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

Are you accurately billing for your services? This collection covers the fundamentals of palliative care billing.

The Palliative Care Team: Who Can Bill?
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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.

Palliative Care Billing and Coding Tip Sheet
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Key concepts to get started. Center to Advance Palliative Care, 2018.

Billing Outpatient Tip Sheet
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Quick reference to help clinicians with clinic based outpatient billing and coding. Center to Advance Palliative Care, 2019.

Billing Home Tip Sheet
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Quick reference to help clinicians with home based billing and coding. Center to Advance Palliative Care, 2019.

Billing Inpatient Tip Sheet
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Quick reference to help clinicians with inpatient billing and coding. Center to Advance Palliative Care, 2019.

Payment Quick Tips: Understanding Medicare, Medicaid, and Commercial Insurance
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US health insurance and what it means for palliative care. Center to Advance Palliative Care, 2019.

Medicare Billing Algorithm Example
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Visual aide to determine if you are billing for an established or a new office visit. Peter R. Jensen, MD, CPC.

Summary Structure - Medicare Part A and Part B
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Diagram of which services are billed through Part A vs. Part B.

How to Bill for a Medicare Part B Provider
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Guidance on Part B billing for community agencies. Palliative Care of the Bluegrass.

Billing Worksheet
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Sample worksheet describing potential billing revenue from Medicare patients seen in the hospital. Center to Advance Palliative Care, 2017.

Inpatient Billing and Coding

In this Virtual Office Hour, expert faculty will explore commonly asked inpatient palliative care billing questions and describe billing and coding practices.

Billing 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.

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)
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Deep dive on time-based vs. complexity billing, including two case examples. Center to Advance Palliative Care, 2018.

Setting-Based Evaluation and Management Table
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E/M codes by setting and unit of time. Center to Advance Palliative Care, 2018.

National Government Services Evaluation and Management Documentation Training Tool

Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.1.

Resource Tool for Documentation of Component Billing
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Interpreting Medicare guidelines for billing by complexity. Center to Advance Palliative Care, 2018.

DHHS Evaluation and Management Services Guide

Department of Health and Human Services and Centers for Medicare and Medicaid Service 2017 Evaluation and Management Services Guide. 2017.

Commonly Used ICD-10 Codes for the Palliative Care Program
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Common ICD-10 codes for palliative care patient encounters. Center to Advance Palliative Care, 2018

ICD-10 CM Official Guidelines for Coding and Reporting (2018)

Center for Medicare and Medicaid Services and National Center for Health Statistics, 2018 ICD-10 CM Official Guidelines for Coding and Reporting.

Top Ten Inpatient Palliative Medicine Billing and Coding Mistakes (and How to Fix Them This Week)

Jones CA, Bull J, Acevedo J, Kamal AH. Journal of Palliative Medicine, 2015.

Medicare Claims Processing Manual

Centers for Medicare & Medicaid Services. Revised October 2017.

Which face-to-face and which non-face-to-face prolonged services can be billed?

Prolonged Services Billing With Face-to-Face Patient Contact
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Billing for prolonged services with direct face-to-face contact. Center to Advance Palliative Care, 2018.

Prolonged Services Without Direct Face-to-Face Patient Contact
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Billing for prolonged services without direct face-to-face contact. Center to Advance Palliative Care, 2018.

CMS Prolonged Services Update (2017)

On changes to using CPT codes 99358 and 99359 for "non face-to-face" prolonged services. Center for Medicare and Medicaid Services, updated 2017.

Threshold Time to Bill: Inpatient/Observation Table
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Time spent cutoffs to bill prolonged services codes in the inpatient or observation setting. Center to Advance Palliative Care, 2018

Threshold Time to Bill: Office/Outpatient Table
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Time spent cutoffs to bill prolonged services codes in the outpatient or office setting. Center to Advance Palliative Care, 2018.

Relative Value Unit (RVU) Comparison Table
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Differentiates a patient visit type and CPT code by its RVU. Center to Advance Palliative Care, 2018.

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
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Requirements, best practices, documentation requirements, and time thresholds for Advance Care Planning (ACP) services. Center to Advance Palliative Care, 2018.

