ACP billing can be confusing when a physician provides advance care planning during a hospital visit. The physician may treat a patient, discuss future care preferences, and document both services on the same day.

But can both services be billed?

The answer depends on the services performed, the documented time, and the CPT codes involved.

For example, Medicare allows advance care planning (ACP) with many hospital evaluation and management (E/M) services. However, special restrictions apply when the same physician provides critical care on the same date.

In this guide, we’ll explain ACP billing with hospital E/M and critical care, including:

• CPT 99497 and 99498 time requirements
• When ACP and hospital E/M can be billed together
• Why critical care has different reporting rules
• Modifier 25 requirements
• Documentation requirements
• Common coding mistakes
• Practical examples for medical coders

What Is Advance Care Planning (ACP)?

Advance care planning helps patients express their wishes for future medical care.

During an ACP discussion, a physician or other qualified healthcare professional talks with the patient about the treatment they would want if they could no longer make medical decisions.

The discussion may cover:

• Goals of care
• Advance directives and living wills
• Healthcare proxies or decision-makers
• Life-sustaining treatments
• Resuscitation preferences
• Future medical decisions

Sometimes, family members or authorized representatives also participate.

Does the Patient Need to Complete an Advance Directive?

No. Medicare does not require a completed advance directive for qualifying ACP billing.

The physician may discuss future care preferences without completing a written document.

However, the medical record must support the actual ACP service.

Simply writing “ACP discussed” or “patient is DNR” does not automatically support separate billing.

ACP Billing Codes: CPT 99497 and 99498

Medical coders use two CPT codes for advance care planning.

CPT 99497: Initial ACP Service

CPT 99497 represents the initial advance care planning discussion.

For Medicare, the physician must document at least 16 minutes of qualifying ACP time.

The discussion should focus on future healthcare decisions, treatment preferences, and related ACP topics.

CPT 99498: Additional ACP Time

CPT 99498 represents additional ACP time.

It is an add-on code. Therefore, you cannot report it alone.

You must first report CPT 99497.

The first unit of 99498 requires at least 46 total minutes of qualifying ACP time.

ACP Billing Time Requirements

Total ACP time	CPT code
15 minutes or less	No separate ACP code
16–45 minutes	99497
46–75 minutes	99497 + 99498
76–105 minutes	99497 + 99498 × 2

These time ranges follow Medicare’s ACP guidance.

Key point: A 16-minute ACP discussion supports 99497, not 99498.

Also, the documented time must reflect qualifying ACP activities. The physician should not include time spent managing unrelated medical problems.

Can You Bill ACP With Hospital E/M Services?

Yes. Medicare allows ACP billing with many hospital E/M services when the physician performs and documents both services appropriately.

Common subsequent hospital visit codes include:

• 99231: Straightforward or low medical decision-making
• 99232: Moderate medical decision-making
• 99233: High medical decision-making

However, the physician must support the E/M service independently of ACP.

Also, the same time cannot count toward both time-based services.

Let’s review some examples.

Example 1: CPT 99233 With 16 Minutes of ACP

A patient is hospitalized with heart failure and chronic kidney disease.

During the hospital visit, the physician:

• Reviews laboratory results
• Evaluates the patient’s condition
• Adjusts medications
• Updates the treatment plan

The documentation supports CPT 99233 based on high-complexity medical decision-making.

Later, the physician spends 16 minutes discussing advance directives and future treatment preferences with the patient.

The discussion meets the ACP requirements.

Correct coding:

• 99233-25: Subsequent hospital E/M
• 99497: ACP, 16 minutes

Why can both services be billed?

The physician performed two separate services.

The hospital E/M involved active management of the patient’s medical conditions. The ACP discussion focused on future healthcare preferences.

Therefore, Medicare permits reporting both when all requirements are met.

Example 2: CPT 99232 With Only 10 Minutes of ACP

A physician performs a hospital follow-up visit.

The documentation supports CPT 99232.

