CPT (Current Procedural Terminology) codes are five-digit numbers that describe every medical service or procedure. Your doctor, hospital, and insurance company use them to communicate exactly what was done. Every line on your medical bill has a CPT code, and knowing the code lets you look up what Medicare pays for that same service.

Why do providers charge so much more than Medicare pays?

Providers set their own "chargemaster" prices, which are essentially list prices. Medicare pays a fixed rate based on the resources each service actually requires (the RVU system for procedures, or the Clinical Lab Fee Schedule for lab tests). Commercial insurers typically pay 150% to 250% of Medicare rates. Uninsured patients are often billed the full chargemaster price, which can be 2x to 30x what Medicare pays.

Can I use Medicare rates to negotiate my bill?

Yes. Medicare rates are the closest thing to a "fair price" benchmark in U.S. healthcare. When negotiating, ask the provider what they accept from Medicare for the same CPT code. Most providers will accept 150% to 200% of Medicare for cash-pay patients, which is still far less than their chargemaster price. Many hospital financial assistance policies also use a multiple of Medicare as their discount floor.

How are Medicare rates calculated?

For most procedures, Medicare uses the Resource-Based Relative Value Scale (RBRVS). Each CPT code gets three RVU components: Work (physician time and skill), Practice Expense (overhead), and Malpractice. These are multiplied by geographic adjustment factors (GPCIs) and a conversion factor ($33.4009 in 2026). Lab tests (80000-89999 range) use a separate Clinical Laboratory Fee Schedule with flat national rates.

CPT 99497

Advance Care Planning, First 30 Minutes

CPT 99497 covers the first 30 minutes of advance care planning, including discussions about living wills, healthcare proxy designation, DNR orders, and end-of-life care preferences. Providers charge an average of $159.77, while Medicare pays $86.84 (1.8x markup). Many patients do not realize this conversation is a billable medical service that can appear on their statement, sometimes without their awareness.

Updated May 2026Source: CMS Physician Fee Schedule

CPT 99497 at a Glance

Average provider charge: $159.77
Medicare rate (office): $86.84
Medicare rate (facility): $86.84
Typical markup: 1.8x over Medicare rate

Duration: First 30 minutes face-to-face
Medicare cost-sharing: $0 (preventive service)
Beneficiaries (2023): 1.35 million
Add-on code: 99498 (each additional 30 min)

How the Medicare Rate Is Calculated

Medicare values every procedure using Relative Value Units (RVUs) across three components, then multiplies by a national conversion factor of $33.4009 (2026). Here is the exact math for advance care planning:

Component	What It Covers	Office (Non-Facility)	Hospital (Facility)
Work RVU	Physician time, skill, and judgment	1.50	1.50
Practice Expense RVU	Rent, staff, equipment, supplies	0.96	0.96
Malpractice RVU	Professional liability insurance	0.12	0.12
Total RVU		2.58	2.58
x $33.4009	2026 conversion factor	$86.84	$86.84

Medicare covers this at no cost to patients: Under Medicare, advance care planning is classified as a preventive service. This means the Part B deductible is waived and there is no 20% coinsurance. Medicare patients pay $0 out of pocket for this service. This coverage began January 1, 2016.

Medicare Rate by State

Medicare adjusts the national rate based on your location using Geographic Practice Cost Indices (GPCIs). The same advance care planning session pays differently by state, ranging from about $68 in Arkansas to $81 in Alaska.

Medicare Rate by State (2026)

Medicare adjusts payments by location using Geographic Practice Cost Indices (GPCIs). Select your state to see the adjusted rate.

Sample State Rates (Office Setting)

State	Medicare Pays	Avg. Charge	Markup
Texas (Austin)	$73.32	$159.77	2.2x
California (Los Angeles)	$75.94	$159.77	2.1x
New York (Manhattan)	$77.44	$159.77	2.1x
Florida (Fort Lauderdale)	$73.13	$159.77	2.2x
Ohio	$70.21	$159.77	2.3x
Mississippi	$68.17	$159.77	2.3x
Arkansas	$67.94	$159.77	2.4x
Alaska	$81.31	$159.77	2.0x

Rates shown are for the non-facility (office) setting using 2026 GPCIs and the $33.4009 conversion factor. The average provider charge of $159.77 is the 2023 national average from CMS utilization data. Actual charges vary by provider.

What Insured Patients Actually Pay for Advance Care Planning

Coverage and cost-sharing for advance care planning varies significantly between Medicare and commercial insurance. Medicare treats it as preventive (free), but commercial plans often do not.

