Palliative Care: The Strategic Importance of Coding

The term “palliative care” has been around since 1974 and it has grown to become an essential part of healthcare. Some estimates show it could save up to $6 billion per year and that 6 million people in the United States could benefit from it.

What is Palliative Care?

Palliative Care is a medical specialty focusing more on symptom management and symptom control. It is better suited for chronic conditions because it focuses more on patient comfort and pain management, not on curing the illness. It can be provided to patients at any age at any stage of illness.

It is among the most rapidly growing fields of healthcare in the United States over the past two decades. Most of the palliative care programs are run by hospices while roughly 61% of all hospitals with more than 50 beds have a palliative care team today. Home health agencies with palliative care programs only make up a small percentage.

Palliative care can benefit patients, families and providers. For patients, it improves quality of life while reducing caregiver stress and providing support for families. It helps providers improve quality of care and reduce costs.

Optimizing Coding for Palliative Care

The Centers for Medicare and Medicaid Services (CMS) introduced coding and documentation updates that went into effect on January 1, 2023. The new codes are designed to improve the accuracy of billing and to better reflect the services that are provided by palliative care providers. They also aim to improve care coordination and health outcomes and give patients more control over decisions about their own care.

The biggest changes to evaluation and management (E/M) coding in more than 20 years has also been introduced. There is now an increased emphasis on medical decision-making and/or total time spent on patient care and less on documentation requirements.

If coding based on time, the provider should add up the total time spent in service to quantify total time and assign the appropriate level of service:

• Skilled Nursing Facility (SNF): 1 day before, day of visit, 3 days after
• Home: 3 days before, day of visit, 7 days after

Use your documentation to justify the medical necessity for the level of service that is being billed. Ensure that time is documented for all services provided:

• Assessment and plan (A/P)
• Ordering Test
• Tobacco Cessation, etc.

Providers who choose to code based on medical decision making will have to consider four levels to determine the patient complexity. It is either going to be straightforward, moderate, low or high. The level of medical decision making includes the number of complexity or problems addressed, the amount of complexities of the data and the risk of the complications. Two of the three must be met and that is how providers will level their encounter.

Providers must be strategic and have good documentation and a good understanding from either their physicians, coders or outside help. They have to understand the problems and how the provider is addressing them.

There have also been some changes to the codes for prolonged services. This is something that people are having difficulty with. Some are using the wrong codes with the prolonged services; they are using the CPT codes instead of the G codes. It is an area where reimbursement is lost.

Strategic Advantage of Palliative Care

Larger companies are starting to expand into palliative care to diversify their service lines and expand their geographic footprint. Not everyone can start or maintain a palliative care program. The key to getting some of the benefits of palliative care is to build relationships. That way you can identify patients with high supportive care needs and refer them to specialist palliative care in a timely manner based on standardized referral criteria.

One key to this is timely referrals, which require:

• Routine screening of supportive care needs
• Pre-established agency-specific consensual criteria for referral
• System in place to trigger a referral when patients meet criteria
• Availability of palliative care resources to deliver personalized, timely patient-centered care aimed at improving patient and caregiver outcomes.

One of the ways to establish those partnerships and referral networks is by embracing technology. Review the options and invest in technology to improve the patient and referral experience. Also, research disease patterns to understand what care is being delivered and by whom. Another way to go about is to look at who’s establishing different programs, understand that building those relationships takes a personal touch because relationships are at the core of your referral network.

Future of Palliative Care

90 million Americans live with serious illness. That figure is projected to double over the next 25 years as Baby Boomers age, so palliative care will still be needed. As we move into the future we may also see palliative care penetrate into other fields like nephrology, neurology or surgery. Also, expect further discernment of the most effective and cost-effective models.

Other trends and innovations include:

• Personalized Care Plans
  • Tailored to individual patient needs, preferences and goals
  • Utilize advanced technology and data analysis
• Telehealth & Remote Monitoring
  • Increased remote consultations, symptom management
  • Increased access to care
  • Enables early intervention
• Advance Care Planning & Shared Decision-Making
  • Empowers patient and family participation
  • Ensures their values and preferences are respected
• Integration of Machine Learning & AI
  • Predict patient deterioration
  • Optimize symptom management
  • Support clinical decision-making

There will also be advancements in technology like predictive analytics to identify patient needs and prioritize patient visits. It will strengthen innovation and lead to more connected data.

A new opportunity for Post-Acute providers will be the drive into a Value-Based Insurance Design (VBID) Model. Payers will begin to define what hospice value and quality looks like and work on how palliative care impacts hospice and the quality of services provided. As in all areas of health care, coding changes will continue and require more specificity.

Look for provider consolidation to continue along with payers creating their provider networks based on providers they own. In the years to come, flexibility will be necessary to adapt quickly to meet the needs of the communities supported.

Recent research from analysts at the Center for Medicare & Medicaid Innovation (CMMI) found that when deployed at scale, palliative care can help achieve many of the health care systems current goals, including reduced costs, improved patient satisfaction and quality of life. The CMMI analysis examined the results of several programs including community based, hospital based and home health-based programs. Each of the programs demonstrated palliative’s care potential for generating savings and improving quality of care. For example, one model reduced total Medicare spending among beneficiaries served by 14%. It also decreased ED visits by 14% and inpatient admissions by 26% while boosting hospice enrollment by 29%. Total savings per patient reached $7,254.

Recognizing the strategic importance of palliative care is a wise investment in the overall well-being of patients and the efficiency of our healthcare systems. It is imperative that policymakers, healthcare professionals, and the public continue to prioritize and expand access to this invaluable form of care.