During the encounter, the physician also spends 10 minutes discussing future treatment preferences.

Correct coding:

• 99232: Subsequent hospital E/M
• Do not add 99497.

Why?

The ACP discussion lasted only 10 minutes.

Medicare requires at least 16 minutes for CPT 99497.

Although the discussion may help the patient, it does not meet the minimum ACP billing time.

Example 3: CPT 99233 With 50 Minutes of ACP

A physician provides a hospital follow-up service that supports CPT 99233.

Later, the physician conducts a separate 50-minute ACP discussion with the patient and an authorized family member.

They discuss future medical treatment, advance directives, and healthcare decision-making.

Correct coding:

• 99233-25
• 99497
• 99498 × 1

Why?

The ACP discussion lasted 50 minutes.

Therefore, it falls within the 46–75-minute range.

The physician may report 99497 and one unit of 99498, provided the documentation supports both services.

ACP Billing With Critical Care: Can You Report Both?

This is one of the most important distinctions in ACP coding.

Under Medicare guidance, the same physician or qualified healthcare professional should not separately report CPT 99497 or 99498 with critical care codes 99291 or 99292 on the same date.

Critical care often involves discussions about treatment decisions.

For example, a physician may speak with a critically ill patient’s family about ventilator support, life-sustaining treatment, or future healthcare preferences.

However, these conversations do not automatically qualify for separate ACP billing.

Example 4: CPT 99291 With 16 Minutes of ACP

A patient develops acute respiratory failure and requires critical care.

The physician documents:

• 45 minutes of qualifying critical care
• A separate 16-minute ACP discussion

During ACP, the physician discusses the patient’s future treatment preferences.

Correct Medicare coding:

• 99291: Critical care
• Do not separately report 99497.

Why?

The same physician provided ACP and critical care on the same date.

Therefore, Medicare’s ACP reporting restriction applies.

The physician should still document the discussion, even when separate ACP billing is not permitted.

Example 5: Critical Care With 50 Minutes of ACP

A physician spends 85 minutes providing qualifying critical care.

The physician also documents 50 minutes of ACP on the same date.

A coder may initially consider:

• 99291
• 99497
• 99498

However, Medicare does not permit this combination when the same practitioner provides both services on the same date.

Correct Medicare coding:

• 99291: Based on 85 qualifying critical care minutes
• Do not separately report 99497 or 99498.

Although the ACP discussion lasted more than 46 minutes, the same-date critical care restriction still applies.

Can You Add ACP Minutes to Critical Care Time?

Not automatically.

This is another common area of confusion.

Critical care time must involve qualifying critical care activities.

For example, a physician may spend time:

• Managing organ failure
• Reviewing critical test results
• Adjusting urgent treatment
• Making essential treatment decisions
• Coordinating care for a critically ill patient

However, not every family discussion qualifies as critical care time.

Medicare has specific requirements for counting discussions with family members or decision-makers.

Therefore, a physician cannot simply add separate ACP minutes to critical care time.

Example 6: Can 45 Minutes of Critical Care Plus 20 Minutes of ACP Become 65 Minutes?

A physician documents:

• 45 minutes of qualifying critical care
• 20 minutes of separate ACP

A coder might assume the total critical care time is 65 minutes.

However, that calculation is not automatically correct.

First, the coder must determine whether the additional discussion meets Medicare’s critical care time requirements.

If the discussion was solely ACP and did not qualify as critical care, the physician cannot count those 20 minutes toward critical care.

Coding tip: Never combine separately documented service times without reviewing the rules for each service.

When Is Modifier 25 Required With ACP?

Modifier 25 identifies a significant, separately identifiable E/M service performed on the same date as another service.

For example:

99233-25 + 99497

This combination may be appropriate when the documentation supports both hospital E/M and ACP.

However, modifier 25 does not override other Medicare reporting restrictions.

For example, adding modifier 25 does not allow the same physician to separately report ACP with critical care on the same date.

Therefore, always verify the services and applicable payer guidance.

