Introduction   With the rapid growth in palliative care services, many clinicians are practicing as part-time or full-time palliative care “consultants”.  Issues of documentation, coding, and reimbursement are no different for palliative care and hospice care than for any other medical specialty.  That is, clinicians code for each patient encounter in two parts: 1) a procedure/service code, and 2) a diagnosis code (1,2). In 2023, the Centers for Medicare and Medicaid Services (CMS) approved substantial revisions for the completion of procedure/service codes. Diagnostic codes are subject to more frequent changes but in general are evolving to become more specific.

Procedure/Service Codes are available in the Current Procedural Terminology (CPT) book published by the American Medical Association.  This is used universally in US health care; the Evaluation/Management (E/M) codes are used most frequently by hospice and palliative care clinicians.  A code is chosen based on location (inpatient, outpatient, home, skilled nursing facility (SNF), etc.), whether the visit is a consultation, new/initial patient, or an established/subsequent visit, and either the time or complexity of the encounter. Clinicians can utilize EITHER time or medical decision making (MDM) complexity to approximate their clinical effort. 

• Time: this can be the simplest way to bill if the clinician keeps accurate track of time they spent engaged in that specific patient’s care.  Under prior guidelines, outpatient time was based on face-to-face time given that more than 50% of the encounter was spent in counseling and coordinating care; inpatient time was defined by total time on the unit/floor related to patient care. Under the CMS rules of 2023 (3), when billing on time, clinicians should sum all the patient-care-related time (this can be time spent reviewing medical records, performing an evaluation, counseling the patient, documenting the note, coordinating care with other clinicians, etc.) spent on the day of service. Many electronic medical records (EMRs) have built in tools and calculators for calculating an E/M code based on time.  See reference #4 for current CPT codes based on time, keeping in mind these time-based billing codes can change yearly (4). 

Prolonged service codes can be added when applicable. They sum up all time spent on that specific patient’s care during the service period.  For inpatient hospitalizations, office visits, or General Inpatient Hospice (GIP, see Fast Fact #415 for more information), the service period includes just the day of the visit.  For SNFs, service time includes one day before the visit, day of the visit, and 3 days after.  For home visits, service periods for prolonged codes include time spent 3 days before the visit, day of visit, and 7 days after. 

• MDM complexity: while perhaps not as straight-forward, billing based on MDM complexity is usually associated with more reimbursement in hospice and palliative care since complex MDM is normative even in brief encounters (eliciting care preferences, formulating prognosis, assessing the trajectory of illness, etc.). Many EMR systems have built-in tools and calculators for determining MDM billing codes.  See reference #5. There are three main elements to factor into MDM: 
  • Number and complexity of problems addressed at the encounter.Amount and/or complexity of data to be reviewed and analyzed.
  • Risk of complications and/or morbidity or mortality of patient management.

Diagnosis codes are chosen from the International Classification of Diseases (ICD). The list is broader than pathophysiological entities. For example, there are many symptom codes (e.g., neoplastic related fatigue 780.79, cancer related pain 338.3, nausea and vomiting 787.02), however, “goals of care” is not a billable diagnosis.  Most EMRs can look up the ICD code when clinicians type in a diagnosis. When working with a clinician-in-training (e.g., intern, resident, fellow), a CPT modifier GC should be used.

Advance care planning (ACP): Clinicians can utilize time-based CPT Codes (99497 or 99498) to bill for visits related to ACP (6).  This includes visits counseling or discussion about advance directives, code status, or other care preferences or values. These codes can be utilized as the sole billing diagnostic code or as an additional code when billing medical care services; however, it is best to use them as an additional code only with a MDM complexity billing to avoid using two time-based bills in a day. CPT code 99497 pertains to ACP discussions last from 16-45 minutes; CPT code 99498 gets added to 99497 for ACP discussions lasting 46-75 minutes.  

Consultations: When billing as a consultation, clinicians should document the referring clinician and the consult question they are being asked to address. Medicare has not paid for consultations since 2012 though rare insurers still do.

Hospice care:  If the patient has elected the Medicare Hospice Benefit, the primary clinician (if not associated with the hospice organization, i.e., as a hospice medical director) caring for the terminal condition submits bills to Medicare under Part B by filling out a CPT code and utilizing a “GV” modifier.  All other clinicians (e.g., consultants) submit their bills to the hospice organization, which then submits the claims to Part A and reimburse the “consultant” directly. See reference #7 for more information (7).

References

1. von Gunten CF, Ferris FD, Kirschner C, Emanuel L. Coding and reimbursement mechanisms for physician services in hospice and palliative care. J Palliat Med. 2000; 3(2):157-164.
2. Jones CA, Bull J, Acevedo J, Kamal AH. Top ten inpatient palliative medicine billing and coding mistakes (and how to fix them this week). J Palliat Med. 2015;18(3):211-216. doi:10.1089/jpm.2015.0005.18.3
3. American Medical Association. CPT Evaluation and Management (E/M) Code and Guideline Changes effective January 1, 2023. Available at https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf Last accessed 12/14/23.
4. American Medical Association. Documenting time for each task during outpatient vists.  Available at: https://www.aan.com/siteassets/home-page/tools-and-resources/practicing-neurologist–administrators/billing-and-coding/cpt–em/2023-cpt-revised-mdm-grid.pdf Last accessed 12/14/23
5. American Medical Association. CPT Evaluation and Management: Updated May 12, 2023.  Available at: Last accessed 12/14/23
6. Jones CA, Acevedo J, Bull J, Kamal AH. Top 10 Tips for Using Advance Care Planning Codes in Palliative Medicine and Beyond. J Palliat Med. 2016;19(12):1249-1253. doi:10.1089/jpm.2016.0202
7. Pa.metto GBA. Billing hospice physician, nurse practitioner, and physician assistant services related to terminal diagnosis.  Available at:  https://www.palmettogba.com/palmetto/providers.Nsf/files/Billing_Hospice_Physician_NP_PA_Services_Job_Aid.pdf/$File/Billing_Hospice_Physician_NP_PA_Services_Job_Aid.pdf Last accessed 12/15/23.

Version History:  This Fast Fact was originally edited by David E Weissman MD.   2^nd Edition published August 2005; 3^rd Edition May 2015; 4^th Edition January 2024.
Conflicts of Interest: None to report.