CPT Code Overview

CPT code 99498 is used to report each additional 30 minutes of advance care planning services, provided face-to-face with patients, their family members, or surrogates. This code is listed separately and must be used in conjunction with the primary procedure code 99497. Advance care planning involves discussions about the patient's preferences for end-of-life care, including the completion of advance directives. The typical site of service for this procedure is the office setting (Place of Service 11).

Clinical Context

A typical patient scenario involves an adult patient visiting the office (Place of Service 11) for advance care planning. The provider, such as an internal medicine physician, family medicine physician, or general practice physician, conducts a face-to-face discussion regarding the patient's preferences for future medical care, including goals, values, and options for life-sustaining treatments. After the initial 30 minutes of advance care planning (billed with 99497), the conversation continues for an additional 30 minutes, which is billed separately using 99498. This extended time may be necessary when the patient or their family requires more in-depth counseling, clarification of complex medical issues, or additional time to address questions and concerns about advance directives and end-of-life care options.

Coding Specifications

• Modifiers:

  • Modifier 33: Used to indicate preventive services. This modifier is applied when the advance care planning is considered a preventive service under the payor's policy.

  • Modifier 25: Used to denote a significant, separately identifiable evaluation and management (E/M) service performed on the same day as another procedure or service. This modifier is appropriate when advance care planning is provided in addition to another E/M service.

• Provider Taxonomies:

These taxonomies represent providers who commonly deliver advance care planning services and are eligible to report 99498.

Related Diagnoses

• Z71.89 – Other specified counseling

  • Used when the advance care planning involves counseling beyond standard medical advice, such as discussing end-of-life preferences.

• Z51.81 – Encounter for therapeutic drug level monitoring

  • Relevant when advance care planning includes discussions about ongoing medication management and monitoring.

• Z00.00 – Encounter for general adult medical examination without abnormal findings

  • Used when advance care planning is part of a routine adult medical exam with no abnormal findings.

• Z00.01 – Encounter for general adult medical examination with abnormal findings

  • Used when advance care planning is conducted during a general medical exam where abnormal findings are present.

• Z02.89 – Encounter for other administrative examinations

  • Applicable when advance care planning is performed during an administrative examination, such as for legal or insurance purposes.

Related CPT Codes

• 99497: Advance care planning first 30 minutes (face-to-face time that the provider spends). Used for the initial 30 minutes of advance care planning. 99498 is always reported in addition to 99497 for extended time.

• 99291: Critical care, evaluation and management of the critically ill or critically injured patient; first 30–74 minutes. Not reported on the same date as 99497 or 99498.

• 99292: Critical care… each additional 30 minutes. Not reported with 99497 or 99498.

• 99468: Neonatal critical care, per day, for the evaluation and management of a neonate (critically ill newborn). Not reported with 99497 or 99498.

• 99469: Subsequent neonatal critical care, for the evaluation and management of a critically ill newborn. Not reported with 99497 or 99498.

• 99471: Pediatric critical care, first 30–74 minutes. Not reported with 99497 or 99498.

• 99472: Pediatric critical care, each additional 30 minutes. Not reported with 99497 or 99498.

• 99475: Pediatric critical care, first 30–74 minutes (higher complexity). Not reported with 99497 or 99498.

• 99476: Pediatric critical care, each additional 30 minutes (higher complexity). Not reported with 99497 or 99498.

• 99477: Pediatric critical care (even higher complexity), first 30–74 minutes. Not reported with 99497 or 99498.

• 99478: Pediatric critical care (even higher complexity), each additional 30 minutes. Not reported with 99497 or 99498.

• 99479: Pediatric critical care (most complex), first 30–74 minutes. Not reported with 99497 or 99498.

• 99480: Pediatric critical care (most complex), each additional 30 minutes. Not reported with 99497 or 99498.

99497 and 99498 are commonly used together for advance care planning. The other codes listed are alternatives for critical care services and are not reported on the same date as advance care planning codes.

For CPT code 99498, the national mean rate for Medicare is $80.37, while the BUCA (average commercial) mean rate is higher at $90.23. Commercial payers such as UnitedHealth Group and Cigna report even higher mean rates, at $115.28 and $110.23 respectively, compared to both Medicare and BUCA.

Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Medicare exhibits the tightest range at $5.00, indicating minimal variation in rates. In contrast, UnitedHealth Group and Cigna show the widest dispersions, with ranges of $60.33 and $60.50 respectively, reflecting greater variability in commercial reimbursement. Aetna and Blue Cross Blue Shield fall in between, with ranges of $30.80 and $31.67.

The table and chart below present a detailed breakdown of national benchmarks for each payer, including mean rates and percentile values.