Palliative Care Billing 101
Billing Toolkit Guide
Introduction to the Toolkit
Billing for Advance Care
Planning (ACP)
Billing for Care Management:
• Principal Care Management (PCM)
• Chronic Care Mgmt & Complex
Chronic Care Mgmt (CCM/CCCM)
• Transitional Care Mgmt (TCM)
• Care Plan Oversight
Palliative Care Billing and Fundamentals of Billing and
Coding 101 Coding: Inpatient
You are here
Fundamentals of Billing and
Prolonged Services Billing Coding: Outpatient
New Billing Opportunities 2024
• Social Determinants of Health
Assessment
• Community Health Integration Productivity and Relative Value
• Principal Illness Navigation Units (RVUs) 101 - 103
• Complex Patient Add-On
• Caregiver Training Services
Learning Outcomes

➔ Name the clinician team members who can bill

➔ Define common billing terms

➔ Name the two types of billing for palliative care

services

➔ Discuss how your work translates into revenue

Important Terms I
➔ Healthcare Common Procedure Coding System (HCPCS)
– A collection of codes that represent procedures, supplies,
products and services which may be provided to Medicare
beneficiaries and to individuals enrolled in private health
insurance programs.

➔ Qualified Health Care Professionals (QHCP): Health professionals

who can report services through billing: Physicians, physician
assistants/associates, clinical nurse specialists, nurse practitioners,
certified nurse midwives

➔ Supervision
– General supervision means that the service may be performed by
clinical staff under the billing practitioner’s direction and control
without the requirement of their physical presence during the
service.
Important Terms II
➔ NPP: Non-Physician Providers (NPPs), as defined by CMS, such
as physician assistants/associates, nurse practitioners, and clinical
nurse specialists. NPPs are able to enroll and bill Medicare for
services that they are licensed or certified to perform within their
state.

➔ Community Health Worker (CHW): An individual that serves as a

liaison between health and social services and the community to
facilitate access to services and to improve the quality and cultural
competence of service delivery.

➔ Caregiver: An adult family member or other individual who has a

significant relationship with, and who provides a broad range of
assistance to, an individual with a chronic or other health condition,
disability, or functional limitation, and "a family member, friend, or
neighbor who provides unpaid assistance to a person with a chronic
illness or disabling condition.”
 Important Terms III
➔ Auxiliary Personnel: Any individual who is acting under the supervision
of a physician, regardless of whether the individual is an employee,
leased employee, or independent contractor of the physician, or of the
legal entity that employs or contracts with the physician.

➔ Social Determinants of Health (SDOH) - the non-medical factors that

influence health outcomes. They are the conditions in which people are
born, grow, work, live, and age, and the wider set of forces and systems
shaping the conditions of daily life.

➔ Clinical Procedural Terminology - Current Procedural Terminology

(CPT®) is the shared language of health care – a five-number or
lettered coding system is the foundation for how health care procedures
are tracked, reimbursed, and studied. The CPT code set is updated
frequently throughout the year, in a process that is guided by an
independent board of medical professionals.
Important Terms IV
➔ Evaluation and Management - E/M coding is the process by which
non-procedural provider-patient encounters are translated into five-
digit CPT codes to facilitate billing
• Can be based on Medical Decision-Making
• Can be time-based
➔ ICD-10 Codes International Classification of Disease and Health
Related Conditions
• Contains codes for diseases, signs and symptoms, abnormal
findings, complaints, social circumstances, and external causes
of injury or diseases
➔ RVU – Relative Value Unit – A numeric value assigned to each
CPT code that reflects the resources required to deliver that service
➔ Conversion Factor - Multiplier set by CMS to determine the dollar
value of each RVU
New Vs. Established Patients

➔ A new patient is one who has not received

any professional services from the physician
or other qualified health care professional, or
another physician or other qualified health
care professional of the exact same specialty
and subspecialty, who belongs to the same
group practice, within the past three years.
New Vs. Established Patients
➔ An established patient is one who has received professional
services from the physician or other qualified health care
professional, or another physician or other qualified health care
professional of the exact same specialty and subspecialty, who
belongs to the same group practice, within the past three years.
• In the instance where a physician or other qualified health care
professional is on call for or covering for another physician or
other qualified health care professional, the patient’s encounter
will be classified as it would have been by the physician or other
qualified health care professional who is not available.
• When advanced practice nurses and physician
assistants/associates are working with physicians, they are
considered as working in the exact same specialty and
subspecialty as the physician.
 Initial Vs. Subsequent Visits
➔ In addition to whether the patient is new or established, there is also the
delineation of initial vs. subsequent visits

➔ An initial service is when the patient has not received any professional
services from the physician or other qualified health care professional, or
another physician or other qualified health care professional of the exact
same specialty and subspecialty, who belongs to the same group practice,
during the inpatient, observation, or nursing facility admission and stay.

