical care, for the evaluation and management of a critically ill newborn.Related by code family; not used in adult advance care planning workflow.
    99471Pediatric critical care, first 30–74 minutes.Related by code family for time-based critical care services; not used for advance care planning.
    99472Pediatric critical care, each additional 30 minutes.See 99471 note.
    99475Pediatric critical care, first 30–74 minutes (higher complexity).See 99471 note.
    99476Pediatric critical care, each additional 30 minutes (higher complexity).See 99471 note.
    99477Pediatric critical care (even higher complexity), first 30–74 minutes.See 99471 note.
    99478Pediatric critical care (even higher complexity), each additional 30 minutes.See 99471 note.
    99479Pediatric critical care (most complex), first 30–74 minutes.See 99471 note.
    99480Pediatric critical care (most complex), each additional 30 minutes.See 99471 note.