How to bill for palliative care in the ICU ... legally - PulmCCM
May 102012
Reimbursement for Palliative Care in the ICU By Intensivists

To an intensivist, providing palliative care often means having multiple time-consuming and emotionally challenging interactions with families struggling to cope with the impending loss of their loved one. The emotional content of these interactions can be strongly positive, negative, or somewhere in between, but frequently it's an intense and draining experience, possibly contributing to burnout among ICU physicians.

So at least you should get paid for it, right?

Dana Lustbader et al explain how to do so while complying with the regulations of the Centers for Medicare and Medicaid (CMS) in the April 2012 Chest:

  • Current Procedural Terminology (CPT) time-based codes 99291 (for critical care services from 30 - 74 minutes) and 99292 (for each additional 30 minutes over 74 minutes) can legally and ethically be used to bill payers for palliative care services by intensivists.
  • Examples that authors say meet the standard include family meetings discussing goals of care, end-of-life care, tracheostomy placement or other procedures, and managing distressing symptoms in a patient under comfort care.
  • Needless to say, everything must be documented well to support the billing.
  • 99291 (30-74 min.) pays about $243 and is valued at 4.5 revenue value units (RVUs).
  • 99292 pays about $122 for each additional 30 minutes spent.
  • (If total time is <30 minutes, it's to be reported under a different set of E/M codes 99231-99233. The highest-paying in this set, a level 3 visit under 99233, pays $105 and is only 1.0 RVU.)
  • Time spent after returning to a patient's bedside late in the day for a family meeting to establish goals of care can be added to the time spent earlier that morning providing direct medical care.
  • All the initial time under 99291 (30-74 min.) must be performed by the billing MD (i.e., not a midlevel).
  • Any physician, not just a palliative care physician or critical care-boarded physician, may bill for palliative care using these time codes.
Caveats and Pitfalls to Billing for Palliative Care in the ICU

"Split or shared service performed by a physician and a qualified nonphysician provider of the same group practice is not reportable as a critical care service; only cumulative critical care time provided by physicians within a group is reported as such." In other words, midlevels cannot bill for palliative care services (i.e., a PA can't have a 30 minute meeting and you bill it under the "+30 min" 99292 code).

The above goes for residents' work, as well, at teaching hospitals, where attendings must also document care well enough for it to justify billings independent of the resident's note.

Critical care services must be medically necessary (just being in the ICU is not sufficient). CMS's definition of this for critical care services is: “The treatment and management of the patient’s condition, while not necessarily emergent, shall be required, based on the threat of imminent deterioration.”

Counseling, bereavement, and general emotional support are not billable under the critical care codes 99291 and 99292. Apparently, Medicare decided just being nice should be on the house.

Lustbader DR et al. Physician Reimbursement for Critical Care Services Integrating Palliative Care for Patients Who Are Critically Ill. Chest 2012;141:787-792.

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  4 Responses to “How to bill for palliative care in the ICU … legally”

  1. Does anyone else have trouble deciding what/how to bill if there is a joint meeting with a family, the intensivist and an MD from a formal palliative care team at the same meeting. The palliative care team clearly needs to bill, but it is still an hour of time from the intensivist.

    • Lewis: this is a great question; thanks for posting it. I’ve emailed Dr. Lustbader to see if we can get some clarity. Anyone else have a good answer for this?

    • In situations where multiple consultants are present for a family meeting the critical care codes may be used as long as the following conditions are met and clearly documented. The patient must have organ failure and be unable to participate in medical decision making. The family meeting is requried for medical decision making. An intensivst and a palliative medicine physician may both code 99291 as long as they document their contribution to the family meeting. It may be that the intensivist describes the patient’s current condition and prognosis along with risks and benefits to ongoing treatments. The palliative medicine physician may present the option of withdrawing life sustaining treatments, and the plan for treatment of terminal dyspnea. Time spent providing emotional support may not be included in the 99291, only time spent discussing and making treatment decisions.

      • Thanks. This makes sense and is in line with how I understand it, but I had not seen it laid out so clearly anywhere else.