Palliative care has experienced significant growth, leading many clinicians to serve as palliative care consultants, either part-time or full-time. Similar to any medical specialty, accurate documentation, coding, and appropriate reimbursement are crucial. For each patient encounter, clinicians must assign both a procedure/service code and a diagnosis code (1,2). The Centers for Medicare and Medicaid Services (CMS) implemented substantial revisions to procedure/service codes in 2023, while diagnostic codes are continuously updated for greater specificity. Understanding the nuances of coding and billing for encounters for palliative care is essential for healthcare providers to ensure accurate claims and optimal practice management. This guide provides a detailed overview of the current coding landscape for palliative care services, designed to enhance your understanding and streamline your billing processes.
Navigating Procedure and Service Codes (CPT) for Palliative Care
Procedure/Service codes are derived from the Current Procedural Terminology (CPT) manual, published by the American Medical Association, and are the standard across US healthcare. Evaluation/Management (E/M) codes are the most frequently utilized by palliative and hospice care professionals. The selection of an appropriate E/M code hinges on several factors: the setting of care (inpatient, outpatient, home, skilled nursing facility (SNF), etc.), the nature of the visit (consultation, new patient, or established patient), and either the time spent on the encounter or the complexity of medical decision making. Clinicians can base their code selection on either time or Medical Decision Making (MDM) complexity to reflect their clinical effort.
Time-Based Billing for Palliative Care Encounters
Time-based billing offers a straightforward approach, particularly if clinicians meticulously record the time dedicated to each patient’s care. Historically, outpatient time calculations were based on face-to-face time, provided that counseling and care coordination comprised over 50% of the encounter. Inpatient time was defined as the total time spent on the unit or floor related to patient care. However, under the revised CMS guidelines from 2023 (3), time-based billing now encompasses the total time spent on patient care activities on the day of service. This includes time spent reviewing medical records, conducting evaluations, counseling patients and families, documenting notes, and coordinating care with other healthcare professionals. Electronic Medical Records (EMRs) often include integrated tools and calculators to assist in determining E/M codes based on time. For current CPT codes based on time, refer to updated resources (4), as these codes are subject to annual changes.
For situations requiring extended time commitments, prolonged service codes can be appended. These codes account for the cumulative time spent on a patient’s care during the service period. For inpatient hospitalizations, office visits, and General Inpatient Hospice (GIP), the service period is limited to the day of the visit. For SNF encounters, the service period extends to include the day before, the day of, and three days after the visit. Home visit service periods for prolonged codes are the most extensive, covering three days before the visit, the day of the visit, and seven days after. Understanding these service period definitions is crucial for accurate billing of prolonged palliative care services.
Medical Decision Making (MDM) Complexity in Palliative Care Coding
While potentially more nuanced, billing based on MDM complexity often yields higher reimbursement rates in palliative care. This is because complex MDM is frequently inherent in palliative care encounters, even brief ones, which involve addressing goals of care, prognosis formulation, and illness trajectory assessments. Many EMR systems incorporate tools to calculate MDM billing codes. There are three core components that contribute to MDM level:
- Number and Complexity of Problems Addressed: This considers the scope and severity of the patient’s health issues addressed during the encounter. In palliative care, this often involves complex symptom management, psychological distress, and existential concerns.
- Amount and/or Complexity of Data to Be Reviewed and Analyzed: This encompasses the volume and intricacy of medical information reviewed, including lab results, imaging studies, specialist reports, and the patient’s medical history. Palliative care frequently requires synthesizing extensive and varied data to develop a comprehensive care plan.
- Risk of Complications and/or Morbidity or Mortality: This evaluates the potential risks associated with patient management decisions. Given the serious illnesses often encountered in palliative care, the risk of complications, morbidity, and mortality is often significant, influencing the MDM level.
Refer to updated resources for detailed guidance on MDM complexity levels and their corresponding CPT codes (5). Accurately assessing and documenting MDM complexity is key to appropriate reimbursement for palliative care services.
