Optimizing Billing Practices
Last Reviewed: March 4, 2019
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.
What’s in the Toolkit
Foundational Principles of Palliative Care Billing
Are you accurately billing for your services? This collection covers the fundamentals of palliative care billing.
The Palliative Care Team: Who Can Bill?
Last Updated: February 3, 2019
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.
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Palliative Care Billing and Coding Tip Sheet
Last Updated: February 3, 2019
Key concepts to get started. Center to Advance Palliative Care, 2018.
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Billing Outpatient Tip Sheet
Last Updated: September 5, 2019
Quick reference to help clinicians with clinic based outpatient billing and coding. Center to Advance Palliative Care, 2019.
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Billing Home Tip Sheet
Last Updated: September 5, 2019
Quick reference to help clinicians with home based billing and coding. Center to Advance Palliative Care, 2019.
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Billing Inpatient Tip Sheet
Last Updated: October 11, 2019
Quick reference to help clinicians with inpatient billing and coding. Center to Advance Palliative Care, 2019.
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About Health Insurance (excerpted from the CAPC Payment Primer)
Last Updated: February 24, 2019
How health insurance and health plans operate. Center to Advance Palliative Care, 2017.
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Medicare Billing Algorithm Example
Last Updated: February 3, 2019
Visual aide to determine if you are billing for an established or a new office visit. Peter R. Jensen, MD, CPC.
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Summary Structure - Medicare Part A and Part B
Last Updated: February 3, 2019
Diagram of which services are billed through Part A vs. Part B.
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How to Bill for a Medicare Part B Provider
Last Updated: February 3, 2019
Guidance on Part B billing for community agencies. Palliative Care of the Bluegrass.
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Billing Worksheet
Last Updated: February 3, 2019
Sample worksheet describing potential billing revenue from Medicare patients seen in the hospital. Center to Advance Palliative Care, 2017.
members loginBilling and RVUs in Hospital-Based Palliative Care
In this Virtual Office Hour, ask questions about when to bill for certain services, which codes to use, and other reimbursement topics.
registerBilling for Community-Based Palliative Care
In this Virtual Office Hour, ask questions about billing for services provided in the home, office, or long-term care setting.
registerEvaluation and Management (E/M)
Guidance on time-based and complexity billing.
Elements of Evaluation and Management (E/M) Billing and Coding: ICD-10, Complexity vs. Time-Based Billing, and Place of Service (POS)
Last Updated: May 24, 2019
Deep dive on time-based vs. complexity billing, including two case examples. Center to Advance Palliative Care, 2018.
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Setting-Based Evaluation and Management Table
Last Updated: February 3, 2019
E/M codes by setting and unit of time. Center to Advance Palliative Care, 2018.
members loginNational Government Services Evaluation and Management Documentation Training Tool
Last Updated: February 3, 2019
Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.1.
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Resource Tool for Documentation of Component Billing
Last Updated: February 3, 2019
Interpreting Medicare guidelines for billing by complexity. Center to Advance Palliative Care, 2018.
members loginDHHS Evaluation and Management Services Guide
Last Updated: February 3, 2019
Department of Health and Human Services and Centers for Medicare and Medicaid Service 2017 Evaluation and Management Services Guide. 2017.
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Commonly Used ICD-10 Codes for the Palliative Care Program
Last Updated: February 3, 2019
Common ICD-10 codes for palliative care patient encounters. Center to Advance Palliative Care, 2018
members loginICD-10 CM Official Guidelines for Coding and Reporting (2018)
Last Updated: February 3, 2019
Center for Medicare and Medicaid Services and National Center for Health Statistics, 2018 ICD-10 CM Official Guidelines for Coding and Reporting.
download"Quick Take on the 2017 Medicare Physician Fee Schedule: 5 Things You Should Know"
Last Updated: February 3, 2019
Highlights the 5 key Medicare FFS opportunities for palliative care. AAHPM Blog, 2016.
viewTop Ten Inpatient Palliative Medicine Billing and Coding Mistakes (and How to Fix Them This Week)
Last Updated: February 3, 2019
Jones CA, Bull J, Acevedo J, Kamal AH. Journal of Palliative Medicine, 2015.
downloadMedicare Claims Processing Manual
Last Updated: February 3, 2019
Centers for Medicare & Medicaid Services. Revised October 2017.
viewProlonged Services
Which face-to-face and which non-face-to-face prolonged services can be billed?
Prolonged Services Billing With Face-to-Face Patient Contact
Last Updated: February 3, 2019
Billing for prolonged services with direct face-to-face contact. Center to Advance Palliative Care, 2018.
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Prolonged Services Without Direct Face-to-Face Patient Contact
Last Updated: February 3, 2019
Billing for prolonged services without direct face-to-face contact. Center to Advance Palliative Care, 2018.
members loginCMS Prolonged Services Update (2017)
Last Updated: February 3, 2019
On changes to using CPT codes 99358 and 99359 for "non face-to-face" prolonged services. Center for Medicare and Medicaid Services, updated 2017.
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Threshold Time to Bill: Inpatient/Observation Table
Last Updated: February 3, 2019
Time spent cutoffs to bill prolonged services codes in the inpatient or observation setting. Center to Advance Palliative Care, 2018
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Threshold Time to Bill: Office/Outpatient Table
Last Updated: February 3, 2019
Time spent cutoffs to bill prolonged services codes in the outpatient or office setting. Center to Advance Palliative Care, 2018.
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Relative Value Unit (RVU) Comparison Table
Last Updated: February 3, 2019
Differentiates a patient visit type and CPT code by its RVU. Center to Advance Palliative Care, 2018.
members loginAdvance Care Planning (ACP)
How to bill for ACP services and capture Relative Value Units (RVUs) for this valuable work.
