Optimizing Billing Practices
This toolkit has been updated for 2023. Check the virtual events calendar for additional billing Virtual Office Hours and Webinars.
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 Covering Costs and Generating Revenue toolkit.
What’s in the Toolkit
Recent Medicare Billing Updates
CMS changes and updates.
In this short webinar, Chris Jones, MD, provides a brief overview of the key 2023 changes to the billing and coding regulations that will affect clinicians who take care of patients with serious illness.
Summary of January 1, 2023 changes to the Medicare fee schedule, with a focus on relevant codes for the palliative care team.
Foundational Principles of Palliative Care Billing
Are you accurately billing for your services? This collection covers the fundamentals of palliative care billing.
A guide to navigating CAPC's billing and coding resources, with pathways for new and experienced palliative care professionals.
The basics of palliative care billing: billing terminology, who can bill, and strategies for reflecting the work of the palliative care team in Medicare billing.
Review of inpatient E/M codes, including time-based billing vs. medical decision-making, prolonged services, and inpatient billing case examples.
Review of outpatient E/M codes, including time-based billing vs. medical decision-making, prolonged services, and outpatient billing case examples.
A summary document of Medicare-reimbursable codes for telehealth and telephone encounters.
At-a-glance Medicare RVUs and national non-facility payments for codes commonly used by community-based palliative care programs.
How the interdisciplinary team can bill, and the differences between Advanced Practice Provider (APP) independent and APP 'incident to' or 'shared visits' billing.
Monograph introducing U.S. health insurance with a focus on Medicare and what it means for palliative care.
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.
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.
The basics of palliative care billing: billing terminology, who can bill, and strategies for reflecting the work of the palliative care team in Medicare billing.
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.
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.
A summary document of Medicare-reimbursable codes for telehealth and telephone encounters.
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.
Overview of the Principal Care Management (PCM) billing codes and requirements. Updated 2023.
Billing for CCM and CCCM, including patient eligibility, which providers can bill, required documentation, and tips for avoiding claim denials. Updated January 2023.
This webinar examines how CCM & CCCM are critical components of coordinated care that contribute to better outcomes and higher satisfaction for patients.
Tips for getting started, requirements for implementing a CCM program, and materials to share with patients.
Sample consent agreement required for CCM and CCCM billing. ResolutionCare, 2018.
Sample certification of time spent, required for CCM and CCCM billing. ResolutionCare, 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. Updated January 2023.
Tips for billing CPO. Center to Advance Palliative Care, 2018.
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. Updated January 2023.
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)
Relevant billing codes for palliative care in the ICU and the ED have changed as of 1/1/23. New resources on billing will be posted to CAPC's toolkit very soon.
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.
Summary of January 1, 2023 changes to the Medicare fee schedule, with a focus on relevant codes for the palliative care team.
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.
2023 at-a-glance listing of all wRVUs relevant to palliative care and hospice services across settings.
Simple interactive tool for estimating annual wRVU volume ranges with customizable assumptions. Data from 2023 CMS RVU tables (as of 12/19/22).
Faculty
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Diane E. Meier, MD, FACP, FAAHPM
Founder, Director Emerita and Strategic Medical Advisor, Center to Advance Palliative Care
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Andrew E. Esch, MD, MBA
Senior Education Advisor
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Constance Dahlin, MSN, ANP-BC, ACHPN, FPCN, FAAN
Consultant
Center to Advance Palliative Care -
Nancy Guinn, MD
Consultant, Center to Advance Palliative Care
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Phillip Rodgers, MD, FAAHPM
George A. Dean, M.D. Chair of Family Medicine
Professor of Family Medicine and Internal Medicine
Di… -
Nadine Marshall, LMSW, MSc
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Christopher A. Jones, MD, MBA
Director of Outpatient Palliative Care at Duke Health System
Virtual Office Hours
Inpatient Billing and Coding