Diagnosis Codes (ICD) in Palliative Care Billing
Diagnosis codes are selected from the International Classification of Diseases (ICD). This classification system is broader than just pathophysiological diagnoses. It includes a wide range of symptom codes relevant to palliative care, such as neoplastic-related fatigue (R53.83), cancer-related pain (G89.3), and nausea and vomiting (R11.2). It is important to note that “goals of care” discussions, while central to palliative care, are not billable diagnoses. Most EMR systems facilitate ICD code lookup as clinicians input diagnoses. When palliative care services are provided by a clinician-in-training (e.g., intern, resident, fellow), the CPT modifier GC should be appended to the service code.
Advance Care Planning (ACP) Codes in Palliative Care
Clinicians can utilize specific time-based CPT codes (99497 or 99498) to bill for encounters dedicated to Advance Care Planning (ACP) (6). This includes sessions involving counseling and discussions about advance directives, code status, and other care preferences and values. These ACP codes can be used as the primary billing code for a visit focused solely on ACP, or as an additional code when billing for medical care services provided on the same day. However, it is generally recommended to use ACP codes as additional codes in conjunction with MDM complexity-based billing to avoid submitting two time-based bills for a single day. CPT code 99497 is used for ACP discussions lasting 16-45 minutes, while CPT code 99498 is added to 99497 for discussions extending 46-75 minutes. Proper utilization of ACP codes ensures reimbursement for these vital conversations in palliative care.
Consultations and Hospice Billing Considerations
When billing for palliative care consultations, it is essential to document the referring clinician and the specific consultation question being addressed. While Medicare no longer reimburses for consultations since 2012, some private insurers may still offer reimbursement.
In cases where a patient has elected the Medicare Hospice Benefit, billing procedures differ. If the primary clinician is not affiliated with the hospice organization (e.g., acting as a hospice medical director), they should submit bills to Medicare under Part B using a CPT code with a “GV” modifier for care related to the terminal condition. All other clinicians (e.g., consultants) should submit their bills to the hospice organization. The hospice organization then submits claims to Part A and directly reimburses the consultant. Refer to specific guidelines for detailed information on hospice billing (7).
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Conclusion
Accurate coding and billing for encounters for palliative care are crucial for ensuring the financial sustainability of palliative care services and recognizing the valuable contributions of palliative care clinicians. By understanding the nuances of CPT and ICD coding, time-based and MDM complexity billing, ACP codes, and specific guidelines for consultations and hospice care, healthcare providers can navigate the billing process effectively. Staying updated on annual coding changes and utilizing available EMR tools are essential for optimal palliative care billing practices.
References
- von Gunten CF, Ferris FD, Kirschner C, Emanuel L. Coding and reimbursement mechanisms for physician services in hospice and palliative care. J Palliat Med. 2000; 3(2):157-164.
- Jones CA, Bull J, Acevedo J, Kamal AH. Top ten inpatient palliative medicine billing and coding mistakes (and how to fix them this week). J Palliat Med. 2015;18(3):211-216. doi:10.1089/jpm.2015.0005.18.3
- American Medical Association. CPT Evaluation and Management (E/M) Code and Guideline Changes effective January 1, 2023. Available at https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf Last accessed 12/14/23.
- American Medical Association. Documenting time for each task during outpatient vists. Available at: https://www.aan.com/siteassets/home-page/tools-and-resources/practicing-neurologist–administrators/billing-and-coding/cpt–em/2023-cpt-revised-mdm-grid.pdf Last accessed 12/14/23
- American Medical Association. CPT Evaluation and Management: Updated May 12, 2023. Available at: Last accessed 12/14/23
- Jones CA, Acevedo J, Bull J, Kamal AH. Top 10 Tips for Using Advance Care Planning Codes in Palliative Medicine and Beyond. J Palliat Med. 2016;19(12):1249-1253. doi:10.1089/jpm.2016.0202
- Pa.metto GBA. Billing hospice physician, nurse practitioner, and physician assistant services related to terminal diagnosis. Available at: https://www.palmettogba.com/palmetto/providers.Nsf/files/Billing_Hospice_Physician_NP_PA_Services_Job_Aid.pdf/$File/Billing_Hospice_Physician_NP_PA_Services_Job_Aid.pdf Last accessed 12/15/23.
