CARE DELIVERY MODELS have been evolving for many years, with new types of services introduced regularly. While new services may benefit patients, they can create major billing challenges for the clinicians who provide them. Say hello to palliative care.
Palliative care is one of those emerging specialties, and hospitalists made nearly half (48%) of all palliative care referrals in 2015, according to a recent report.
But contrary to what some believe, palliative care is not the same as hospice. Unlike hospice, palliative care services do not focus on terminal illness and dying. Instead, they emphasize meeting the physical, emotional and spiritual needs of individuals and families facing serious, chronic or life-threatening illness.
Make sure your documentation clearly supports the medical necessity for palliative care services.
But clinicians can run into operational problems when billing for palliative care. That’s because those services are often closely aligned with hospice care and, sometimes, the service lines become blurred. This creates the perfect opportunity for claim denials.
Another problem: Unlike critical care or observation care, palliative care doesn’t come with its own set of specific CPT or HCPCS codes that you can report. How, then, should you bill for these services to give yourself the best chance of being paid?
Numbers to use
First, before you refer a patient to palliative care or provide such services yourself, verify whether or not the patient has elected for hospice.
That may affect what services you can bill for and where you need to submit claims. And if a patient has elected hospice and clinicians are managing a condition unrelated to that patient’s terminal illness, Medicare requires them to append a modifier to the service being reported.
When billing for palliative care, make sure the clinicians providing those services are appropriately credentialed in hospice and palliative medicine. (Both the American Board of Medical Specialties and the American Academy of Hospice and Palliative Medicine, for instance, offer certification programs.) In addition to a provider’s NPI number, Medicare has assigned a specialty code (17) for this type of provider.
Further, hospice and palliative care both come with specific taxonomy numbers, depending on the credential of the individual provider (such as an MD, DO or NPP). Using the specialty code and the right taxonomy number helps ensure timely, appropriate adjudication of claims.
Speaking of numbers: Make sure you report the evaluation and management (E/M) service codes that apply to the setting in which you’re providing palliative care. These services can be delivered in many different locations: acute care hospital, skilled nursing facility, nursing home or assisted living, outpatient office, or a patient’s home. Each location has its own set of CPT codes for reporting E/M services.
Spell out who is doing what
If you work as a palliative care consultant, make sure the attending physician or specialist makes a formal written request for you to evaluate the patient. If you are being asked to manage a specific problem, that formal request is not strictly necessary, but it will help support the medical necessity of your services.
You also need to make sure your documentation in the medical record clearly supports the medical necessity for palliative care services. Because these services may be subject to payers’ pre- or post-payment reviews, the medical record needs to demonstrate not only the specific conditions you are managing for the patient, but why.
At the same time, avoid duplicating clinical efforts or producing conflicting treatment plans. Each specialty involved in the care of a patient must make it very clear which condition(s) each is responsible for managing. Further, each provider should submit the diagnosis he or she is managing as the “primary” diagnosis on the claim.
Take, for instance, a patient with COPD, hypertension, and severe peripheral vascular disease (PVD) that causes intractable leg and foot pain. A pulmonologist may be managing the COPD, a hospitalist the hypertension and the palliative care physician the intractable pain from the PVD.
Also, be sure you understand any billing requirements that Medicare or commercial plans may have for palliative care services. Does the plan even cover these services? Or does the plan require any special certification for providers performing those services?
And if you are part of a hospitalist group that provides these services, make sure everyone in the group reports them in a consistent manner.
As an example: Say there is no change in a patient’s condition, and physicians haven’t identified new problems, issues or concerns, so they don’t need to spend more time with the patient and family answering questions. In such a case, one hospitalist providing palliative care shouldn’t report a high level of service while the next hospitalist reports a low-level one. One of your physicians shouldn’t be billing a 99231 while another bills a 99233, unless there’s a documented reason why.
Same group, same specialty
When it comes to billing, keep in mind that Medicare views physicians who are part of the same group and same specialty as one physician. If a hospitalist provides palliative care services on the same day that a colleague in the group makes a subsequent visit, for instance, billing both visits would result in one claim being denied.
However, you could base the level of service your group decides to bill for that calendar day on the combined documentation from both visits. Have a coder review both notes to assign the appropriate service level.
Collaboration and collegiality
If you do experience billing and reimbursement challenges with certain payers, have an administrator in your group set up time to meet with them to discuss the specifics of palliative care services. Establishing a collegial relationship with your payers can be very revenue-friendly.
Until palliative care services are assigned a specific set of codes, collaboration and documentation are the keys to making sure you will be reimbursed for this important and valuable care.
Sue A. Lewis, RN, CPC, PCS, has more than 40 years of health care experience.
Published in the May 2017 issue of Today’s Hospitalist
I have started billing palliative care visits for our primary care physician. All that I was told was to use 99221-99223 and 99231-99233 along with icd 10 code Z51.5 as the secondary diagnosis with symptoms as the primary. However, we are getting denials that patient is on hospice. When we use the QV modifier which is for hospice we are still being denied stating patient is enrolled in hospice. Are we to add the modifier because with or without it we are being denied. Is there another way of billing palliative visits?
I am new to the palliative coding and have been trying to figure it all out. I have found that 99221-99223 is used. However, we are being denied for denial 97. Should I be using the 99497 and 99498 instead? We are using the Z51.5 for icd code as secondary diagnosis and symptoms as primary.
Does the physician billing for palliative care service have to have a specialty or subspecialty in palliative care?
Thank you for the question: Here is the author’s response: “A straightforward answer with a very broad brush stroke is that physicians, DOs, nurse practitioners and physician assistants can provide palliative care services. The reality is that there are rules and regulations related to palliative care services such as scope of practice (practice act) and physician practice of medicine that vary from state-to-state. Providers should know and understand what their license allows them to do in the state in which they practice. One of the other challenges is when providers are in the same group practice. Hospitalists typically carry a… Read more »
I have providers called in for a palliative consult, and document the appropriate E/M, but they also want to add 99497, 99498, Advanced Care Planning. I need some guidance. Do I apply Z51.5 on the E/M and the 99497? Are these valid encounters using both?
We have passed these questions along to Ms. Lewis and hope to have an answer soon. We will let you know if we will publish them in an upcoming article. Thank you.
Are palliative care providers to get assigned the appropriate e/m code plus a 99497 or 99498 every time they see the patient? What is criteria for assigning the additional code of 99497 or 99498.
Do you or does the revenue code used for the services provided for palliative care drive the contract, or would a preferred stand be the NPI Specialty? I see that the Rev codes were to have been “unreserved” with CMS for 0690-699 in 2014, yet they are not used? Help