Billing and Coding
This toolkit has been updated for 2025. Join upcoming Virtual Office Hours on inpatient and community-based billing and 2025 Billing and Coding for Palliative Care webinar. Other webinars related to billing and coding are available on-demand
Optimized billing and coding are critical to the financial stability of the palliative care program. Palliative care providers can bill for Part B Professional Services, and revenue from billing often covers a substantial portion of direct costs (staff time).
The degree to which you can cover costs billing fee-for-service (FFS) is impacted by:
- Quality of documentation and billing processes
- Mix of team members—who on the team can bill for services, and which staff are counted in your direct costs
- Place of service (care setting)
- Contracts with payers and payer mix
- Proportion of time spent on direct patient care vs. other activities (such as education) that may impact patient care but not be billable
Programs must seek specific interpretation and advice from their local billing staff and regional payer and CMS administrators.
Looking for more information about financing your palliative care program? Browse CAPC's Beyond Billing: Covering Costs and Generating Revenue toolkit.
What’s in the Toolkit
2025 Medicare Billing Updates
An introduction to CAPC's billing resources, and overview of CMS changes and updates effective January 1, 2025.
Summary of January 1, 2025 changes to the Medicare fee schedule, with a focus on relevant codes for the palliative care team.
A summary of the new codes introduced in 2024: Social Determinants of Health Risk Assessment, Principal Illness Navigation, Community Health Integration, Billing for Complexity Add-on, and Caregiver Training Services
The Basics of Palliative Care Billing: Foundational Concepts, E/M Codes, and Telehealth
Are you accurately billing for your services? This collection covers the fundamentals of palliative care billing.
The basics of palliative care billing: terminology, who can bill, and strategies for reflecting the work of the palliative care team in Medicare billing.
Review of inpatient E/M codes, including time-based billing vs. medical decision-making, prolonged services, and inpatient billing case examples.
Review of outpatient E/M codes, including time-based billing vs. medical decision-making, prolonged services, and outpatient billing case examples.
Deep dive on prolonged services billing in all care settings.
A summary document of Medicare-reimbursable codes for telehealth and telephone encounters.
At-a-glance Medicare RVUs and national non-facility payments for codes commonly used by community-based palliative care programs.
How the interdisciplinary team can bill, and the differences between Advanced Practice Provider (APP) independent and APP 'incident to' or 'shared visits' billing.
Common ICD-10 codes for palliative care patient encounters.
In this Virtual Office Hour, expert faculty will explore commonly asked inpatient palliative care billing questions and describe billing and coding practices.
In this Virtual Office Hour, ask questions about billing for services provided in the home, office, or long-term care setting.
Monograph introducing U.S. health insurance with a focus on Medicare and what it means for palliative care.
Diagram of which services are billed through Part A vs. Part B.
A slide deck detailing the opportunities and considerations for palliative care teams billing for social work services. Courtesy of Brandi Rutan, LCSW, LISW-CP, Four Seasons Clinical Social Worker and Tranquil Counseling & Consulting, LLC and Christine Lau, RN, LCSW, APHSW-C, Sr. Director of Serious Illness Care Management for Teleios and VP of Operations for UNC Community Palliative Care.
Advance Care Planning (ACP)
How to bill for ACP services and capture Relative Value Units (RVUs) for this valuable work.
Requirements, best practices, documentation requirements, and time thresholds for Advance Care Planning (ACP) services.
Length of time requirements for the Advance Care Planning service CPT codes.
Shows the RVUs associated with each Advance Care Planning CPT code.
One-page reference guide to billing for advance care planning conversations.
CMS Requirements for billing Advance Care Planning codes 99497 and 99498. Centers for Medicare and Medicaid Services, updated February 2023.
Jones CA, Bull J, Acevedo J, Kamal AH. Journal of Palliative Medicine, 2015.
Addressing Social Needs and Caregiver Support
Codes and RVUs, requirements, and special considerations for billing a Social Determinants of Health risk assessment; Health and Behavioral Assessment and Intervention; defining community health integration; and
providing individual or group caregiver training.
Codes and RVUs, requirements, and special considerations for billing for a SDOH risk assessment.
