Hospice care” and “palliative care” are not synonymous terms. Hospice care is defined as a comprehensive set of services (see “Hospice Coverage,” below) 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.1 Palliative care is defined as 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.1
As an approach, 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, center, skilled-nursing facility, or hospital setting. In contrast, palliative-care services can be provided during hospice care, or coincide with care that is focused on a cure.
Many hospitalists provide both hospice care and palliative-care services to their patients. Different factors affect how to report these services. These programs 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.
When a patient enrolls in hospice, all rights to Medicare Part B payments are waived during the benefit period involving professional services related to the treatment and management of the terminal illness. Payment is made through the Part A benefit for the associated costs of daily care and the services provided by the hospice-employed physician. An exception occurs for professional services of an independent attending physician who is not an employee of the designated hospice and does not receive compensation from the hospice for those services. The “attending physician” for hospice services must be an individual who is a doctor of medicine or osteopathy, or a nurse practitioner identified by the individual, at the time they elect hospice coverage, as having the most significant role in the determination and delivery of their medical care.2
Patients often receive hospice in the hospital setting, where the hospitalist manages the patient’s daily care. If the hospitalist is designated as the “attending physician” for hospice services, the visits should be reported to Medicare Part B with modifier GV (e.g. 99232-GV).3 This will allow for separate payment to the hospitalist (the independent attending physician), while the hospice agency maintains its daily-care rate. Reporting services absent this modifier will result in denial.
In some cases, the hospitalist is not identified as the “attending physician” for hospice services but occasionally provides care related to the terminal illness. This situation proves most difficult. Although the hospitalist might be the most accessible physician to the staff and is putting the patient’s needs first, reimbursement is unlikely. Regulations stipulate that patients must not see independent physicians other than their “attending physician” for care related to their terminal illness unless the hospice arranges it. When the service is related to the hospice patient’s terminal illness but was furnished by someone other than the designated “attending physician,” this “other physician” must look to the hospice for payment.3
Nonhospice Palliative Care
Members of the palliative-care team often are called to provide management options to assist in reducing pain and suffering. When the palliative-care specialist is asked to provide opinions or advice, the initial service may qualify as a consultation for those payors that still recognize these codes. However, all of the requirements4 must be met in order to report the service as an inpatient consultation (99251-99255):3
- There must be a written request from a qualified healthcare provider who is involved in the patient’s care (e.g. physician, resident, nurse practitioner); this may be documented as a physician order or in the assessment/plan of the requesting provider’s progress note. Standing orders for consultation are not permitted.
- The requesting provider should clearly and accurately identify the reason for consult request to support the medical necessity of the service.
- The palliative-care physician renders and documents the service.
- The palliative-care physician reports his or her findings to the requesting physician via written communication; because the requesting physician and the consultant share a common inpatient medical record, the consultant’s inpatient progress note satisfies the “written report” requirement.
Consider the nature of the request when reporting a consultation. If the request demonstrates the need for opinions or advice from the palliative-care specialist, the service can be reported as a consultation. If the indication cites “medical management” or “palliative management,” payors are less likely to consider the service as a consultation because the physician is not seeking opinions or advice from the consultant to incorporate into his or her own plan of care for the patient and would rather the consultant just take over that portion of patient care. When consultations do not meet the requirements, subsequent hospital care services should be reported (99231-99233).3
The requesting physician can be in the same or a different provider group as the consultant. The consultant must possess expertise in an area that is beyond that of the requesting provider. Because most hospitalists carry a specialty designation of internal medicine (physician specialty code 11), hospitalists providing palliative-care services can distinguish themselves by their own code (physician specialty code 17, hospice and palliative care).5 Payor concerns arise when physicians of the same designated specialty submit a claim for the same patient on the same date. The payor is likely to pay the first claim received and deny the second claim received pending review of documentation. If this occurs, submit a copy of both progress notes for the date in question to distinguish the services provided. The payor may still require that both encounters be reported as one cumulative service under one physician.
Consultations are not an option for Medicare beneficiaries. Hospitalists providing palliative care can report initial hospital care codes (99221-99223) for their first encounter with the patient.3 This is only acceptable when no other hospitalist from the group has reported initial hospital care during the patient stay, unless the palliative-care hospitalist carries the corresponding designation (i.e. enrolled with Medicare as physician specialty code 17). Without this separate designation, the palliative-care hospitalist can only report subsequent hospital care codes (99231-99233) as the patient was seen previously by a hospitalist in the same group.3
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.
- U.S. Government Printing Office. Electronic Code of Federal Regulations: Title 42: Public Health, Part 418: Hospice Care, §418.3. June 2012. U.S. Government Printing Office website. Available at: http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=818258235647b14d2961ad30fa3e68e6&rgn=div5&view=text&node=42:18.104.22.168.5&idno=42#42:22.214.171.124.126.96.36.199. Accessed June 23, 2012.
- Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 11: processing hospice claims. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c11.pdf. Accessed June 23, 2012.
- Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.
- American Medical Association. Consultation services and transfer of care. American Medical Association website. Available at: http://www.ama-assn.org/resources/doc/cpt/cpt-consultation-services.pdf. Accessed June 23, 2012.
- Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 26: completing and processing form CMS-1500 data set. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf. Accessed June 23, 2012. Department of Health and Human Services.
- Hospice Payment System: payment system fact sheet series. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/hospice_pay_sys_fs.pdf. Accessed June 23, 2012.