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Medical Billing for Palliative Care Services


Article-Medical-Billing-for-Palliative-Care-Services

Care delivery models have been evolving for many years and palliative care services is no exception. Palliative care can be provided in hospitals, nursing homes, outpatient palliative care clinics and certain other specialized clinics, or at home. Most often clinicians run into operational problems when billing for palliative care. These services are often closely aligned with hospice care if not documented properly creates the perfect opportunity for claim denial. Unlike critical care or observation care, palliative care doesn’t come with its own set of specific CPT or HCPCS codes, making it really difficult to get reimbursement.

Palliative Care vs Hospice

Most often hospice care and palliative care are considered synonymous terms. Unlike hospice, palliative care services do not focus on terminal illness and dying. Instead, palliative care focuses on meeting the physical, emotional, and spiritual needs of individuals and families facing serious, chronic, or life-threatening illness.

  • Hospice care is defined as a comprehensive set of services identified and coordinated by an interdisciplinary group to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care. 
  • Palliative care is defined as the patient- and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and facilitates patient autonomy, access to information, and choice.

Generally, hospice care of terminally ill individuals involves palliative care (relief of pain and uncomfortable symptoms) and emphasizes maintaining the patient at home with family and friends as long as possible. Hospice services can be provided in a home, skilled nursing facility, or hospital setting. In contrast, palliative-care services can be provided during hospice care, or coincide with the care that is focused on a cure.

Billing Guidelines for Palliative Care

  • Electing hospice: You have to verify whether the patient has elected for hospice before you refer a patient to palliative care or provide such services yourself. This directly affects services you can bill for and where you need to submit claims. If a patient has elected hospice and you are managing a condition unrelated to that patient’s terminal illness, Medicare requires to append a modifier to the service being reported.
  • Clinician Credentialing: Before offering palliative care, you need to verify if you are appropriately credentialed in hospice and palliative medicine. Medicare has assigned a specialty code (17) for palliative care which is required while billing along with your NPI, and taxonomy code (for MD, DO or NPP). 
  • Place of Service: Make sure you report correct place of service codes that apply to the setting in which you’re providing palliative care. These services can be delivered in many different locations like 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.
  • Medical Necessity:  If you are a palliative care consultant, make sure the attending physician or specialist makes a formal written request for you to evaluate the patient. This written request is not strictly necessary, but it will help support the medical necessity of your services.
  • Diagnosis: Submit the diagnosis you are managing as the ‘primary’ diagnosis on the claim. 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. 
  • Group Practice: Keep in mind that as per Medicare, physicians who are part of the same group and same specialty as one physician. If you provide palliative care services on the same day that as your colleague in the group makes a subsequent visit, billing both visits would result in one claim being denied. You could base the level of service your group decides to bill for that calendar day on the combined documentation from both visits. 
  • Documentation: You 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. Documentation is the keys to making sure you will be reimbursed for this important and valuable care.

Palliative care services can be quite costly, as they involve several team members and a substantial amount of time delivering these services. Capturing services appropriately and obtaining reimbursement to help continue program initiatives are significant issues. For getting accurate reimbursement for palliative care, you can connect with expert medical billing company like Medical Billers and Coders (MBC). To know more about medical billing for palliative care you can contact us at 888-357-3226/info@medicalbillersandcoders.com

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