Direct Answer
Palliative care billing encompasses two distinct concepts that are frequently confused: palliative care (specialist consultation and management for symptom control and goals-of-care discussions in patients with serious illness, which is billed like any other specialty using E&M codes) and hospice (a Medicare benefit for patients with a terminal prognosis of six months or less, billed using hospice-specific billing through Part A). Patients on the Medicare hospice benefit generally cannot receive Medicare-covered curative treatment for their terminal illness — but they CAN receive palliative care from a hospice physician billed to the hospice benefit. The most commonly misunderstood billing situation is concurrent care: when a patient is on hospice but also receives physician services unrelated to the terminal illness, those non-hospice-related services can be billed to Medicare Part B. Understanding these distinctions is essential for both palliative care specialists and primary care providers who manage patients at the end of life.
Table of Contents
Palliative Care E&M Billing
Palliative care specialists bill using the same E&M CPT codes as other medical specialists — there is no specialty-specific E&M code for palliative care: Outpatient palliative care E&M: 99202-99215 — Office or other outpatient E&M services; palliative care outpatient visits for symptom management, goals-of-care discussions, and psychosocial support typically support Moderate-to-High MDM or substantial total physician time; Inpatient palliative care consultations: 99252-99255 — Inpatient consultation codes (for payers that still accept consultation codes); 99221-99223 — Initial hospital care (if the palliative care team is taking over attending role); 99231-99233 — Subsequent hospital care (daily inpatient visits by the palliative care team); The most appropriate code depends on whether the palliative care team is acting as a consultant (performing a consultation requested by another physician) or as the primary attending; Documentation of medical complexity: palliative care patients typically have: multiple serious comorbidities; multiple prescription medications (opioids for pain, antiemetics, anxiolytics); complex psychosocial issues (family conflict, goals-of-care disagreement, caregiver distress); interpretation of outside records (oncology notes, imaging); these factors support High MDM for most palliative care visits; Total time billing option: under the 2021 E&M revisions, physician total time (including non-face-to-face time on the date of encounter) can be used to determine the E&M level; palliative care often involves extensive time on documentation, care coordination, and family communication — total time billing may support higher E&M levels; Care conference billing: family conferences for goals-of-care discussions are a core palliative care service; face-to-face family conferences with the patient and/or family where the physician is present are billed under the E&M codes; the time spent in the conference can be counted toward total time billing; care conferences where the physician is not present (team meetings) are not separately billable physician services.
Advance Care Planning Codes
Advance care planning (ACP) codes specifically capture the time spent discussing advance directives, health care proxies, and future care preferences: 99497 — Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes face-to-face with the patient, family member(s), and/or surrogate; +99498 — Each additional 30 minutes (add-on to 99497); Coverage: Medicare covers 99497 as a separate voluntary benefit — it can be billed as a standalone service or on the same day as an E&M visit; when billed with an E&M on the same date: the ACP service must be beyond the routine care of the patient (i.e., a separate, distinct conversation about advance directives); the E&M note must document the E&M service separately from the ACP conversation; Modifier 33 is NOT required for ACP (it is a preventive service under Medicare); ACP is not subject to Medicare cost-sharing for beneficiaries; Time requirement: 99497 requires at least 16 minutes of face-to-face ACP discussion; for the full 99497 (30 minutes), at least 16 minutes must be spent; for each additional 30 minutes (+99498), at least 16 minutes beyond the prior 30-minute threshold must be spent; Documentation: the ACP note must document: the specific topics discussed (health care proxy designation, DNR/DNI preferences, artificial nutrition and hydration, hospitalization preferences, CPR preferences, mechanical ventilation preferences); the patient's and/or family's responses and stated preferences; whether advance directive forms were completed; the identity of the participants (patient, family members, surrogate decision-maker); the time spent in the ACP discussion; Practical billing guidance: many practices under-bill ACP — they provide ACP discussions but don't separately document or bill for them; implementing a standardized ACP documentation template that captures the required elements and time enables consistent billing and revenue capture for these valuable services.
