CAPC Palliative Care Discussion Forum
Billing and Finance
We are struggling with some billing questions at MGH and would like input.
1) Is there recent info on whether CMS (or regional CMS carriers) has been more definitive on the issue of whether family meetings (held in the absence of a patient lacking capacity) can be billed as face to face time for prolonged service? We have been billing prolonged service for these type of family meetings and understand that there are variable results with audits around the country. We have heard that Medicare will be looking at this more carefully in the upcoming year. Our billers will be speaking with our local CMS carrier, but wanted the larger view.
2) We are also trying to understand Critical Care billing and whether it can be applied to palliative care sedation, including on the floor. We read Dana Lustbader's article on this issue, but it doesn't seem to clarify the issue on the floor (and perhaps not completely in the ICU.)
Any updates/guidance on any of this?
Many thanks!
Eva
IMPORTANT: In order to post a new message or reply to an existing post in the discussion you must
login. If you are not a registered member you may
join here.
The statements posted in the forum section of capc.org are opinions expressed by website visitors and do not necessarily represent the viewpoints or positions of the Center to Advance Palliative Care(CAPC). CAPC is not responsible for the factual or legal accuracy of any of the statements posted.
General questions about using the
CAPCconnect™ palliative care discussion forum?
Email:
Jennifer.Raiten@mssm.edu
Lost login username/password questions? Email:
Margaret.Schutz@mssm.edu
Prolonged service and critical care codes
However, AMA and Medicare are silent on whether or not a patient’s representative can be considered equivalent to the patient, and thus meet the standard of face-face contact.
To avoid a potential audit, you should check with your Medicare carrier or insurance company. If they decide that you may not use 99356–57 it is worth appealing the decision.
2. Re: palliative care staff using Critical Care billing codes--all depends on how your Fiscal Intermediary interprets what you are doing as within the definition of Critical Care; Im not aware of any uniform interpretation.
3. The third level of complexity is the billing philosophy of your setting--many academic centers stick to a philosophy of the most conservative interpretation of billing rules to avoid any chance of audit; you should include your billing/compliance staff in your deliberations.
4. Billing rules are a moving target--what is true today may be different in a few months--another reason to keep in close contact with your compliance staff
David Weissman, MD
CAPC Consultant
Wow, great questions!
1. Thorn in my side. We have not been successful in getting reimbursed by CMS for ANY prolonged service codes (99356), even when the patient is present AND has capacity for medical decision making and we list total time and content of meeting. We recently changed our template note to state time in/time out to see if this helps.
2. We do get reimbursed for all critical care coding (99291) for palliative care services provided to patients in the ICU AND on the med/surgery floors with organ failure. We code for critical care for palliative sedation, withdrawal of mechanical ventilation and other palliative services including family meetings for medical decision making when the patient lacks capacity and the family meeting is necessary for treatment decisions including withdrawal. The provider must be immediately available to the patient, so we are clear to code critical care when the family meeting occurs "near" or in the patient's room.
Dana Lustbader MD
Julie Pipke, CPC
CAPC Consultant
Reimbursement Manager, MCW
Per CPT Guidelines, a provider may perform inpatient prolonged services (99356-99357)beyond the designated E/M service. This includes additional unit/floor time.
My question: Is this acceptable for Medicare patient as well OR can the prolonged visit be captured with ONLY Direct face-to-face time with patient? Also, what if the provider is speaking extensively to the patient family instead of the patient (due to mental or physical condition), can this be included in the inpatient prolonged service codes 99356-99357? What MUST be documented in order to code for the prolonged visits?
Their response: To answer your first question, the time counted toward payment for prolonged evaluation & management services included only direct face-to-face contact between the physician and the patient (whether or not the service was continuous). If you were addressing both patient and family, it would fall under the face-to-face contact for prolonged E&M.
The medical record documents the content of the evaluation and management service code, the duration and content of prolonged services that the physician personally furnished after the typical time of the evaluation & management service has been exceeded by at least 30 minutes.
Hope this helps!
Per CPT Guidelines, a provider may perform inpatient prolonged services (99356-99357)beyond the designated E/M service. This includes additional unit/floor time.
My question: Is this acceptable for Medicare patient as well OR can the prolonged visit be captured with ONLY Direct face-to-face time with patient? Also, what if the provider is speaking extensively to the patient family instead of the patient (due to mental or physical condition), can this be included in the inpatient prolonged service codes 99356-99357? What MUST be documented in order to code for the prolonged visits?
Their response: To answer your first question, the time counted toward payment for prolonged evaluation & management services included only direct face-to-face contact between the physician and the patient (whether or not the service was continuous). If you were addressing both patient and family, it would fall under the face-to-face contact for prolonged E&M.
The medical record documents the content of the evaluation and management service code, the duration and content of prolonged services that the physician personally furnished after the typical time of the evaluation & management service has been exceeded by at least 30 minutes.
Hope this helps!