Advncd care plan addl 30 min
CPT 99498 covers additional 30-minute increments spent with a patient discussing their wishes for future medical care when they become seriously ill or unable to speak for themselves.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
Billing tips
Report 99498 only when documentation demonstrates a full additional 30 minutes beyond the first 30 minutes (99497). Time must be clearly documented with start and stop times.
Impact: Missing or incomplete time documentation is the #1 denial reason, resulting in loss of $68.90 per unit. Each additional 30-minute increment requires separate reporting.
99498 can be reported multiple times in a single encounter if the session extends beyond 60 minutes. For example: 75 minutes total = 99497 + 99498 x2 (pays $68.90 per add-on unit).
Impact: Failing to report all qualifying time leaves money on the table. An 85-minute session should yield 99497 + 99498 x2 for maximum reimbursement.
This code has no deductible or copay for Medicare patients when billed with modifier 33, making it highly acceptable to patients and increasing utilization opportunities.
Impact: Improves patient acceptance and compliance. Zero out-of-pocket cost increases willingness to engage in these important conversations.
Document not just time, but specific content: advance directive types discussed, patient decisions made, family members present, and forms completed or reviewed.
Impact: Rich documentation reduces audit risk and supports medical necessity. Vague notes like 'discussed advance directives' frequently trigger denials.
99498 cannot be billed on the same date as Critical Care codes (99291-99292) even if time is separately identifiable, per CMS bundling rules.
Impact: Attempting to bill both results in automatic denial of 99498 ($68.90 loss per unit). Schedule advance care planning on a different date from critical care services.
Verify patient eligibility before providing service. While no frequency limits exist, some Medicare Advantage plans may have prior authorization requirements for multiple units.
Impact: Proactive verification prevents denials. Commercial payers may have different policies than traditional Medicare, potentially affecting $68.90 per unit reimbursement.
Common denials
Insufficient time documentation - missing start/stop times or total time not clearly reaching 30 additional minutes
How to appeal: Submit appeal with corrected or detailed documentation showing exact start and stop times, calculated duration, and itemized time spent on each planning element. Include provider attestation confirming face-to-face time and continuous service.
Billed without primary code 99497 - 99498 is an add-on code and cannot stand alone
How to appeal: Verify that 99497 was billed and paid for the same date of service. If 99497 was denied, appeal both codes together. If 99497 was inadvertently omitted, submit corrected claim with both codes and explanation.
Bundling denial when billed with E/M codes or other preventive services on same date
How to appeal: Submit documentation proving the advance care planning was a separate, distinct service from the E/M visit with different medical necessity. Note that advance care planning is separately payable from annual wellness visits and most E/M codes with modifier 25 if documented separately.
Medical necessity not established - documentation lacks detail about patient condition warranting extended discussion
How to appeal: Provide comprehensive clinical notes describing patient's serious illness, complexity of decisions, family dynamics requiring extended time, cognitive or language barriers, or other factors necessitating prolonged discussion. Reference patient's diagnosis codes supporting need for advance care planning.
Frequently asked questions
How much does Medicare pay for CPT 99498 in 2025?
Medicare pays $68.90 for CPT 99498 under the 2025 Physician Fee Schedule (non-facility rate). The facility rate is $68.57. This represents each additional 30-minute increment of advance care planning beyond the first 30 minutes covered by 99497.
Can CPT 99498 be billed multiple times in one session?
Yes, 99498 can be reported multiple times in a single encounter. Each unit represents an additional 30 minutes. For example, a 90-minute advance care planning session would be coded as 99497 (first 30 minutes) plus 99498 x2 (two additional 30-minute increments).
What is the difference between CPT 99497 and 99498?
CPT 99497 is the primary code for the first 30 minutes of advance care planning discussion, while 99498 is an add-on code for each additional 30 minutes. 99498 cannot be billed without 99497 being reported for the same date of service.
Does CPT 99498 require a copay or deductible for Medicare patients?
No, advance care planning services (99497 and 99498) are covered preventive benefits under Medicare with no copay or deductible when billed with modifier 33, making them free to Medicare beneficiaries.
Can nurse practitioners and physician assistants bill CPT 99498?
Yes, nurse practitioners, physician assistants, and clinical nurse specialists can bill 99498 as qualified healthcare professionals. However, clinical staff without these credentials cannot independently bill this code, even under incident-to billing rules.
Can CPT 99498 be billed via telehealth?
Yes, 99498 can be billed for telehealth services using modifier 95. The same time and documentation requirements apply, and the reimbursement rate remains $68.90 for synchronous audio-video encounters meeting telehealth standards.
How do I document time for CPT 99498 to avoid denials?
Document the exact start and stop times of the entire advance care planning encounter, specify which portion was the first 30 minutes (99497) and which was additional time (99498), and describe the content of discussion throughout the session. For example: 'Advance care planning 2:00 PM - 3:15 PM (75 minutes total). First 30 minutes discussed goals of care and healthcare proxy designation. Additional 45 minutes spent reviewing specific treatment preferences and completing POLST form with patient and daughter.'