Medical Coding: Hospice Care vs. Palliative Care

The Hospitalist. 2012 November;2012(11):

November 1, 2012 | The Hospitalist

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.

Hospice Coverage

The Medicare hospice benefit includes the following hospice services for a terminal illness and related conditions⁶:

Physician services furnished by hospice-employed physicians and nurse practitioners (NPs) or by other physicians under arrangement with the hospice;
Nursing care;
Medical equipment;
Medical supplies;
Drugs for symptom control and pain relief;
Hospice aide and homemaker services;
Physical therapy;
Occupational therapy;
Speech-language pathology services;
Social worker services;
Dietary counseling;
Spiritual counseling;
Grief and loss counseling for the individual and his or her family;
Short-term inpatient care for pain control and symptom management and for respite care; and
Any other services as identified by the hospice interdisciplinary group.

Medicare will not pay for the following services when hospice care is chosen:

Hospice care furnished by a hospice other than the hospice designated by the individual (unless furnished under arrangement by the designated hospice);
Any Medicare services that are related to treatment of the terminal illness or a related condition for which hospice care was elected or that are equivalent to hospice care, with the exception of the following:
- Care furnished by the designated hospice;
- Care furnished by another hospice under arrangements made by the designated hospice; or
- Care furnished by the individual’s attending physician who is not an employee of the designated hospice or receiving compensation from the hospice under arrangement for those services.
Room and board if hospice care is provided in the home, a nursing home, or a hospice residential facility. However, room and board are allowable services under the Medicare hospice benefit for short-term inpatient care that the hospice arranges; and
Care in an emergency room, inpatient facility care, outpatient services, or ambulance transportation, unless these services are either arranged by the hospice medical team or are unrelated to the terminal illness.