CPT 99497 and 99498: Medicare Advance Care Planning Pay 2026

Posted in Healthcare Compliance

CPT 99497 pays a national average of $86.84 in the office setting and $65.80 in the facility setting under the 2026 Medicare Physician Fee Schedule, and its add-on CPT 99498 pays $78.16 and $63.46, respectively. Those figures come from the relative value units in the CY 2026 final rule multiplied by the 2026 non-qualifying conversion factor of $33.40, before geographic adjustment. Office rates rose 9 percent and 13 percent from 2025; facility rates fell 9 percent and 7 percent. The CPT 99497 amounts are only half the answer. Whether the practice collects them depends on a 16-minute threshold, a documentation list CMS publishes, a modifier that decides whether the patient owes anything, and the setting the claim is billed from. 

What Is CPT 99497

CPT 99497 is the base code for advance care planning. The first 30 minutes of a face-to-face discussion by a qualified health care professional with the patient, their family members, or anyone covering advance directives. The discussion is voluntary and concerns the patient’s health care wishes if they later cannot make their own decisions.

CMS allows hospitals, physicians, and non-physician practitioners, including nurses, physician assistants, and clinical nurse specialists, to bill it when their scope of practice and Medicare benefit category include the service. 

Medicare pays for it in two ways: 

1. As an optional element of the annual wellness visit.
2. As a separate Part B medically necessary service. 

No specific diagnosis is required, and it can be billed in any care setting, including the office, hospital, nursing home, the patient’s home, and through telehealth. 

Because the code is time-based, the time billed must be spent on advance care planning alone; CMS states that active management of other problems and time spent on any concurrent time-based service cannot be counted.

What Is CPT 99498

CPT 99498 is the add-on code for each additional 30 minutes of the same advance care planning discussion, listed separately in addition to the primary code. It is never billed on its own; the MLN fact sheet ties every unit of 99498 to one unit of 99497 on the same date. The 2026 fee schedule values it at 1.40 work RVUs against 1.50 for the base code, which is why the two codes pay within about nine dollars of each other in the office setting.

The add-on follows the same midpoint rule as the base code: a unit is billable once the midpoint of its 30-minute block has passed. Under Medicare hospital outpatient payment, the Florida and US Virgin Islands Medicare contractor notes that, as an add-on code, its payment is unconditionally packaged under OPPS, so the separate dollar amounts below apply to the professional fee schedule, not to a hospital’s facility claim.

CPT 99497 vs 99498: 2026 Payment 

Item	CPT 99497	CPT 99498
Descriptor	Advance care planning, first 30 minutes, face-to-face	Each additional 30 minutes, add-on to 99497
Minimum time to bill one unit	16 minutes	16 minutes beyond the prior block (46 minutes total for the first unit)
Work RVU (2026)	1.50	1.40
Non-facility total RVU (2026)	2.60	2.34
Facility total RVU (2026)	1.97	1.90
2026 national rate, non-facility	$86.84	$78.16
2026 national rate, facility	$65.80	$63.46
2025 national rate, non-facility	$79.57	$68.90
2025 national rate, facility	$72.46	$68.57
Change 2025 to 2026, non-facility	+9%	+13%
Change 2025 to 2026, facility	-9%	-7%
Patient cost sharing	Deductible and coinsurance apply unless billed with the AWV and modifier 33	Same rule as 99497
Frequency limit	None; document a change in health status or wishes when repeated	Same, and only with 99497 on the same claim

 National rates are total RVUs multiplied by the $33.4009 non-qualifying APM conversion factor and are quoted before geographic practice cost index adjustment. Qualifying APM participants are paid on the $33.57 factor, which raises each amount by about half a percent. Source rows are from the CY 2026 final rule RVU file and the CMS MLN fact sheet.

CPT 99497 and 99498: How the 2026 Rate Is Built

Every fee schedule payment, CPT 99497 included, is the sum of three relative value units: work, practice expense, and malpractice- multiplied by a conversion factor. 

CMS’s 2026 fact sheet finalized two conversion factors for the first time: 

• $33.57 for qualifying alternative payment model participants 
• $33.40 for everyone else, up 3.77 percent and 3.26 percent from the single 2025 factor of $32.35. 

For CPT 99497 in the office, the 2026 total of 2.60 RVUs is 1.50 work, 1.01 practice expense, and 0.09 malpractice; multiplied by $33.4009, it yields $86.84. The same arithmetic on 2.34 RVUs gives $78.16 for 99498.

CPT 99497 and 99498: Office vs Facility Rates

The setting on the claim changes CPT 99497 payment by $21.04 in 2026. The non-facility amount applies when the practice bears the overhead, as in a physician office; the facility amount applies in hospitals, skilled nursing facilities, and similar settings that bill their own costs separately. 

The MLN fact sheet confirms that advance care planning can be furnished and billed in both. For 2026, the gap widened because the practice expense redistribution raised the office figure to $86.84 and lowered the facility figure to $65.80, a difference that was $7.11 in 2025. A practice that furnishes most of its advance care planning in hospital rounds will see a smaller 2026 payment per conversation than one that does it in clinic, with identical work.