Your Situation	What You Likely Pay	How It Works
Medicare Part B	$0	Classified as preventive: no deductible, no coinsurance
Commercial plan (preventive classification)	$0	Some plans follow Medicare's preventive classification
Commercial plan (non-preventive)	$25 to $75 copay	Treated as a regular office visit, subject to plan cost-sharing
High-deductible plan (deductible NOT met)	$100 to $160	Full negotiated rate applies if not classified as preventive
Medicaid	$0 to $5	Minimal or no cost-sharing in most states

Check whether your plan classifies this as preventive. Not all commercial insurers treat advance care planning the same way Medicare does. If your plan does not classify 99497 as a preventive service, it will be subject to your deductible and copay like any other office-based service. Call your insurer before the appointment to confirm.

Should You Use Insurance or Pay Cash?

Because advance care planning is typically a one-time or infrequent service, the cost calculation is straightforward. For most patients, using insurance makes sense because it is either free (Medicare) or subject to a modest copay.

When Cash-Pay May Win

Your plan does not cover the code and you would pay $160 out of network
You want to use a specific attorney or non-medical professional for the documents (not billable under 99497)
Free alternatives exist: many hospitals, senior centers, and nonprofits offer advance directive assistance at no cost

When Using Insurance Wins

You have Medicare (100% covered, $0 out of pocket)
Your commercial plan classifies it as preventive
You want the conversation documented in your medical record for clinical purposes
Your doctor initiates the discussion during a regular visit (no extra appointment needed)

Free alternatives: You do not need a doctor to create advance directives. Every state has free advance directive forms available online (typically from state bar associations, AARP, or Five Wishes). The medical billing code 99497 covers the physician counseling conversation, not the legal documents themselves.

Common Billing Problems with 99497

Billed without a substantive conversation

Some providers bill 99497 based on a brief mention of advance directives or handing the patient a form to fill out. The code requires 16 minutes of face-to-face counseling (the threshold for billing 30-minute time-based codes). If your entire appointment was 15 minutes and included a physical exam plus a brief "do you have a living will?" question, the 99497 charge may not be justified.

Charged on top of a regular office visit unexpectedly

CPT 99497 can be billed alongside a regular E/M visit (99214, 99215, etc.) on the same day. This is legitimate when a genuine goals-of-care discussion occurs. However, it catches patients off guard when they expected a routine follow-up and receive a separate $160 charge for a brief end-of-life discussion they did not request. If you see 99497 on your EOB and do not recall a 15+ minute advance planning conversation, question it.

Commercial plan applies deductible instead of covering as preventive

Unlike Medicare, many commercial plans do not classify advance care planning as a preventive service. If your insurer applies this to your deductible and you believe it should be covered as preventive, check your plan's preventive services list. Some plans updated their coverage after Medicare's classification, but others have not. You may need to appeal with documentation that the ACA preventive services task force recommendations support coverage.

Add-on code 99498 billed without sufficient time

CPT 99498 is the add-on code for each additional 30 minutes beyond the first. If both 99497 and 99498 are billed, the provider is claiming at least 46 minutes of face-to-face advance care planning time. For most patients, a complete advance directive discussion takes 20 to 30 minutes. If you see both codes and your appointment was under 45 minutes total, the add-on code may not be supported.

Related Planning and Counseling Codes

Code	Description	Medicare Rate	Avg. Charge
99497	Advance care planning, first 30 min	$86.84	$159.77
99498	Advance care planning, each add'l 30 min	$75.21	$138.44
99214	Office visit, established (moderate)	$135.61	$263.55
99490	Chronic care management, 20 min/month	$66.13	$106.88
99483	Cognitive assessment and care planning	$282.47	$450.00

Frequently Asked Questions

Is advance care planning covered by Medicare?

Yes. Medicare covers advance care planning (CPT 99497) with no deductible and no coinsurance when billed as a preventive service. Medicare patients pay $0 out of pocket. It can be billed once per year or whenever there is a significant change in health status. The conversation can take place during a wellness visit or as a standalone appointment.

What does advance care planning include?

Advance care planning under CPT 99497 includes face-to-face discussion of advance directives, living wills, healthcare power of attorney, DNR/POLST orders, and goals-of-care conversations about end-of-life preferences. The discussion can include the patient, family members, or a surrogate decision-maker. It requires at least 16 minutes of counseling time.

Can advance care planning be billed on top of an office visit?

Yes. CPT 99497 can be billed on the same day as an E/M office visit (such as 99214) using modifier -25. This means you could see charges for both the office visit and the advance care planning discussion on the same date of service. If you did not have a substantive goals-of-care conversation lasting at least 16 minutes, question the 99497 charge.

How much does advance care planning cost without insurance?

Without insurance, advance care planning costs $100 to $200 per session, with a national average charge of $159.77. However, many free alternatives exist. State-specific advance directive forms are available online at no cost, and many hospitals and community organizations offer free assistance completing them. The $160 charge covers the physician counseling conversation, not the legal documents.

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