➔ A subsequent service is when the patient has received professional

service(s) from the physician or other qualified health care professional, or
another physician or other qualified health care professional of the exact
same specialty and subspecialty, who belongs to the same group practice,
during the admission and stay.
 More details on Subsequent Visits
➔ When a physician or other qualified health care professional is on call for
or covering for another physician or other qualified health care
professional, the patient’s encounter will be classified as it would have
been by the physician or other qualified health care professional who is
not available.
➔ When advanced practice nurses and physician assistants are working
with physicians, they are considered as working in the exact same
specialty and subspecialty as the physician.
➔ For reporting hospital inpatient or observation care services, a stay that
includes a transition from observation to inpatient is a single stay.
➔ For reporting nursing facility services, a stay that includes transition(s)
between skilled nursing facility and nursing facility level of care is the
same stay.
Palliative Care Billing and Coding 101

WHO CAN BILL

Palliative Care IDT and Billing: Who Can Bill
➔ Advanced practice registered nurses (APRNs)
– Includes Clinical Nurse Specialists (CNSs) and Nurse Practitioners (NPs)
– Depends on state regulations on scope of practice.

➔ Physicians – Includes Medical Doctors (MDs) or Doctors of Osteopathy

(DOs) - Can bill in all settings and all codes

➔ Physician Assistants (PAs) – May be able to bill - This depends on state

regulations on scope of practice

➔ Social Workers (SWs) – Must have a master’s degree and be licensed to bill
– Varies by state
– Usually billing occurs under a mental health benefit
➔ Marriage and Family Therapists (MFTs) – see Caregiver Training Services
➔ Mental health Counselors (MHCs) - see Caregiver Training Services
➔ Chaplains – Unable to bill independently
➔ Registered Nurses (RNs) – Unable to bill independently
 Independent APP Billing
(APRNs and PAs)
➔ APP bills under own National Provider Identifier (NPI)

➔ May independently evaluate a patient and establish a plan of

care

➔ Independent billing enables each bill to stand alone without

additional documentation to meet ‘incident to’ or ‘shared visit’
criteria – this may build capacity for the palliative care service

➔ Reimbursement may be lower than physician billing

‘Incident to’ or ‘Shared Visits’ APP Billing
(APRNs and PAs)

➔ APP bills under physician NPI.

– Physician must establish a plan of care for
each new problem.
• The physician must be on-site and immediately
available to the rendering clinician.
– Remember: ‘incident to’ is a Medicare
guideline. Not all insurance plans follow
CMS’s (Medicare’s) lead on this issue.
 Tradeoffs: Methods for Advanced
Practice Provider* (APP) Billing
Independent
➔ 85% of MD reimbursement
➔ APP bills under own NPI
➔ Variability with organizational
bylaws and state scope of
practice
➔ Easier documentation
➔ Improves capacity
*CNSs, NPs, PAs
'Incident to' or 'Shared Visits'
➔ 100% of MD reimbursement
➔ Bill under MD or DO NPI
➔ Requires initial MD/DO care plans
for EACH new problem
➔ If new problem and no MD care
plan, doesn't qualify
➔ Requires specific documentation
Palliative Care Billing and Coding 101

HOW BILLING REVENUE IS

DETERMINED
 How Billing Works

Clinician The RVU

Clinician chooses CPT value(s) are
chooses the code based Clinician Each CPT multiplied by
Payment is
Clinician diagnoses on location must select code is a
made for the
sees patient and medical place of assigned an conversion
ICD-10 visit
decision- service RVU value factor that is
code(s) making OR determined
time by CMS