CPT 99497 and 99498: The 16-Minute Threshold

No advance care planning code, CPT 99497 included, can be billed for 15 minutes or less. CMS’s timetable sets the units: 16 to 45 minutes is one unit of 99497; 46 to 75 minutes is 99497 plus one unit of 99498; 76 to 105 minutes is 99497 plus two units of 99498. A conversation that runs 15 minutes is billed, if at all, inside a separate evaluation and management service. 

The time counted must be face-to-face with the patient, family, or surrogate and spent on advance care planning; CMS directs that time on concurrent time-based services and on active management of the patient’s other conditions be excluded. 

The MLN example makes the point: a physician who adjusts a patient’s heart failure, diabetes, and dementia medications and then discusses advance directives may bill the E/M visit and the ACP codes together only if the ACP time does not overlap the management time.

CPT 99497 and 99498: Cost Sharing and Modifier 33

Medicare waives the Part B deductible and coinsurance for CPT 99497 and 99498 only when four conditions are all met: the service is provided on the same day as a covered annual wellness visit, HCPCS G0438 or G0439; by the same provider; billed with modifier 33 for preventive services; and billed on the same claim as the AWV. 

Outside that combination, advance care planning is a medically necessary Part B service, and the patient owes the deductible and coinsurance on the allowed amount. One consequence practices miss: if the AWV on the claim is denied for exceeding its once-per-year limit, CMS applies the ACP deductible and coinsurance to the patient even though the service was billed as preventive.

Documentation Requirements for CPT 99497 and 99498

CMS requires four elements in the record for every billed CPT 99497 or 99498 discussion: that the visit was voluntary, an explanation of advance directives, who was present, and the time spent discussing advance care planning during the face-to-face encounter. 

Those four items are the stated requirements, and a note that lacks the time element cannot support a time-based code. The condition discussed is reported with an ICD-10-CM code, and when the service is part of an AWV, the diagnosis shows an administrative or exam diagnosis. 

Advance directives themselves vary by state; CMS lists do-not-resuscitate orders, health care powers of attorney, health care proxies, instruction directives, living wills, medical orders for life-sustaining treatment, and psychiatric advance directives as examples, and points to state attorneys general for the forms.

Repeat Billing and Frequency for CPT 99497 and 99498

There is no limit on how many times CPT 99497 and 99498 can be reported for a patient or within a period. CMS attaches one condition: when the codes are billed more than once, the record must document a change in the patient’s health status, a change in their wishes about end-of-life care, or both. 

A second conversation after a new diagnosis, a hospitalization, or a change in the patient’s decision-maker meets that test; a repeat of the same discussion with nothing changed does not.

The 2027 Proposal for CPT 99497 and 99498

The 2026 office rate for CPT 99497 is the high point of the current cycle unless Congress acts. On July 14, 2026, CMS proposed CY 2027 conversion factors of $33.17 for qualifying APM participants and $32.84 for everyone else, decreases of 1.19 percent and 1.68 percent. CMS attributes the drop to the expiry of a one-year 2.5 percent conversion factor increase that Public Law 119-21 provided for 2026 only. If the RVUs for 99497 and 99498 are unchanged in the final rule, the 2027 office rates would fall to roughly $85.39 and $76.85 at the proposed non-qualifying factor. The proposal is open to change until the final rule is published later in 2026; practices should budget on the proposed factor and adjust when the final rule lands.

Folio3 Digital Health for ACP Workflows

Folio3 Digital Health builds and connects clinical and financial software for health systems and digital health companies, including workflows that capture time, participants, and modifier logic for time-based services like advance care planning inside the EHR and claim path. If your team is designing an advance care planning program and wants the documentation and claim rules above enforced in software rather than on checklists, our healthcare revenue cycle management solutions team can scope it.

Closing Note

Every CPT 99497 and 99498 dollar figure in this guide is a national amount computed from the CY 2026 final rule’s relative value units and CMS’s published conversion factor, and every billing rule is taken from CMS’s March 2026 MLN fact sheet. Locality adjustments, Medicare Advantage plan terms, and commercial payer policies all change the amount a given claim pays, and this guide does not estimate them. Two things it deliberately leaves out: it does not quote a single rate for hospital outpatient claims, because 99498 is packaged under OPPS and 99497’s treatment belongs to the hospital’s own fee schedule; and it does not treat the 2027 proposed figures as settled. Check the CMS fee schedule lookup for your locality before setting a charge master, and recheck after the CY 2027 final rule.

FAQs

1. How much does Medicare pay for CPT 99498 in 2026?

$78.16 in the office setting and $63.46 in the facility setting, from 2.34 and 1.90 total RVUs at $33.4009. It can only be paid alongside 99497 on the same claim.

2. What is the minimum time to bill CPT 99497?

16 minutes of face-to-face advance care planning. CMS’s table assigns 16 to 45 minutes to one unit of 99497; 15 minutes or less is not billable as ACP.

3. Does the patient pay anything for advance care planning?

Yes, a patient can sometimes pay out-of-pocket, but it depends entirely on how the service is billed.

Under standard Medicare Part B rules, the breakdown of costs is straightforward:

• You pay $0: If the advance care planning (ACP) conversation is done as part of your Medicare Annual Wellness Visit, it is 100% covered. You owe nothing.
• You pay a copay: If the conversation happens during a normal doctor’s visit or as a standalone appointment, standard cost-sharing applies. You will typically owe a 20% coinsurance after meeting your yearly deductible.

About the Author