Billing and Coding for Advance Care Planning (ACP) Services
Last Updated: February 28, 2019
Requirements, best practices, documentation requirements, and time thresholds for Advance Care Planning (ACP) services. Center to Advance Palliative Care, 2018.
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ACP Billing Threshold Times
Last Updated: February 3, 2019
Length of time requirements for the Advance Care Planning service CPT codes. Center to Advance Palliative Care, 2018.
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Relative Value Units (RVUs) of Advance Care Planning
Last Updated: February 3, 2019
Shows the RVUs associated with each Advance Care Planning CPT code. Center to Advance Palliative Care, 2018.
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Billing the Physician Fee Schedule for Advance Care Planning Services
Last Updated: February 3, 2019
One-page reference guide to billing for advance care planning conversations. Center to Advance Palliative Care and Acevedo Consulting, August 2016.
members loginAdvance Care Planning (The ABCs of Getting Paid)
Last Updated: February 3, 2019
Detail on the intricacies of ACP billing. Coding Leader, 2016.
downloadCMS Advance Care Planning
Last Updated: February 3, 2019
CMS Requirements for billing Advance Care Planning codes 99497 and 99498. Centers for Medicare and Medicaid Services, updated 2018.
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Advance Care Planning Tool
Last Updated: August 20, 2019
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.
members loginTop 10 Tips for Using Advance Care Planning Codes in Palliative Medicine and Beyond
Last Updated: February 3, 2019
Jones CA, Bull J, Acevedo J, Kamal AH. Journal of Palliative Medicine, 2015.
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Sample Policy: Advance Care Planning Billing
Last Updated: February 3, 2019
Example of institutional policy to guide clinicians in providing and billing for ACP services. Shared by Mount Sinai Hospital (Hertzberg Palliative Care Institute), 2016.
members loginBuilding Physician Skills in Basic Advance Care Planning
Last Updated: September 5, 2019
This CAPC curriculum, 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.
viewCMS ACP Fact Sheet
Last Updated: September 27, 2019
CMS Medicare Learning Network guidance for advance care planning billing and coding. CMS, August 2019.
viewChronic 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.
Billing and Coding for Chronic Care Management (CCM) & Complex Chronic Care Management (CCCM) Codes
Last Updated: February 3, 2019
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, 2018.
members loginChronic Care Management in Practice: How, When, and Why to use the CCM & CCCM Codes to Maximize Provider Reimbursement
Last Updated: July 18, 2019
watchConnected Care: Health Care Professional Toolkit
Last Updated: February 3, 2019
Tips for getting started, requirements for implementing a CCM program, and materials to share with patients.
downloadChronic Care Management Services Changes for 2017
Last Updated: February 3, 2019
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).
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Consent Agreement
Last Updated: February 24, 2019
Sample consent agreement required for CCM and CCCM billing. ResolutionCare, 2018.
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Certification of Time Spent Sample
Last Updated: February 24, 2019
Sample certification of time spent, required for CCM and CCCM billing. ResolutionCare, 2018.
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Care Management Services Comparison Table
Last Updated: February 3, 2019
Summarizes the billing tools available for managing patients that need care management. Center to Advance Palliative Care, 2018.
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Billing for Services in the Community: Supplemental Resource Sheet
Last Updated: February 3, 2019
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.
members loginCare 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.
Billing and Coding for Care Plan Oversight (CPO)
Last Updated: February 3, 2019
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, 2018.
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CPO Medicare Claims Do's and Don't
Last Updated: February 3, 2019
Tips for billing CPO. Center to Advance Palliative Care, 2018.
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Care Management Services Comparison Table
Last Updated: February 3, 2019
Summarizes the billing tools available for managing patients that need care management. Center to Advance Palliative Care, 2018.
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Billing for Services in the Community: Supplemental Resource Sheet
Last Updated: February 3, 2019
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.
members loginTransitional 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 and Coding for Transitional Care Management (TCM)
Last Updated: February 3, 2019
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, 2018.
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Care Management Services Comparison Table
Last Updated: February 3, 2019
Summarizes the billing tools available for managing patients that need care management. Center to Advance Palliative Care, 2018.
members loginDHHS Transitional Care Management Services
Last Updated: February 3, 2019
Department of Health and Human Services and Centers for Medicare and Medicaid Service 2016. Transitional Care Management Services.
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Billing for Services in the Community: Supplemental Resource Sheet
Last Updated: February 3, 2019
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.
members loginBilling 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.
Billing For Palliative Care Consultation in the Emergency Department
Last Updated: February 3, 2019
Which providers can bill, what codes apply, and what documentation is required for each.
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Billing and Coding for Critical Care Codes in the ICU and ED
Last Updated: February 3, 2019
Patient eligibility, which providers can bill, understanding time-based billing, and what documentation is required.
members loginRelative Value Units (RVUs)
Understanding the complex relationship between palliative care workflow, billing, and RVUs.
RVUs 101
Last Updated: November 26, 2019
Why RVUs exist, how they are calculated, and why they are important. Center to Advance Palliative Care, 2019.
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RVU 102: Exploring the Relationship Between Provider Work and Payment
Last Updated: December 10, 2019
Accurately capturing workload through RVUs, and calculating payment. Center to Advance Palliative Care, 2019.
members loginFaculty
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Diane E. Meier, MD, FACP, FAAHPM
Director, Center to Advance Palliative Care
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Andrew E. Esch, MD, MBA
Medical Education Consultant, 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
Education Program Manager
Related Toolkits See all 29 toolkits
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Includes 28 resources:
- Palliative Care Impact
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- Measurement
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Toolkit for building a business plan and budget, forming financial partnerships, and operating the program efficiently.
Includes 49 resources:
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