Does 99497 require prior authorization?

No, 99497 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 99497?

Medicare facility rate: $65.80. Non-facility rate: $86.84. Work RVU: 1.50.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

1.50

Facility

$65.80

Non-Facility

$86.84

Medical record must document the content and medical necessity of the ACP discussion, the voluntary nature of the encounter, the content of any advance directives (and completion of forms, when performed), the names of participants, and the time spent in the face-to-face encounter (start and end times recommended).
If the patient is unable to be present for ACP, the medical record must document the reason the patient is unable to participate.
The patient’s or surrogate’s agreement to voluntary ACP must be documented in the medical record.
Place of service (POS) must be included on claims when reporting ACP services.

Advance Care Planning (ACP) is covered when performed face-to-face by a Medicare physician or other qualified health care professional with the patient and/or family member(s) and/or surrogate to discuss the patient’s healthcare wishes.
ACP may be billed as part of a Medical Wellness Visit/Annual Wellness Visit (MWV/AWV, HCPCS G0438 or G0439) or as a separate Medicare Part B medically necessary service.
ACP services are covered in facility and non-facility settings including office, hospital, skilled nursing facility (SNF), home, and by telehealth per CMS telehealth guidelines in effect at time of service.
Qualified providers who may report CPT codes 99497 and 99498 are physicians (MD/DO), nurse practitioners (NP), physician assistants (PA), and clinical nurse specialists (CNS); other team members may participate under the treating physician’s order and direct supervision.
For patients receiving hospice benefits, ACP may be billed under Medicare Part B only if the practitioner is not employed by the hospice; otherwise ACP is billed on hospice Type of Bill 081x or 082x.
ACP codes 99497 and 99498 may be reported on the same date or a different date as most E/M services and may be reported during the same service period as transitional care management or chronic care management services, subject to CPT rules.

A58664 — Billing and Coding: Advance Care Planning

A59036 — Billing and Coding: Cognitive Assessment and Care Plan Service

L38970 — Advance Care Planning

L39266 — Cognitive Assessment and Care Plan Service

Ask Verity about documentation requirements, denial risks, or coverage in your state.