CMS codes and requirements to bill for Health and Behavioral Assessment and Intervention (HBAI) services.
Defining community health integration, Medicare requirements, and considerations for palliative care teams.
New codes for individual and group caregiver training - when and how to bill.
Billing for Care Management and Navigation Services
Palliative care teams often manage and coordinate care for complex patients with multiple chronic conditions. Learn how to bill for the services you are already providing to patients. This includes Principal Care Management (PCM), Chronic Care Management (CCM), Complex Chronic Care Management (CCCM), and Principal Illness Navigation (PIN) codes. Transitional Care Management (TCM) codes are used when managing and coordinating care for patients transitioning from hospitals or other facilities back into the community.
Overview of the Principal Care Management (PCM) billing codes and requirements.
Billing for CCM and CCCM, including patient eligibility, which providers can bill, required documentation, and tips for avoiding claim denials.
This webinar examines how CCM & CCCM are critical components of coordinated care that contribute to better outcomes and higher satisfaction for patients.
Tips from CMS for getting started, requirements for implementing a CCM program, and materials to share with patients.
Sample consent agreement required for CCM and CCCM billing.
Sample certification of time spent, required for CCM and CCCM billing.
CMS codes and requirements for palliative care teams billing for Principal Illness Navigation (PIN).
This document from the American Cancer Society is intended to help answer frequently asked questions around Principal Illness Navigation (PIN)
Billing for patients transitioning from institutions to the community. Includes which patients are eligible, required services, who can provide services, who can bill, documentation requirements, and mistakes to avoid.
Department of Health and Human Services and Centers for Medicare and Medicaid Services, updated May 2023.
Summarizes the billing tools available for managing patients that need care management.
Care Plan Oversight (CPO)
CPO codes are used when managing and coordinating care for patients in Certified Home Health or Hospice agencies. Learn the fundamentals of billing for CPO: who is eligible, who can bill, and what is required.
Care Plan Oversight: who is eligible, who can provide the service, and required service and documentation elements for successful reimbursement.
Tips for billing care plan oversight.
Information for community-based providers about care plan oversite, transitional care management, and chronic and complex care management.
High-Complexity Patients
Billing for complexity add-on and dementia.
Definitions, code requirements, and when to bill the complexity add-on.
Applicable services, how to bill, and documentation requirements for cognitive assessment and care planning for people living with dementia.
Billing for Palliative Care in the Intensive Care Unit (ICU) and the Emergency Department (ED)
Patient eligibility, which providers can bill, understanding time-based billing, and what documentation is required.
Relative Value Units (RVUs)
Understanding the complex relationship between palliative care workflow, billing, and RVUs.
Why RVUs exist, how they are calculated, and why they are important.
Accurately capturing workload through RVUs, and calculating payment.
Steps palliative care teams can take to improve quality and efficiency to increase RVUs.
An at-a-glance listing of all wRVUs relevant to palliative care.
Simple interactive tool for estimating annual wRVU volume ranges with customizable assumptions.
Faculty
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Diane E. Meier, MD, FACP, FAAHPM
Founder, Director Emerita and Strategic Medical Advisor, Center to Advance Palliative Care
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Andrew E. Esch, MD, MBA
Director, Palliative Care Program Development
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Constance Dahlin, MSN, ANP-BC, ACHPN, FPCN, FAAN
Consultant
Center to Advance Palliative Care -
Nancy Guinn, MD
Consultant, Center to Advance Palliative Care
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Phillip Rodgers, MD, FAAHPM
George A. Dean, M.D. Chair of Family Medicine
Professor of Family Medicine and Internal Medicine
Di… -
Christopher Jones, MD, MBA, FAAHPM
Associate Professor and Director of Outpatient Palliative Care
Duke Health
Includes 21 resources:
- Defining Palliative Care
- Palliative Care Value Across Settings
- Calculators, Templates, and Case Studies
Includes 19 resources:
- Designing for Efficiency
- Optimizing Productivity
Includes 21 resources:
- Introduction to Payment
- Fee-for-Service Billing
- Value-Based Payment
- Foundation Fundraising Guidance
Virtual Office Hours
Inpatient Billing and Coding
