Medicare Reimbursement for Palliative Care

Guest Contributor: Kathy Brandt

I just finished a great interview with the head of a Medicaid nursing home diversion program as part of a community-based palliative care needs assessment. I love these calls because I learn so much about the range and scope of services offered in communities.

No matter whom I talk to, each person expresses support for community-based palliative care. And each call also includes a discussion about the reimbursement mechanism for palliative care. Everyone – physicians, caseworkers, administrators, and patient advocates – recognizes the value of palliative care and the challenge in delivering a service that relies on traditional fee-for-service billing.

How is Community-Based Palliative Care Reimbursed via Medicare?

The short answer is that it isn’t. The long answer is that there are a few ways that palliative care providers can bill, but Medicare does not currently pay for interdisciplinary palliative care management.

Fee-for-service Medicare reimbursement for palliative care services:

1. Physicians, nurse practitioners, and physician assistants can submit bills based on time and intensity of services under fee-for-service Medicare.
2. Physicians, nurse practitioners, and physician assistants can also be reimbursed for advance care planning conversations.
3. Clinicians can provide ongoing chronic care management — at least 20 minutes of clinical staff time directed by a physician.
4. Transitional care management can be billed for up to 30-days to help a Medicare beneficiary transition from an inpatient hospital to their home or similar community setting.

What are the Requirements for Time and Intensity Billing?

Each of the above referenced fee-for-service billing opportunities has specific requirements related to who can bill, what constitutes a billable encounter, documentation, and coding. This blog cannot begin to cover all the information that you’ll need to bill for your palliative care services. Here are a few things to keep in mind:

“Incident to” Billing:

In order to bill for advance practice nurse or physician assistant services under the provider number for the physician:

• The services cannot be delivered in hospital or long-term care settings
• The physician must perform initial visit and initiate the plan of treatment
• The physician must be physically present (in the building) and participating in a direct supervisory role, regardless of the scope of practices of the practitioners – it is a billing rule

As a result of these requirements, incident to billing is perfect for palliative care clinic, adult day care, and similar settings.

Split/Shared Evaluation and Management Services

If a physician and non-physician provider from the same group practice share the evaluation and management, service may be billed under either’s National Provider Identifier if the following criteria are followed:

• Both the physician and nurse practitioner or physician assistant must each personally document and sign their encounter
• The physician cannot simply review the note and make a comment
• The physician can document something from at least one evaluation/management key component, such as medical decision making.

What Are the Key Concepts Related to Fee-for-Service Billing?

• Legibly document what you do and the length of time it takes to do it
• When making billing decisions, start with complexity when considering coding
• Know when and how to use extender codes

To learn more about fee-for-service billing register for the Billing for Palliative Care Services course today.