Provided by Clinician Determined by CMS

Case Example
➔ Your patient is discharged from hospital with newly diagnosed
pulmonary embolism in the setting of lung cancer. He sees you for
the first time at your clinic in follow up 2 days after discharge. You
perform a history and physical, review discharge summary, and will
be managing his pulmonary embolism, coordinating his care and
monitoring his warfarin.
– Diagnosis: Pulmonary embolism (ICD-10 = I27), chest pain (ICD-10 =
R07.9), dyspnea (ICD-10 = R06.0)
– CPT Code: outpatient high complexity is code 99215 (don’t worry - you
will learn this later!)
– Place of service: outpatient clinic
– RVU assigned for 99215 = 2.8 work related RVUs (wRVU)
– Conversion Factor for 2024 = $32.74
– Payment (approximate due to cost and geographic variation)
= 2.8 x $32.74 = $91.67
Elements of Billing and
Coding:
1. ICD-10
2. CPT Codes: Medical Decision-Making vs.
Time-based Billing
3. Place of Service (POS)
Elements of E/M Coding and
Billing
All encounters to be billed need to include the following:
➔ Diagnosis: ICD–10 Codes (International Classification of
Disease and Health Related Conditions)
– Contains codes for diseases, signs and symptoms, abnormal
findings, complaints, social circumstances, and external causes
of injury or diseases
– Codes are designed not just to indicate diagnoses, but to offer
the ability to track epidemiology and population health
– Every encounter needs at least one ICD-10 code to identify why
the patient is being seen
– Many palliative care consultations can be billed/reported by
symptom codes, thus differentiating palliative care services from
another specialist who uses a disease code
1. ICD-10 Codes
➔ Codes describe the reasons for physician services
➔ List of ICD-10 codes are updated annually in October
➔ Both diagnosis (ex. pneumonia) and symptom codes (ex.
dyspnea) are available – important to be specific
Palliative care applicability :
➔ Consider using symptom codes, instead of disease
codes, to distinguish your services from those of other
specialists
➔ In addition to diagnosis, code for the chronic conditions
described in your notes to assist your agency and your
partners in identifying the true level of disease
Examples: cachexia, wounds, mental health diagnoses, use of assistive
devices, advanced diabetes or heart disease
 Commonly Used ICD-10 Codes
Symptom ICD-10 Symptom ICD-10 Symptom ICD-10
Agitation R45.1 Headache R51 Pain: leg M79.603
Anorexia R63.0 Hemorrhage R58 Pain: muscle M79.1
Anxiety F41.9 Inanition E46 Pain: neck M54.2
Coma R40.20 MS Change R41.82 Pain: non- R52
specified
Confusion F29 Nausea R11.0 Pain: sacroiliac M53.3
Cough R05 Nausea & R11.2 Pain: throat R070
Vomiting
Debility R53.81 Pain: abdomen R10.9 SOB R06.00
Diarrhea R19.7 Pain: arm M79.603 Unconscious R40.1
Dyspnea R06.00 Pain: back M54.9 Vomiting R11.10
Encounter for Z51.5 Pain: bone M89.9 Weakness R53.1
palliative care
Failure to Thrive R62.7 Pain: chest R07.89 Weight loss R63.4
Fatigue R53.83 Pain: foot M79.673
Fever R50.9 Pain: hip M25.559
Elements of Billing and
Coding:
1. ICD-10
2. CPT Codes: Medical Decision-Making vs.
Time-Based Billing
3. Place of Service (POS)
 CPT Codes: What They Are
➔ The “Current Procedural Technology” or CPT code set is a medical code
set designed to communicate uniform information (the type and level of
service) about medical services and procedures
➔ The majority of palliative care professional services are described by
Evaluation and Management (E/M) codes, which are a small fraction of all
CPT codes (compared to those used for procedures)
– Some procedures may be relevant to palliative care professionals (e.g.
paracentesis, thoracentesis)
– In other words, these codes aren’t awesome for us – because they don’t
characterize all of the services palliative care teams provide
– Books of all codes are available for purchase -
https://www.aapc.com/medical-coding-books/cpt-code-book
• But, the most pertinent codes to palliative care are available in this
toolkit
 CPT and E/M Codes
➔ CPT codes can describe:
– Location of care
– Type of Service
• New vs. Established (outpatient)
• Initial vs. Subsequent (inpatient)
– Medical Decision-Making of Service
– Duration of Service
➔ E/M Codes (non-procedural CPT codes)
– E/M coding is the process by which non-procedural
provider-patient encounters are translated into five-digit
CPT codes to facilitate billing
• Can be medical decision-making based
• Can be time-based
Classification of Evaluation and
Management (E/M) Services

➔ The E/M section of the CPT catalog is divided into broad categories,
such as office visits, hospital inpatient or observation care visits, and
consultations.