ACP Documentation Requirements for Medical Coders

Good documentation is essential for accurate ACP billing.

The physician should record what was discussed, who participated, and how much qualifying time was spent.

Let’s review the main requirements.

1. Voluntary Participation

Advance care planning is voluntary.

The documentation should reflect that the patient or appropriate representative agreed to participate.

2. Participants in the Discussion

The physician should identify the participants.

For example:

• Patient
• Family member
• Healthcare proxy
• Authorized surrogate

If the patient cannot participate, the physician should explain the circumstances when relevant.

3. Topics Discussed

The note should describe the ACP discussion.

For example, the physician may review:

• Future treatment choices
• Patient values
• Advance directives
• Healthcare decision-makers
• Preferences about life-sustaining treatment

A brief statement such as “ACP discussed” may not provide enough detail.

4. Total ACP Time

The physician must document qualifying ACP time.

For example:

“Total face-to-face ACP time: 20 minutes.”

CMS also recommends documenting the start and end times as a best practice.

5. Separate ACP and E/M Services

When billing both hospital E/M and ACP, the physician must support each service.

Also, the same minutes cannot count toward two separate time-based services.

Example of ACP Documentation

The following is a fictional example for coding education.

“The patient voluntarily participated in an advance care planning discussion with the physician and an authorized representative. We reviewed future treatment preferences, advance directives, goals of care, and healthcare decision-making. The patient shared preferences and asked questions. Total face-to-face ACP time was 20 minutes, separate from the hospital E/M service.”

This example includes several important elements.

However, the final medical record must accurately reflect the services performed.

Does ACP Require a Specific ICD-10-CM Diagnosis?

No. Medicare does not require one specific ICD-10-CM diagnosis for ACP.

Instead, the coder should select an appropriate diagnosis based on the documented service and clinical circumstances.

For example, the patient may have:

• Heart failure
• Cancer
• Chronic kidney disease
• Another serious medical condition

However, coders should never add an unsupported diagnosis simply to obtain payment.

The ICD-10-CM code must reflect the medical record.

Can Medicare Pay for ACP More Than Once?

Yes. Medicare does not set a fixed annual limit on ACP services.

However, every billed discussion must meet the requirements.

For example, a patient’s medical condition may change significantly.

As a result, the patient may want to reconsider earlier treatment preferences.

In this situation, another ACP discussion may be appropriate.

CMS recommends documenting changes in the patient’s condition or wishes when ACP services are repeated.

Common ACP Billing Mistakes to Avoid

Mistake 1: Reporting 99498 Instead of 99497

A physician documents 16 minutes of ACP.

Incorrect: 99498

Correct: 99497, when all other requirements are met.

Remember, 99498 is an add-on code.

Mistake 2: Billing ACP for Less Than 16 Minutes

A physician documents only 12 minutes.

Because the discussion does not meet the minimum time, do not report 99497.

Mistake 3: Reporting ACP With Same-Day Critical Care

A physician documents critical care and a separate ACP discussion.

Under the cited Medicare guidance, the same practitioner cannot separately report 99497 or 99498 with 99291 or 99292 on the same date.

Mistake 4: Counting the Same Time Twice

A physician documents 50 minutes of hospital E/M and 20 minutes of separate ACP.

The coder should not include the 20 ACP minutes again in the E/M time.

Mistake 5: Billing ACP Based Only on Code Status

The physician writes:

“Patient is DNR.”

That statement alone does not establish a separately reportable ACP service.

The record must support the actual discussion.

Mistake 6: Missing Modifier 25

When the physician separately reports qualifying hospital E/M and ACP, verify the modifier requirements.

For example:

99232-25 + 99497

Mistake 7: Trusting the Charge Sheet Without Reviewing the Note

The charge sheet lists 99498.

However, the physician documents only 16 minutes of ACP.

The documented time supports 99497 rather than 99498, provided the other requirements are met.

Therefore, always compare the charge sheet with the clinical documentation.