ACP Billing Threshold Times
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Length of time requirements for the Advance Care Planning service CPT codes. Center to Advance Palliative Care, 2018.

Relative Value Units (RVUs) of Advance Care Planning
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Shows the RVUs associated with each Advance Care Planning CPT code. Center to Advance Palliative Care, 2018.

Billing the Physician Fee Schedule for Advance Care Planning Services
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One-page reference guide to billing for advance care planning conversations. Center to Advance Palliative Care and Acevedo Consulting, August 2016.

Advance Care Planning (The ABCs of Getting Paid)

Detail on the intricacies of ACP billing. Coding Leader, 2016.

CMS Advance Care Planning

CMS Requirements for billing Advance Care Planning codes 99497 and 99498. Centers for Medicare and Medicaid Services, updated 2018.

Advance Care Planning Tool
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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.

Top 10 Tips for Using Advance Care Planning Codes in Palliative Medicine and Beyond

Jones CA, Bull J, Acevedo J, Kamal AH. Journal of Palliative Medicine, 2015.

Sample Policy: Advance Care Planning Billing
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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

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 ACP Fact Sheet

CMS Medicare Learning Network guidance for advance care planning billing and coding. CMS, August 2019.

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.

Principal Care Management (PCM)
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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 and Coding for Chronic Care Management (CCM) & Complex Chronic Care Management (CCCM) Codes
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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.

Chronic Care Management in Practice: How, When, and Why to use the CCM & CCCM Codes to Maximize Provider Reimbursement
Connected Care: Health Care Professional Toolkit

Tips for getting started, requirements for implementing a CCM program, and materials to share with patients.

Chronic Care Management Services Changes for 2017

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).

Consent Agreement
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Sample consent agreement required for CCM and CCCM billing. ResolutionCare, 2018.

Certification of Time Spent Sample
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Sample certification of time spent, required for CCM and CCCM billing. ResolutionCare, 2018.

Care Management Services Comparison Table
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Summarizes the billing tools available for managing patients that need care management. Center to Advance Palliative Care, updated 2020.

Billing for Services in the Community: Supplemental Resource Sheet
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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.

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)
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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.

CPO Medicare Claims Do's and Don't
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Tips for billing CPO. Center to Advance Palliative Care, 2018.

Care Management Services Comparison Table
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Summarizes the billing tools available for managing patients that need care management. Center to Advance Palliative Care, updated 2020.

Billing for Services in the Community: Supplemental Resource Sheet
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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.

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)
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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.

Care Management Services Comparison Table
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Summarizes the billing tools available for managing patients that need care management. Center to Advance Palliative Care, updated 2020.

DHHS Transitional Care Management Services

Department of Health and Human Services and Centers for Medicare and Medicaid Service 2016. Transitional Care Management Services.

Billing for Services in the Community: Supplemental Resource Sheet
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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 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
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Which providers can bill, what codes apply, and what documentation is required for each.

Billing and Coding for Critical Care Codes in the ICU and ED
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Patient eligibility, which providers can bill, understanding time-based billing, and what documentation is required.

Billing for palliative care services in long-term care facilities.

Skilled Nursing Facility (SNF) and Nursing Facility (NF) Billing and Coding
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Billing practices that reflect the complexity of palliative care services delivered in skilled nursing facilities and nursing homes. Center to Advance Palliative Care, 2020.

Understanding the complex relationship between palliative care workflow, billing, and RVUs.

RVUs 101
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Why RVUs exist, how they are calculated, and why they are important. Center to Advance Palliative Care, 2019.

RVU 102: Exploring the Relationship Between Provider Work and Payment
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Accurately capturing workload through RVUs, and calculating payment. Center to Advance Palliative Care, 2019.

RVU 103: Work Smarter, Not Harder: Moving the Needle on RVUs
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Steps palliative care teams can take to improve quality and efficiency to increase RVUs. Center to Advance Palliative Care, 2020.

2020 Work Relative Value Units (wRVU) Table: Palliative Care and Hospice
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2020 listing of all wRVUs relevant to palliative care and hospice services. University of Pennsylvania Medicine.