➔ Most of the categories are further divided into two or more

subcategories of E/M services.
– For example, there are two subcategories of office visits (new patient
and established patient)
– There are two subcategories of hospital inpatient and observation care
visits (initial and subsequent).
Classification of Evaluation and
Management (E/M) Services (continued)
➔ The basic format of codes is the same, whether the levels of E/M
services are based on medical decision-making (MDM) or based on
time:
– First, a unique code number is listed.
– Second, the place and/or type of service is specified (e.g. office
or other outpatient visit).
– Third, the content of the service is defined.
– Fourth, time is specified.

➔ The place of service and service type are defined by the location where
the face-to-face encounter with the patient and/or family/caregiver
occurs. For example, service provided to a nursing facility resident
brought to the office is reported with an office or other outpatient code.
Evaluation and Management (E/M) Codes:
Medical Decision-Making vs. Time

Medical Decision-Making (MDM):

– Codes describe the level of medical decision-making (low,
moderate, or high)
OR
Time: Duration of visit (time of beginning and end of encounter)

Note: Some CPT codes are time-based only (e.g., Advance

Care Planning). For some CPT codes, the provider can decide
whether to use MDM or time to bill for the encounter.
MDM vs. Time
➔ Historically palliative care teams have relied on time-
based billing; however, with the advent of Advance Care
Planning (ACP) and other time-based only billing codes,
there may be value in revisiting that assumption.

➔ Consider billing E/M codes more regularly on MDM

(especially when engaging symptoms), then adding
advance care planning (ACP) or other codes for longer
Goals of Care/ACP services. In many cases this
combination can create more revenue than time-based
E/M alone.
 Common E/M type CPT Codes
Code Description Level of MDM Time Threshold
99221 Initial hospital inpatient or Low 40
observation care

99222 Initial hospital inpatient or Moderate 55

observation care

99223 Initial hospital inpatient or High 75

observation care

99231 Subsequent hospital Low 25

inpatient or observation care

99232 Subsequent hospital Moderate 35

inpatient or observation care

99233 Subsequent hospital High 50

inpatient or observation care
Billing By Time
➔ Each E/M service code is also associated
with an amount of time known as a threshold
time. Consider using time-based billing when:

– Counseling and educating patients and families

– Formulating and communicating prognosis and
goals of care
– Exploring the burden/benefit of various
approaches to meeting the patient’s goals of care
– Coordinating differing medical opinions
Billing By Time
➔ Counseling and coordination of care is time spent
that is above and beyond the normal provider-
patient communication. Almost all palliative care
encounters meet this threshold.
➔ Time spent must be documented in the note
➔ There must be “sufficient detail” to support the time

➔ This is frustrating and gray – but you basically need

to say what you did and what you talked about
Billing by Time
Outpatient Inpatient
➔ In the outpatient setting ➔ In the inpatient setting,
time must be ‘face-to- time includes:
face’ • Reviewing current and old
• Patient interview and records
examination • Patient interview and
• Writing notes in the examination
presence of the patient • Writing notes
• Communication with other
professionals
• Communication with families
Elements of Billing and
Coding:
1. ICD-10
2. CPT Codes: Medical Decision-Making vs.
Time-based Billing
3. Place of Service (POS)
 Place of Service Codes (POS)
3. Place of Service Codes (POS)
– Place of service codes commonly used in palliative care:
• Office-11
• Home-12
• ALF-13
• Inpatient Hospital-21
• SNF-31
• NF-32
– Only coders and billers use these codes, not clinicians
– The POS must be documented in your note to support
accurate billing. If it is a facility, the name of the facility
should be included.
Case
➔ Ms. Smith is a 45-year old female with stage IV
breast cancer referred by the surgical oncologist
for neuropathic arm pain, nausea, and establishing
goals of care. She is seen for 50 minutes on the
inpatient oncology floor of the hospital as a new
patient for her symptoms and for counseling that
was face to face. Your documentation reflects a
comprehensive history, comprehensive exam and
medical decision-making of moderate complexity.

