2025 CPT code 99497
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Evaluation and Management - Advance Care Planning Evaluation and Management Feed
Advance care planning; first 30 minutes of face-to-face time spent with the patient, family member(s), and/or surrogate, including explanation and discussion of advance directives.
Modifiers 25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) and others may be applicable depending on the clinical context.Consult the AMA CPT manual for appropriate modifier use.
Medical necessity for 99497 and 99498 is established when the patient has a serious health condition or is at an age where future decision-making capacity may be impaired.The documentation must show the patient's clinical needs and justify the need for this type of care planning.It should focus on the patient's condition and the reason for planning ahead.
The physician or other qualified healthcare professional is responsible for conducting a thorough discussion with the patient (or their representative) regarding their end-of-life care preferences and ensuring the appropriate documentation is completed. This requires careful listening, explaining complex medical information clearly, answering questions, addressing concerns, and facilitating the execution of advance directives if desired.
In simple words: This code covers the doctor's or other qualified healthcare professional's time spent talking with you, your family, or someone representing you about your wishes for future healthcare. This includes discussing documents that explain your healthcare preferences if you can't make decisions yourself later on.This code is for the first 30 minutes of this discussion.
This CPT code, 99497, represents the physician or other qualified healthcare professional's services in providing advance care planning (ACP).This includes the explanation and discussion of advance directives (such as a living will or durable power of attorney for healthcare) with the patient, family member(s), and/or surrogate. The service encompasses the initial 30 minutes of face-to-face time dedicated to this activity.No active management of the patient's medical problems should occur during this time.Code 99498 is used for each additional 30-minute increment beyond the initial 30 minutes.
Example 1: A 78-year-old patient with a history of heart failure and dementia is admitted to the hospital.The physician spends 30 minutes discussing advance directives (including a living will and durable power of attorney for healthcare) with the patient's daughter, clarifying her understanding of the patient's condition and treatment options. Code 99497 is used., A 65-year-old patient with newly diagnosed metastatic cancer schedules a meeting with their oncologist to discuss advance care planning. The oncologist spends 45 minutes with the patient and their spouse, reviewing treatment options, discussing end-of-life care preferences, and helping them complete advance directive forms.Codes 99497 and 99498 would be reported (99497 for the first 30 minutes, and 99498 for the additional 15 minutes)., A 50-year-old patient with a family history of early-onset Alzheimer's disease desires to establish an advance care plan. The patient meets with their primary care physician for an initial 30-minute session to discuss the possibility of appointing a healthcare proxy and document their healthcare wishes for the future. Code 99497 is utilized.
Detailed documentation should include the date and time of the ACP discussion, the individuals present (patient, family members, surrogate), topics covered (explanation of advance directives, discussion of patient's wishes, etc.), the duration of the session, and completion of any advance directive forms.The record must clearly demonstrate the medical necessity of the service.
** Accurate documentation is crucial for proper reimbursement.Understand the differences between 99497 and 99498.Always refer to the most current CPT codebook for the most accurate and up-to-date information.
- Revenue Code: Y1 (OTHER - MEDICARE FEE SCHEDULE)
- RVU: RVUs will vary based on geographic location, facility type (if applicable), and payer. Consult the appropriate fee schedule for specific values.
- Global Days: Not applicable. This is not a surgical procedure with a global period.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Fee Schedule: The historical fee schedule varies significantly by year and payer; consult appropriate fee schedules.
- Specialties:Family Medicine, Internal Medicine, Geriatric Medicine, Oncology, Hospice and Palliative Care
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Skilled Nursing Facility, Hospice, Other Place of Service (depending on clinical context)