Hospice Billing Overview
The Medicare Hospice Benefit is a capitated Part A benefit distinct from the fee-for-service billing described in this guide: Medicare hospice billing: hospice agencies bill Medicare using four per-diem rates based on the level of care: Routine Home Care (RHC): 1051-1152 (two rates — days 1-60 and days 61+); Continuous Home Care (CHC): per-hour rate for crisis periods; Inpatient Respite Care (IRC): per-diem for SNF or hospital respite; General Inpatient Care (GIP): per-diem for symptom management in a hospital or inpatient hospice facility; hospice agencies submit claims on UB-04 claim forms to Medicare Part A using revenue codes; hospice billing is fundamentally different from professional fee (CMS-1500) billing; Hospice eligibility: the patient must have a terminal prognosis of 6 months or less if the illness runs its normal course; two physicians (the hospice medical director and the patient's attending physician) certify the terminal prognosis; patients must elect the hospice benefit and sign the hospice election statement; the hospice benefit begins on the election date; Hospice attending physician billing: the patient's attending physician who is not employed by the hospice can continue to see the patient and bill Medicare Part B for non-hospice related services; if the attending physician provides services related to the terminal illness, those services should not be billed to Part B — they are covered under the hospice per-diem; billing the wrong services to Part B when the patient is on hospice is a compliance risk; Hospice medical director: the hospice medical director's services to hospice patients are billed by the hospice agency to Medicare Part A (included in the hospice per-diem); the hospice medical director does not separately bill Part B for hospice-related services.
Concurrent Care and Hospice Rules
Concurrent care — providing billable physician services to a patient who is enrolled in Medicare hospice — is one of the most nuanced areas in end-of-life billing: The general rule: when a patient elects the Medicare Hospice Benefit, Medicare covers all care related to the terminal illness under the hospice per-diem; Medicare Part B does NOT pay for physician services related to the terminal illness when the patient is on hospice; Concurrent care exception: a non-hospice physician can bill Medicare Part B for services that are unrelated to the terminal illness; example: a patient on hospice for end-stage lung cancer develops an unrelated condition (urinary tract infection, new fracture) — the treating physician can bill Part B for evaluation and management of the unrelated condition; the claim must identify the condition as unrelated to the terminal illness; using a diagnosis code clearly unrelated to the terminal diagnosis helps support the unrelated nature of the service; Palliative care specialists and hospice patients: a palliative care specialist who sees a hospice patient for services related to pain management, symptom control, or goals-of-care conversations that are part of the hospice plan of care CANNOT separately bill Part B for those services — they are covered under the hospice per-diem; if the palliative care visit addresses something unrelated to the terminal illness, Part B billing may be appropriate; Attending physician billing for hospice patients: the patient's attending physician may continue to bill Part B for attending physician services IF the attending physician is not employed by the hospice; the attending must document the service is not duplicating the hospice physician's services; GV modifier: Modifier GV is added to physician claims for services to a hospice patient that are NOT related to the hospice diagnosis — it identifies the claim as a concurrent care service by the attending physician; GW modifier: Modifier GW is used for services that are unrelated to the terminal condition for a patient enrolled in a hospice; Hospice elections and revocations: if a patient revokes their hospice election, they return to standard Medicare benefits; after revocation, all Medicare-covered services (including curative treatment) are again billable to Medicare Part B.
Palliative Care Program RCM
Palliative care programs — whether hospital-based consultative teams or outpatient palliative care practices — have specific RCM considerations: Hospital-based palliative care consultation team billing: inpatient palliative care consultation is billed using inpatient consultation codes (99252-99255) where accepted, or initial/subsequent hospital care codes (99221-99233) where consultation codes are not recognized; the consulting palliative care team must document: the requesting physician's name and reason for consultation; history and examination relevant to the palliative care assessment; a specific palliative care management plan; HCPCS code G2211 for complex, ongoing relationships: G2211 — Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services; G2211 is billable for office/outpatient E&M visits where the physician serves as the continuing focal point of care; palliative care physicians managing complex symptom control for oncology patients in an outpatient setting may qualify for G2211 as an add-on to the E&M; Documenting separately-identifiable services: when the palliative care team sees a patient on the same day as the primary team, Modifier 25 on the consulting team's E&M may be needed; the palliative care note must be clearly distinct from the primary team's note; Social work and chaplain services: licensed clinical social workers (LCSWs) bill under their own NPI for psychotherapy (90832-90838) and counseling services; chaplain services are generally not billable to Medicare; dietitian services: registered dietitians bill MNT codes (G0270, G0271) for palliative nutrition counseling; Telehealth palliative care: Medicare permanently expanded telehealth for many palliative care services; outpatient ACP and E&M visits can be conducted via telehealth; audio-only telehealth is covered for patients who are unable to use video.