How would you bill and code for the visit – based on
time, or on MDM?
 Recall: How Billing Works

Clinician The RVU

chooses Value(s) are
Clinician CPT code
chooses the Clinician Each CPT multiplied by
based on must Select Payment is
Clinician diagnoses code is a
location and made for the
sees patient POS place assigned an conversion
visit
ICD-10 medical of service RVU value factor that is
code(s)) decision determined
making OR by CMS
time

Provided by Clinician Determined by CMS

Remember That You Need:

➔ ICD-10
– Diagnosis
or
– Symptoms
➔ CPT Code
– Complexity
Or
– Time
➔ POS
 Step #1: Commonly Used ICD-10 Codes
Symptom ICD-10 Symptom ICD-10 Symptom ICD-10
Agitation R45.1 Headache R51 Pain: leg M79.603
Anorexia R63.0 Hemorrhage R58 Pain: muscle M79.1
Anxiety F41.9 Inanition E46 Pain: neck M54.2
Coma R40.20 MS Change R41.82 Pain: non- R52
specified
Confusion F29 Nausea R11.0 Pain: sacroiliac M53.3
Cough R05 Nausea & R11.2 Pain: throat R070
Vomiting
Debility R53.81 Pain: abdomen R10.9 SOB R06.00
Diarrhea R19.7 Pain: arm M79.603 Unconscious R40.1
Dyspnea R06.00 Pain: back M54.9 Vomiting R11.10
Encounter for Z51.5 Pain: bone M89.9 Weakness R53.1
palliative care
Failure to Thrive R62.7 Pain: chest R07.89 Weight loss R63.4
Fatigue R53.83 Pain: foot M79.673
Fever R50.9 Pain: hip M25.559
Coding I
➔ ICD-10
– Diagnosis
• C50.111 Malignant neoplasm of central portion of right female
breast
or
– Symptoms
• Pain arm: M79.603
• Nausea : R11
➔ CPT Code
– MDM
Or
– Time
➔ POS
 Step #2: CPT Codes

Inpatient Codes: Initial Visit

CPT Description Medical Time wRVU Conversion Revenue
Code Decision- Threshold Factor from
Making wRVU

99221 Initial Low 40min 1.63 $32.74 $53.37

Hospital
level 1
99222 Initial Moderate 55min 2.60 $32.74 $85.12
Hospital
level 2
99223 Initial High 75min 3.5 $32.74 $114.59
Hospital
level 3
Coding II
➔ ICD-10
– Diagnosis
or
– Symptoms
• Pain arm: M79.603
• Nausea : R11
➔ CPT Code
– MDM : 99222 (moderate decision-making)
Or
– Time (since your visit doesn’t meet the time threshold
(55m) for the second-level time code, billing on MDM
makes more sense in this instance)
➔ POS
Step #3: Place of Service

➔ Office-11

➔ Home-12

➔ ALF-13

➔ Inpatient Hospital-21

➔ SNF-31

➔ NF-32
Coding III
➔ Diagnosis/Symptoms - ICD-10 codes:
– Symptoms
1. M79.2 neuropathy
2. R11 nausea
– Diagnosis:
1. C50.111 Malignant neoplasm of central portion of
right female breast
➔ CPT: Time or Complexity
– Initial Inpatient Visit = 99222
➔ POS (You won’t code this – but your biller will)
– Inpatient hospital = 21
Putting It All Together
➔ Palliative Care clinicians who can bill
– MD/DO
– APP
– Others can bill incident to
➔ Clinicians are responsible for submitting
– Diagnosis code(s) ICD-10
– CPT codes
• Use Evaluation and Management (subset of CPT codes for non-
procedural encounters)
• CPT/E/M Based on:
– Location
– Patient status ( new vs established)
– MDM or Time
– POS – this is implied in the CPT you choose
Putting It All Together (continued)

➔ RVUs are assigned based on the CPT code(s) chosen

➔ Conversion factor for 2024 = $32.74

➔ RVU x Conversion Factor = approximate revenue