Optimizing Billing Practices
Optimized billing and coding are critical to the financial stability of the palliative care program. Palliative care providers can bill for Part B Professional Services, and revenue from billing often covers a substantial portion of direct costs (staff time).
The degree to which you can cover costs billing fee-for-service (FFS) is impacted by:
- Quality of documentation and billing processes
- Mix of team members—who on the team can bill for services, and which staff are counted in your direct costs
- Place of service (care setting)
- Contracts with payers and payer mix
- Proportion of time spent on direct patient care vs. other activities (such as education) that may impact patient care but not be billable
Programs must seek specific interpretation and advice from their local billing staff and regional payer and CMS administrators.
Looking for more information about financing your palliative care program? Browse CAPC's toolkit.
What’s in the Toolkit
CMS 2021 Updates
Year 2021 CMS changes and updates.
This slide deck covers the billing updates from CMS for the calendar year 2021 that will impact providers taking care of patients with serious illness.
Foundational Principles of Palliative Care Billing
Are you accurately billing for your services? This collection covers the fundamentals of palliative care billing.
How the interdisciplinary team can bill, and the differences between Advanced Practice Provider (APP) independent and APP 'incident to' or 'shared visits' billing. Center to Advance Palliative Care, March 2018.
Key concepts to get started. Center to Advance Palliative Care, 2018.
Quick reference to help clinicians with clinic based outpatient billing and coding. Center to Advance Palliative Care, 2019.
Quick reference to help clinicians with home based billing and coding. Center to Advance Palliative Care, 2019.
Quick reference to help clinicians with inpatient billing and coding. Center to Advance Palliative Care, 2019.
US health insurance and what it means for palliative care. Center to Advance Palliative Care, 2019.
Visual aide to determine if you are billing for an established or a new office visit. Peter R. Jensen, MD, CPC.
Diagram of which services are billed through Part A vs. Part B.
Guidance on Part B billing for community agencies. Palliative Care of the Bluegrass.
Sample worksheet describing potential billing revenue from Medicare patients seen in the hospital. Center to Advance Palliative Care, 2017.
In this Virtual Office Hour, expert faculty will explore commonly asked inpatient palliative care billing questions and describe billing and coding practices.
In this Virtual Office Hour, ask questions about billing for services provided in the home, office, or long-term care setting.
A slide deck detailing the opportunities and considerations for palliative care teams billing for social work services. Courtesy of Brandi Rutan, LCSW, LISW-CP, Four Seasons Clinical Social Worker and Tranquil Counseling & Consulting, LLC and Christine Lau, RN, LCSW, APHSW-C, Sr. Director of Serious Illness Care Management for Teleios and VP of Operations for UNC Community Palliative Care
Evaluation and Management (E/M)
Guidance on time-based and complexity billing.
Deep dive on time-based vs. complexity billing, including two case examples. Center to Advance Palliative Care, 2018.
E/M codes by setting and unit of time. Center to Advance Palliative Care, 2018.
Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.1.
Interpreting Medicare guidelines for billing by complexity. Center to Advance Palliative Care, 2018.
Department of Health and Human Services and Centers for Medicare and Medicaid Service 2017 Evaluation and Management Services Guide. 2017.
Common ICD-10 codes for palliative care patient encounters. Center to Advance Palliative Care, 2018
Center for Medicare and Medicaid Services and National Center for Health Statistics, 2018 ICD-10 CM Official Guidelines for Coding and Reporting.
Jones CA, Bull J, Acevedo J, Kamal AH. Journal of Palliative Medicine, 2015.
Centers for Medicare & Medicaid Services. Revised October 2017.
A slide deck that reviews the why, what, and how of Medicare payment for telehealth and telephone encounters during the COVID-19 public health emergency.
Prolonged Services
Which face-to-face and which non-face-to-face prolonged services can be billed?
Billing for prolonged services with direct face-to-face contact. Center to Advance Palliative Care, 2018.
Billing for prolonged services without direct face-to-face contact. Center to Advance Palliative Care, 2018.
On changes to using CPT codes 99358 and 99359 for "non face-to-face" prolonged services. Center for Medicare and Medicaid Services, updated 2017.
Time spent cutoffs to bill prolonged services codes in the inpatient or observation setting. Center to Advance Palliative Care, 2018
Time spent cutoffs to bill prolonged services codes in the outpatient or office setting. Center to Advance Palliative Care, 2018.
Differentiates a patient visit type and CPT code by its RVU. Center to Advance Palliative Care, 2018.
Advance Care Planning (ACP)
How to bill for ACP services and capture Relative Value Units (RVUs) for this valuable work.
Requirements, best practices, documentation requirements, and time thresholds for Advance Care Planning (ACP) services. Center to Advance Palliative Care, 2018.
Length of time requirements for the Advance Care Planning service CPT codes. Center to Advance Palliative Care, 2018.
Shows the RVUs associated with each Advance Care Planning CPT code. Center to Advance Palliative Care, 2018.
One-page reference guide to billing for advance care planning conversations. Center to Advance Palliative Care and Acevedo Consulting, August 2016.
Detail on the intricacies of ACP billing. Coding Leader, 2016.
CMS Requirements for billing Advance Care Planning codes 99497 and 99498. Centers for Medicare and Medicaid Services, updated 2018.
