Still Billing on Time? The Case for Billing on Medical Decision-Making in Palliative Care

Every palliative care program has wrestled with the same question: “How should we bill?

“Should we focus on time because we spend so much of it in complex family meetings and prolonged visits? Or should we lean into medical decision-making, where the codes reflect the depth, complexity, and risk of what we actually do?”

There isn’t a single right answer, but in this blog, I make the case that medical decision-making is often the more accurate reflection of palliative care’s true value, and that learning to document and bill accordingly is not just compliance—it’s sustainability.

Palliative care is inherently complex. We see the sickest patients, treat their pain and other symptoms, help them make the hardest decisions, and coordinate care across fragmented systems. Yet our documentation and billing practices often undersell that complexity.

Most programs under-bill their encounters—not out of neglect, but because they default to time-based coding. After all, time feels easy to justify: “I spent 30 minutes with this patient and family.” But the reality is, most of that work involves high-level decision-making, risk management, and clinical judgment that isn’t captured by billing on time alone.

Chris Jones, MD, MBA, a longtime CAPC collaborator and a billing sage in our field, reminds us that accurate billing is not about maximizing revenue for its own sake. It’s about ensuring programs can support their full teams. Every under-coded physician or nurse practitioner visit represents potential dollars not reinvested in the social worker, chaplain, or nurse who completes the care model.

When your billing reflects the complexity of your work, you’re not “gaming the system.” You’re telling the system what you do, to get appropriately paid for the work you’re doing.

Let’s start with some basics.

Time-based billing allows you to select the evaluation and management (E/M) level (e.g., 99205 or 99215) based on the total time you personally spent on the date of the encounter. That can include face-to-face and some non-face-to-face time.

MDM-based billing selects the E/M level based on three components:

1. The number and severity of problems addressed
2. The amount and complexity of data reviewed and analyzed
3. The risk of morbidity, mortality, or complications related to management decisions

For years, documentation rules favored lengthy checklists, but in 2021, CMS and the AMA simplified this. Clinicians now choose between time or MDM—whichever best represents the work performed. This flexibility is a gift, but also a challenge. It requires making a conscious choice, and taking the time to understand how MDM works.

I have spent more hours than I’d like to admit talking about billing and emailing or Zooming with CAPC’s billing experts and hundreds of palliative care teams across the country. Over the years, a few consistent patterns have emerged:

• For the base visit, you can bill on time or MDM—but not both. Document according to the method you select. If you’re billing on MDM, don’t mention time in your note.
• Billing on MDM often aligns better with what palliative care actually does. We assess multiple complex conditions, integrate data from many sources, and manage high-risk decisions.
• Accurate billing enables access. Each incremental gain in appropriate revenue helps fund non-billable staff. As Chris says, “Good billing turns into help for your patients.” It also demonstrates strong financial management to your leaders.
• Advance Care Planning (ACP) codes are complementary. They can often be billed alongside E/M codes that use MDM; these can be billed on time, in addition to MDM billing when the discussion meets criteria and is documented correctly.

These principles have shaped how I teach billing to palliative care programs nationwide. It’s not just about picking a code; it’s about accurately describing the cognitive labor, clinical judgment, and coordination that define our field. Your billing should tell the same story that your progress note does, just to a different audience.

Let’s be clear: both billing methods have their place in palliative care.

Time-based billing makes sense when:

• The visit is primarily supportive or follow-up, with limited new data or decisions
• Most of your effort is spent on direct conversation, counseling, or care coordination
• The complexity is moderate, but the time exceeds typical thresholds (e.g., > 40 minutes for 99215)

MDM-based billing makes sense when:

• You’re evaluating a new, seriously ill patient with multiple comorbidities
• You’re interpreting data, synthesizing recommendations, or revising treatment plans
• You’re managing significant risk, prognostic uncertainty, symptom escalation, decisions about hospice, etc.
• Your documentation reflects decision points, not just time

Most palliative care visits meet moderate-to-high complexity criteria when documented properly. The trick is making that visible in your note.

If you decide to bill on MDM, here’s what your documentation should do:

Use descriptive language. Instead of “pain—stable,” write “pain—persistent, requiring opioid adjustment due to side effects.” Each qualifier tells the coder, and auditor, that the case required complexity and judgment.

Include labs, imaging, records, or discussions with other clinicians. In palliative care, this might be a review of hospital notes, oncology updates, or communication with a home health nurse. It all counts.

This is the heart of MDM. Did you adjust high-risk medications? (Yes, you do this all the time.) Discuss de-escalating treatment? Evaluate for hospice eligibility? Document the decisions, the alternatives considered, and the rationale.

A robust assessment and plan tie it all together: medication changes, follow-ups, ACP discussions, and coordination. Avoid generic language, show the thought process.

If you’re billing MDM, do not mention time spent. That can trigger confusion or down-coding.