Quick ACP Billing Checklist

Before submitting an ACP charge, ask:

1. Did the physician perform a qualifying ACP discussion?
2. Was participation voluntary?
3. Does the note describe the discussion and participants?
4. Did the physician document at least 16 minutes?
5. Does additional time support 99498?
6. Was another E/M service provided on the same date?
7. Does the documentation support both services separately?
8. Was critical care reported by the same practitioner on that date?
9. Did the physician count any service time twice?
10. Are the CPT codes and modifiers correct?

This checklist can help reduce common ACP coding errors.

Frequently Asked Questions About ACP Billing

Can 99233 and 99497 Be Billed Together?

Yes. Medicare allows this combination when both services meet their requirements and the E/M service is separately identifiable.

Can 99232 and 99497 Be Billed Together?

Yes. Both may be reported when the documentation supports them. Check modifier 25 requirements.

Can 99291 and 99497 Be Billed Together?

Not by the same physician or qualified healthcare professional on the same date under the cited Medicare guidance.

Is 16 Minutes Enough for CPT 99497?

Yes. Medicare allows 99497 beginning at 16 minutes of qualifying ACP time.

When Can You Bill CPT 99498?

The first unit of 99498 begins at 46 total minutes of qualifying ACP time.

You must report 99497 with it.

Is a Signed Advance Directive Required?

No. A signed advance directive is not required for qualifying ACP billing.

Can ACP Be Billed During a Hospital Stay?

Yes. Medicare permits qualifying ACP services in hospital settings, subject to the applicable reporting rules.

Final Thoughts: How to Code ACP Correctly

ACP billing becomes easier when you focus on three questions:

What service did the physician perform? How much qualifying time did the physician document? What other services did the physician provide on the same date?

Remember these important rules:

• 99497: At least 16 minutes of qualifying ACP
• 99498: First additional unit at 46 total minutes
• 99232 or 99233 with ACP: May be separately reportable
• 99291 or 99292 with ACP: Same-practitioner, same-date reporting restrictions apply under Medicare
• Modifier 25: Check when reporting separately identifiable hospital E/M with ACP
• Documentation: Verify the discussion, participants, time, and service requirements

Finally, remember that Medicare and commercial payer policies may differ.

Always review the applicable coding instructions and payer guidance before submitting the claim.

Read Also: Strengthen Your ICD-10-CM Coding Skills

Understanding CPT billing rules is only one part of medical coding. Accurate diagnosis coding is equally important.

For example, ICD-10-CM combination codes can describe a disease along with its complications or related conditions. Knowing when to use them can help prevent unnecessary multiple coding.

If you want to improve your diagnosis coding skills, read my related article:

ICD-10-CM Combination Codes: A Simple Guide With Examples

It explains combination codes, the “with” convention, common mistakes, and practical examples that can help you understand ICD-10-CM coding more clearly.

Explore Medical Coding Resources for CPC Exam Preparation

Preparing for the CPC® exam or looking to strengthen your medical coding knowledge?

Medical coding involves more than memorizing codes. You also need to understand coding guidelines, medical terminology, anatomy, and the reasoning behind code selection.

To support your learning, I’ve created medical coding study resources covering topics such as ICD-10-CM guidelines, medical terminology and anatomy, CPT concepts, and practical coding examples.

These resources are designed to help learners review difficult topics, understand coding rules, and build confidence while preparing for the CPC exam or improving their coding skills.

Explore my medical coding study resources and notes at Medical Coding With S

Keep practicing, review the official guidelines regularly, and focus on understanding why a code is correct rather than simply memorizing the answer.

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Official References

• CMS – Advance Care Planning Fact Sheet (March 2026)
• CMS – Billing and Coding: Advance Care Planning (A58664)
• CMS – Evaluation and Management Services

Disclaimer: This article is intended for coding education. It focuses on Medicare professional billing guidance. Always review current CPT instructions, CMS updates, and payer-specific rules for the date of service.