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?
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.
members loginPalliative Care Billing and Coding Tip Sheet
Key concepts to get started. Center to Advance Palliative Care, 2018.
members loginBilling Outpatient Tip Sheet
Quick reference to help clinicians with clinic based outpatient billing and coding. Center to Advance Palliative Care, 2019.
members loginBilling Home Tip Sheet
Quick reference to help clinicians with home based billing and coding. Center to Advance Palliative Care, 2019.
members loginBilling Inpatient Tip Sheet
Quick reference to help clinicians with inpatient billing and coding. Center to Advance Palliative Care, 2019.
members loginAbout Health Insurance (excerpted from the CAPC Payment Primer)
How health insurance and health plans operate. Center to Advance Palliative Care, 2017.
members loginMedicare Billing Algorithm Example
Visual aide to determine if you are billing for an established or a new office visit. Peter R. Jensen, MD, CPC.
members loginSummary Structure - Medicare Part A and Part B
Diagram of which services are billed through Part A vs. Part B.
members loginHow to Bill for a Medicare Part B Provider
Guidance on Part B billing for community agencies. Palliative Care of the Bluegrass.
members loginBilling Worksheet
Sample worksheet describing potential billing revenue from Medicare patients seen in the hospital. Center to Advance Palliative Care, 2017.
members loginInpatient 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.
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)
Deep dive on time-based vs. complexity billing, including two case examples. Center to Advance Palliative Care, 2018.
members loginSetting-Based Evaluation and Management Table
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
Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.1.
downloadResource Tool for Documentation of Component Billing
Interpreting Medicare guidelines for billing by complexity. Center to Advance Palliative Care, 2018.
members loginDHHS 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.
downloadCommonly Used ICD-10 Codes for the Palliative Care Program
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)
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"
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)
Jones CA, Bull J, Acevedo J, Kamal AH. Journal of Palliative Medicine, 2015.
downloadMedicare Claims Processing Manual
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
Billing for prolonged services with direct face-to-face contact. Center to Advance Palliative Care, 2018.
members loginProlonged Services Without Direct Face-to-Face Patient Contact
Billing for prolonged services without direct face-to-face contact. Center to Advance Palliative Care, 2018.
members loginCMS 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.
downloadThreshold Time to Bill: Inpatient/Observation Table
Time spent cutoffs to bill prolonged services codes in the inpatient or observation setting. Center to Advance Palliative Care, 2018
members loginThreshold Time to Bill: Office/Outpatient Table
Time spent cutoffs to bill prolonged services codes in the outpatient or office setting. Center to Advance Palliative Care, 2018.
members loginRelative Value Unit (RVU) Comparison Table
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
Requirements, best practices, documentation requirements, and time thresholds for Advance Care Planning (ACP) services. Center to Advance Palliative Care, 2018.
members loginACP Billing Threshold Times
Length of time requirements for the Advance Care Planning service CPT codes. Center to Advance Palliative Care, 2018.
members loginRelative Value Units (RVUs) of Advance Care Planning
Shows the RVUs associated with each Advance Care Planning CPT code. Center to Advance Palliative Care, 2018.
members loginBilling the Physician Fee Schedule for Advance Care Planning Services
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)
Detail on the intricacies of ACP billing. Coding Leader, 2016.
downloadCMS Advance Care Planning
CMS Requirements for billing Advance Care Planning codes 99497 and 99498. Centers for Medicare and Medicaid Services, updated 2018.
downloadAdvance Care Planning Tool
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
Jones CA, Bull J, Acevedo J, Kamal AH. Journal of Palliative Medicine, 2015.
viewSample Policy: Advance Care Planning Billing
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
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
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
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.
members loginChronic 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.
downloadChronic 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).
downloadConsent Agreement
Sample consent agreement required for CCM and CCCM billing. ResolutionCare, 2018.
members loginCertification of Time Spent Sample
Sample certification of time spent, required for CCM and CCCM billing. ResolutionCare, 2018.
members loginCare Management Services Comparison Table
Summarizes the billing tools available for managing patients that need care management. Center to Advance Palliative Care, 2018.
members loginBilling for Services in the Community: Supplemental Resource Sheet
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)
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.
members loginCPO Medicare Claims Do's and Don't
Tips for billing CPO. Center to Advance Palliative Care, 2018.
members loginCare Management Services Comparison Table
Summarizes the billing tools available for managing patients that need care management. Center to Advance Palliative Care, 2018.
members loginBilling for Services in the Community: Supplemental Resource Sheet
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)
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.
members loginCare Management Services Comparison Table
Summarizes the billing tools available for managing patients that need care management. Center to Advance Palliative Care, 2018.
members loginDHHS Transitional Care Management Services
Department of Health and Human Services and Centers for Medicare and Medicaid Service 2016. Transitional Care Management Services.
downloadBilling for Services in the Community: Supplemental Resource Sheet
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
Which providers can bill, what codes apply, and what documentation is required for each.
members loginBilling and Coding for Critical Care Codes in the ICU and ED
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
Why RVUs exist, how they are calculated, and why they are important. Center to Advance Palliative Care, 2019.
members loginRVU 102: Exploring the Relationship Between Provider Work and Payment
Accurately capturing workload through RVUs, and calculating payment. Center to Advance Palliative Care, 2019.
members loginRVU 103: Work Smarter, Not Harder: Moving the Needle on RVUs
Steps palliative care teams can take to improve quality and efficiency to increase RVUs. Center to Advance Palliative Care, 2020.
members login2020 Work Relative Value Units (wRVU) Table: Palliative Care and Hospice
2020 listing of all wRVUs relevant to palliative care and hospice services. University of Pennsylvania Medicine.
members loginFaculty
Diane E. Meier, MD, FACP, FAAHPM
Director, Center to Advance Palliative Care
Andrew E. Esch, MD, MBA
Medical Education Consultant, Center to Advance Palliative Care
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
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