Even though your social worker or chaplain’s work isn’t billable, referencing their involvement shows the full scope of care: “Social worker met with daughter to address caregiver burnout.” This reinforces the complexity and coordination that define palliative care.

The goal is not to inflate your note; it’s to make your thinking visible. Again, your billing should tell coders and auditors exactly what happened in that room, and your note needs to support that.

As my longtime colleague Donna Stevens reminds us, “your passion alone cannot sustain your program.” Our field’s long-term viability depends on more than good intentions. It depends on accurate revenue capture and transparent value demonstration.

Here’s what happens when you shift to MDM-based billing and documentation:

• Revenue increases modestly but meaningfully. Most teams find their average code level rises, not because they’re doing more, but because they’re documenting accurately.
  Here's what a team recently shared with us:
  • “We have provided education and guidance to our palliative care providers on evaluating the value of their visits, with a focus on complexity and MDM. We emphasized that many of our patients have complex diagnoses, which significantly impact their care. Our goal has been to align the quality of care provided with the level of complexity involved, rather than the amount of time spent during patient visits.
    
    By following this practice, we have seen an increase in reimbursement, as well as fewer denials for claims that include both E/M and ACP charges. It is important to note that we should not bill for two time-based services simultaneously. Since ACP can only be billed based on time, basing the E/M service on complexity resolves the issue of billing for two time-based services."
    
    Jennifer Yohman, Billing Specialist/Palliative Care,
    Jaclyn Reppert, Coding Education/Auditor/Palliative Care
    Palliative Care Services, Care Hospice
    

• New revenue funds team positions. Physicians and APPs indirectly support social work, nursing, and chaplaincy, roles essential to quality but often unfunded.

• Your data tells a better story. Complexity codes show hospital or agency leadership the intensity of your caseload. That’s leverage for expansion, contracting, and value-based partnerships.

• Staff morale improves. When clinicians see their cognitive and emotional labor recognized, it validates their work and reduces burnout.

Solution: Use a shared note template with MDM prompts (“Problems addressed,” “Data reviewed,” “Decisions made”). CAPC’s billing toolkit offers examples.

Solution: Teach clinicians to name the risk explicitly, “high risk for hospitalization if pain uncontrolled”, and to capture decisions made in response.

Solution: Re-train your team to recognize MDM opportunities. A 30-minute visit involving two medication changes, hospice discussion, and prognostic counseling is a level 5 by complexity, even if not a full hour.

Solution: Audit yourself first. Regular internal chart reviews, peer feedback, and education sessions protect against compliance issues.

Solution: Partner with your IT team to build documentation shortcuts that capture MDM elements naturally, rather than forcing “ROS/PE” fields that no longer matter for billing.

When you normalize this across the team, billing accuracy becomes part of your quality culture, not a side hustle.

For billing physicians looking to strengthen financial sustainability, start here:

See what proportion of your visits are time-based versus MDM. Most programs are surprised by how many visits could qualify for higher-level codes if documented differently.

Use CAPC’s recorded webinar, Billing and Coding for Palliative Care: Navigating New Opportunities (with Chris Jones and Phil Rodgers), as a shared learning session. Attend CAPC billing virtual office hours.

Build MDM prompts into your EHR. Remove unnecessary boilerplate.

Try it with one clinician or one site. Track revenue per visit, coding level, and denial rates.

Report back to staff how improved documentation directly funds program priorities, new social worker, education budget, or coverage expansion.

Review documentation quarterly. Accuracy is everything.

Within months, most programs find that their billing patterns shift naturally toward higher complexity levels—not because they’re gaming, but because they’re finally capturing the work they’ve always done.

Ultimately, this isn’t just an accounting exercise. It’s a culture shift.

When we bill based on time, we tell a story about duration. When we bill based on MDM, we tell a story about impact.

Time says, “I was present.”
MDM says, “I made complex decisions in a high-risk environment for a seriously ill patient and family.”

One describes effort; the other describes value. In a health care system still learning how to quantify what palliative care brings, that distinction matters.

Billing is part of your mission. It’s not separate from care, it’s how we sustain care.

Every accurately billed visit helps a team stay whole. Every properly documented decision helps leadership see the complexity of what we manage. Every revenue dollar captured with integrity supports the social worker who keeps a family out of crisis, the chaplain who brings calm, the nurse who prevents a readmission.

That’s why I believe palliative care should embrace medical decision-making as its default billing philosophy. It reflects what we do best: navigate complexity, align treatment with values, and manage risk in the face of uncertainty.

Bill on time when it makes sense. But when your visit involves layered decisions, cross-disciplinary coordination, and the hard work of guiding people through serious illness, make the case for your medical decision-making.

Because if we don’t, no one else will.

To learn more about billing and coding, I recommend the CAPC resources below:

• Billing and Coding toolkit
• On-demand billing webinars