Incorporates coding, compliance, and CPT II Codes, which can be added for certain preventive care services and test results to more easily track patients and visits. Trinity Health, 2019.
Jones CA, Bull J, Acevedo J, Kamal AH. Journal of Palliative Medicine, 2015.
Example of institutional policy to guide clinicians in providing and billing for ACP services. Shared by Mount Sinai Hospital (Hertzberg Palliative Care Institute), 2016.
Building Physician Skills in Basic Advance Care Planning, includes three courses intended to build person-centered advance care planning (ACP) skills for physicians and advanced practitioners.
CMS Medicare Learning Network guidance for advance care planning billing and coding. CMS, August 2019.
Dementia Care: Cognitive Assessment and Care Planning
Applicable services, how to bill, and documentation requirements for cognitive assessment and care planning for people living with dementia.
Principal Care Management, Chronic Care Management and Complex Chronic Care Management
Palliative care teams often manage and coordinate care for complex patients with multiple chronic conditions. Learn how to bill for the services you are already providing to patients.
New 2020 billing program offered by the Center for Medicare Services (CMS) called Principal Care Management ( PCM). PCM offers additional care to patients with a single, serious chronic condition. Center to Advance Palliative Care, 2020.
Billing for CCM and CCCM, including patient eligibility, which providers can bill, required documentation, and tips for avoiding claim denials. Center to Advance Palliative Care, updated May 2020.
Tips for getting started, requirements for implementing a CCM program, and materials to share with patients.
2017 update from the Department of Health and Human Services and Centers for Medicare & Medicaid Services. Note: The information in this publication applies only to the Medicare Fee-For-Service Program (also known as Original Medicare).
Sample consent agreement required for CCM and CCCM billing. ResolutionCare, 2018.
Sample certification of time spent, required for CCM and CCCM billing. ResolutionCare, 2018.
Summarizes the billing tools available for managing patients that need care management. Center to Advance Palliative Care, updated 2020.
Information for community-based providers about about care plan oversite, transitional care management, and chronic and complex care management. Center to Advance Palliative Care, 2018.
Care Plan Oversight (CPO)
CPO codes are used when managing and coordinating care for patients in Certified Home Health or Hospice agencies. Learn the fundamentals of billing for CPO: who is eligible, who can bill, and what is required.
Care Plan Oversight: who is eligible, who can provide the service, and required service and documentation elements for successful reimbursement. Center to Advance Palliative Care, updated May 2020.
Tips for billing CPO. Center to Advance Palliative Care, 2018.
Summarizes the billing tools available for managing patients that need care management. Center to Advance Palliative Care, updated 2020.
Information for community-based providers about about care plan oversite, transitional care management, and chronic and complex care management. Center to Advance Palliative Care, 2018.
Transitional Care Management (TCM)
TCM codes are used when managing and coordinating care for patients transitioning from hospitals or other facilities back into the community. Learn the fundamentals of billing for TCM: who is eligible, who can bill, and what is required.
Billing for patients transitioning from institutions to the community. Includes which patients are eligible, required services, who can provide services, who can bill, documentation requirements, and mistakes to avoid. Center to Advance Palliative Care, updated May 2020.
Summarizes the billing tools available for managing patients that need care management. Center to Advance Palliative Care, updated 2020.
Department of Health and Human Services and Centers for Medicare and Medicaid Service 2016. Transitional Care Management Services.
Information for community-based providers about about care plan oversite, transitional care management, and chronic and complex care management. Center to Advance Palliative Care, 2018.
Billing for Palliative Care in the Intensive Care Unit (ICU) and the Emergency Department (ED)
Billing practices that reflect the complexity of palliative care services delivered in the ICU and the ED.
Which providers can bill, what codes apply, and what documentation is required for each.
Patient eligibility, which providers can bill, understanding time-based billing, and what documentation is required.
Long-Term Care
Billing for palliative care services in long-term care facilities.
Billing practices that reflect the complexity of palliative care services delivered in skilled nursing facilities and nursing homes. Center to Advance Palliative Care, 2020.
Relative Value Units (RVUs)
Understanding the complex relationship between palliative care workflow, billing, and RVUs.
Why RVUs exist, how they are calculated, and why they are important. Center to Advance Palliative Care, 2019.
Accurately capturing workload through RVUs, and calculating payment. Center to Advance Palliative Care, 2019.
Steps palliative care teams can take to improve quality and efficiency to increase RVUs. Center to Advance Palliative Care, 2020.
2021 listing of all wRVUs relevant to palliative care and hospice services. Duke University
Faculty
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Diane E. Meier, MD, FACP, FAAHPM
Director Emerita and Strategic Medical Advisor, Center to Advance Palliative Care
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Andrew E. Esch, MD, MBA
Vice President, Education, Center to Advance Palliative Care
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Constance Dahlin, MSN, ANP-BC, ACHPN, FPCN, FAAN
Consultant
Center to Advance Palliative Care -
Nancy Guinn, MD
Medical Director, Presbyterian Healthcare at Home
Lead, Palliative Care Leadership Centers™ (Presbyt… -
Phillip Rodgers, MD, FAAHPM
Associate Professor, Family Medicine and Internal Medicine
Director, Adult Palliative Medicine Clin… -
Nadine Marshall, LMSW, MSc
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Christopher A. Jones, MD, MBA
Director of Outpatient Palliative Care at Duke Health System
