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

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

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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.

Billing 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.

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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.

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Guidance on time-based and complexity billing.

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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.

National 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.

DHHS 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

ICD-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.

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"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.

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Top 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.

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Medicare Claims Processing Manual

Last Updated: February 3, 2019

Centers for Medicare & Medicaid Services. Revised October 2017.

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

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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.

CMS 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.

How to bill for ACP services and capture Relative Value Units (RVUs) for this valuable work.

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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.

Advance Care Planning (The ABCs of Getting Paid)

Last Updated: February 3, 2019

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

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CMS 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.

Top 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.

Building 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.

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CMS ACP Fact Sheet

Last Updated: September 27, 2019

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

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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.

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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.

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

Last Updated: July 18, 2019

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Connected 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.

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Chronic 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.

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.

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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.

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.

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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.

DHHS 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.

Billing practices that reflect the complexity of palliative care services delivered in the ICU and the ED.

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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.

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

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RVUs 101

Last Updated: November 8, 2019

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

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Presented By

Philip H. Santa-Emma

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