FAQ
Can advance care planning be billed on the same day as an annual wellness visit or other preventive service?
Yes — advance care planning (99497/+99498) can be billed on the same day as an Annual Wellness Visit (AWV), a Welcome to Medicare visit (G0402), or another preventive service. Understanding the rules for same-day billing of ACP with other services is important for maximizing ACP billing in practices that provide ACP during preventive visits. Billing ACP with the Annual Wellness Visit (G0438/G0439): ACP is an optional element of the AWV — the AWV template includes a section for advance care planning; when ACP is provided during an AWV, the AWV code is billed for the preventive visit and 99497 is separately billed for the ACP discussion; both services can be billed on the same date; neither service requires cost-sharing for the Medicare beneficiary (both are preventive benefits); the ACP note must clearly document the ACP discussion separately from the AWV documentation; Billing ACP with an E&M visit: when ACP is provided on the same day as an office visit E&M (99213-99215), both can be billed if the ACP represents a service beyond the routine care of the visit; the ACP time must not be double-counted in the E&M time (if the E&M is billed based on total time, the ACP time should be excluded from the E&M time calculation, as ACP is separately billable); Modifier 33 — not required for ACP: for Medicare patients, ACP is considered a preventive service and is not subject to cost-sharing; Modifier 33 (Preventive Services) is NOT required to waive cost-sharing for ACP; the ACP code itself triggers the cost-sharing waiver; Commercial insurance: commercial payer coverage for ACP varies; some commercial plans cover 99497 as a preventive service; others apply the normal cost-sharing; verify payer-specific coverage for ACP before billing; Time documentation: the ACP note must document the total time spent on ACP discussion; if both AWV and ACP are provided, the AWV documentation and ACP documentation should be maintained as separate note sections or documents to clearly distinguish the services.
What are the billing rules when a patient on Medicare hospice requires treatment for a condition unrelated to their terminal illness?
This is one of the most practically important and operationally complex areas in end-of-life care billing. When a patient on Medicare hospice requires treatment for a condition genuinely unrelated to their terminal illness, those services can be billed to Medicare Part B — but the documentation and billing must clearly establish that the services are unrelated to the hospice diagnosis. The fundamental rule: the Medicare Hospice Benefit covers all care related to the terminal illness and related conditions under the per-diem; Medicare Part B remains available for conditions genuinely unrelated to the terminal illness; What is "related" vs. "unrelated": CMS guidance states that hospice covers all conditions related to the terminal illness, including comorbidities that the hospice is actively treating as part of the terminal illness management; example — a patient on hospice for CHF: heart disease and related conditions (arrhythmias, fluid management) are considered related to the terminal diagnosis; an unrelated acute illness (a new UTI, an unrelated skin infection, a new fracture from a fall) can be billed to Part B; the boundary is not always clear — when in doubt, document the clinical rationale for treating the condition as unrelated; Modifier GW: Modifier GW must be appended to Medicare Part B claims for services provided to a patient enrolled in hospice when those services are unrelated to the hospice terminal condition; GW signals to Medicare that the physician is aware the patient is on hospice and is asserting the service is unrelated to the terminal illness; without GW, the claim may be automatically denied as duplicative of the hospice per-diem; Practical documentation: the physician note for a Part B service to a hospice patient should explicitly state: the patient is enrolled in the Medicare Hospice Benefit; the reason for the visit is [specific unrelated condition]; this condition is not related to the patient's terminal diagnosis of [terminal diagnosis] and is not included in the hospice plan of care; the clinical basis for the unrelated determination; Emergency care: emergency room care for a hospice patient is billed to Medicare Part B if the emergency is unrelated to the terminal illness; if the emergency is related to the terminal illness, the hospice should have authorized the ER visit or it may not be covered under either benefit — a coordination issue between the hospice and the ER.
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Valiant Lifecare's palliative care billing specialists handle advance care planning 99497/99498 documentation and billing, palliative care E&M coding for complex symptom management visits, hospice concurrent care Modifier GV and GW billing compliance, inpatient palliative care consultation coding, and palliative care program revenue cycle management for hospital-based and outpatient palliative care teams.
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