Palliative care is specialized care that aims to provide relief from the symptoms of serious illnesses, and it affects 6 million people in the United States. It is a specialized care intended to improve the quality of life of patients suffering from serious illnesses, such as cancer, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), kidney disease, Alzheimer’s, Parkinson’s, Amyotrophic Lateral Sclerosis (ALS), among others. Palliative care teams focus on creating a better quality of life for patients, families, and caregivers. The overall goal of palliative care is to improve the patient’s quality of life by treating their symptoms and alleviating their stress.
This specialized care is provided by nurses and doctors with specialized training who work together to provide support by accessing the needs of the patient. Palliative care services are available to patients of any age and any stage of a serious illness. The objective of these services is to fulfill the patient’s needs and improve overall quality of life.
In 2023, the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) have simplified and streamlined medical coding for providers, with increased emphasis on medical decision-making and/or total time spent on patient care, and less on documentation requirements. The Center to Advance Palliative Care (CAPC) updated their tools and technical assistance to aid providers in navigating these changes. Coding can still be done based on time or complexity. If coding based on time, the provider should add up the total time spent in service within these periods to quantify total time and assign the appropriate level of service:
- Skilled Nursing Facility (SNF): 1 day before, day of visit, and 3 days after
- Home: 3 days before, day of visit, and 7 days after
It is important to note that the time thresholds have been revised based on 2023 coding guidelines. Healthcare providers need to learn and understand these changes thoroughly for complaint documentation and code assignment. Providers who choose to code based on medical decision making will have to consider four levels to determine the patient’s complexity: straight-forward, moderate, low, or high. Components considered when determining the level of medical decision-making include the following:
- Number and complexity of problems that are addressed at the encounter.
- The amount and/or complexity of data to be reviewed and/or analyzed.
- Risk of complications and/or morbidity or mortality of patient management.
Two out of the three components must be met for the patient to be assigned to a designated level of service. Higher levels of complexity have higher reimbursement rates, meaning that coding based on complexity may be more beneficial for clinicians and healthcare organizations.
Additionally, there have been changes in the codes and guidelines for prolonged services provided by physicians in various settings. The prolonged services are now divided based on place of service and payer. HCPCS codes maintained by CMS for Medicare patients based on location of the service and Current Procedural Terminology (CPT) codes maintained by AMA for other payers based on location of the service. There have also been updates to the categories of CPT codes for this population of care, with revisions of the codes for domiciliary, custodial, home, and residential care services, including assisted living facilities, consolidated and combined under one section for coding and reporting. These services are now reported based on Medical Decision-Making (MDM) or time as the leveling components, with specific guidelines.
Another notable change is the level of services for Skilled Nursing facilities, which are now leveled based on MDM or time components only. There have been deletions and revisions to this category of codes for these services as well as enhancement to guidelines.
These are just a few of the many changes to medical coding in palliative care. These updates may impact time reporting for specific categories of codes, and there have been deletions and revisions to the codes and services that affect palliative care.
It is crucial to educate providers about the coding changes that affect documentation requirements to ensure proper reimbursement for services provided. By understanding the available options and carefully selecting the category and level of CPT code for each provider visit, accurate coding and billing can be achieved. Accurate coding relies on complete and precise documentation combined with an understanding of coding updates.
At McBee, a team of certified coders and consultants can help healthcare providers navigate the complexity of palliative care billing and coding to maximize revenue and ensure timely reimbursement of claims. Contact McBee today to get started.