Palliative medicine can relieve the symptoms and emotional stress of serious illnesses, aiming to improve the quality of life for the affected patients and their families. However, unlike more structured medical specialties like hospice, palliative medicine practices can face certain medical billing and coding challenges, as they lack defined, specialized codes. These can result in delayed payments, underpayments, or even denied claims.

Here, we discuss the most common billing and coding mistakes in palliative medicine and offer ways for practices to correct them. Working with a billing expert like StarkBilling can also ensure that these issues are resolved efficiently and smoothly.

Five Billing and Coding Mistakes in Palliative Medicine

Unfortunately, billing errors in palliative medicine are not uncommon and can affect the entire revenue cycle. Small or large, they can ultimately lead to miscommunication between providers, insurers, and patients. The most common mistakes arise due to the absence of specific codes, incorrect documentation, and confusion with other specialties. Here’s a breakdown.

1. Imprecise ICD-9/ICD-10 and CPT Codes

Recording ICD-9/ICD-10 and CPT codes accurately may be one of the most frequent challenges in palliative care billing. Due to the absence of specific palliative codes, in-house billers often rely on broader, less precise codes, which can ultimately lead to errors if the billers are not careful. Incorrect code selection or outdated codes can result in claim denials or delays, slowing reimbursement and impacting the practice’s cash flow.

However, medical billing teams can avoid these pitfalls by staying current with coding guidelines and being well-trained in selecting the most appropriate codes. Additionally, regular audits and updates to the coding system can help prevent costly errors and ensure that claims are processed smoothly.

2. Incorrect Codes for Underlying Conditions During Same-Day Specialist Visits

In cases where palliative care providers treat a patient on the same day as a specialist managing the underlying condition, ensure that the coding reflects each provider’s specific role. Palliative care practitioners should focus their billing on the symptoms that they manage while leaving the underlying disease coding to the referring specialist. This can help prevent claim denials while helping to avoid negative impacts on the referring provider’s reimbursement.

Clear documentation of the symptoms treated during the visit ensures that each physician can accurately bill for their time without overlap, improving the likelihood of reimbursement for both.

3. Errors in Split/Shared Billing Practices

In palliative care, split/shared billing can apply when a physician and an advanced practice provider work together to manage a patient’s symptoms in a hospital setting. Both providers must document their specific contributions to the patient’s care, as errors in split/shared billing, such as incomplete or unclear documentation, can lead to claim denials or delays. Properly distinguishing who treated which aspects of the patient’s condition ensures accurate billing, especially when symptom management and underlying disease treatment overlap in palliative care.

4. Inadequate Documentation of Medical Necessity

Inadequate documentation of medical necessity is a common issue in palliative care billing, often resulting in many denied claims. The chief complaint is essential in establishing the purpose of the visit and justifying why the care was initially needed, as auditors will heavily scrutinize the reason. Unfortunately, when documentation lacks clearly defined reasons for a patient’s visit or condition, insurers may question the services’ necessity.

Billers can avoid this by ensuring that the chief complaint is explicitly stated and by providing supporting details, which offer insurers information about symptom severity and its impact on the patient’s quality of life. Precise documentation is crucial for proper reimbursement and ensures transparency.

5. Time-Based Coding Problems

Time-based coding can be confusing in palliative care, especially when managing challenging cases. To use time-based billing effectively, providers must document that more than half of the visits involved counseling or care coordination. In short, this means noting the time spent with the patient and family during the visit and detailing what was discussed and coordinated.

However, palliative care sometimes involves managing high-risk patients with severe symptoms, such as dealing with chronic pain or managing multiple chronic illnesses. In these cases, coding based on complexity rather than time may be more appropriate, as it better reflects the intensity of care required. Providers should carefully assess each situation to ensure that the coding method aligns with the services provided, preventing underbilling and ensuring proper reimbursement.

Medical billing in palliative care is indeed a complex and meticulous process. Due to the specialty’s unique nature, errors and coding issues are quite common. However, practices can ensure accurate billing and coding for palliative care by implementing the right strategies and working with a seasoned billing partner.

How to Correct Billing and Coding Issues in Palliative Medicine (with StarkBilling’s Help)

Palliative care billing and coding mistakes can be corrected, but the process requires a thorough understanding of the medical and administrative aspects of the services. These can be challenging to grasp and continuously uphold while also tending to other administrative tasks. Fortunately, a medical biller like StarkBilling, which has over forty years of experience, can assist in these critical areas. Here are the solutions to common billing errors and advice for streamlining the process in palliative support.

ICD-10 and CPT Code Mastery

Mastering the correct use of ICD-10 codes and CPT codes is essential for accurate billing in palliative care. The former focus on documenting the patient’s diagnosis, while the latter relate to the specific procedures and services provided. Misunderstanding or misapplying these codes can lead to confusion, delays in reimbursement, or outright claim denials. Palliative care practitioners often deal with complex symptom management, so selecting the appropriate CPT codes for the services rendered is preferred over relying on the diagnosis alone.

With StarkBilling, practices can ensure accuracy, reduce errors, and maximize reimbursement. Their team stays updated on coding guidelines and can offer valuable insights to avoid common pitfalls.

Updated Medicare Specialty Codes to Reflect Palliative Care Practice

In palliative care, clinicians must update their Medicare specialty codes to reflect their Hospice and Palliative Medicine practice. Medicare differentiates between providers based on their specialty. If two providers from the same group bill for the same service on the same day with the same specialty code, the claim will be denied because it is considered a duplicate.

Medical billers can avoid these issues by updating their classification to specialty code 17 (physician/hospice and palliative care). StarkBilling assists practices by ensuring that their providers are correctly classified with Medicare, preventing duplicate service rejections and ensuring smoother billing processes.

Proper Documentation of Key Components for Split/Shared Visits

Getting billing done right requires palliative care providers, physicians, and advanced practice providers to properly document their contributions. Each professional must clearly outline and sign off on the specific parts of their patient’s visit.

StarkBilling works with practices to ensure that this documentation is thorough and compliant with Medicare’s split/shared billing guidelines. This reduces the risk of claim denials by guaranteeing that each practice’s role is clear, helping secure appropriate reimbursements.

Comprehensive Documentation Practices

Comprehensive documentation is significant in palliative care, as every detail matters for Medicare compliance. Failing to include critical information, such as medical necessity, whether due to lack of training or the assumption that specific details are unimportant, can result in denied claims or even reduced reimbursements.

Palliative care providers must document a comprehensive history of the present illness, a thorough review of systems, and relevant medical, social, and family history, even if it seems clinically irrelevant. While StarkBilling is not responsible for medical documentation, it guides providers to ensure that all required documentation is properly completed, helping to avoid issues with Medicare’s strict standards and ensuring accurate billing.

Accurate Time Tracking

Accurate time tracking is essential in palliative care billing, but understanding when to bill based on time versus intensity is equally important. While time-based billing is appropriate when most of the visit is spent on counseling or care coordination, palliative care providers often handle challenging, high-intensity cases that are better billed by intensity rather than time. Unfortunately, misjudgment can cause problems like incorrect billing and lost revenue for the practice.

With StarkBilling, you can ensure that bills are generated accurately and appropriately based on the intensity of care provided, leading to better reimbursement outcomes and decreased errors.

Conclusion

While billing and coding mistakes in palliative support are common due to the challenges of interpreting complex codes, lacking specific palliative care codes, and dealing with the overall less structured nature of the field, there are several ways to address these issues.

In-house billers can practice accurate documentation, properly use ICD-10 and CPT codes, and ultimately work on understanding the nuances of time-based versus intensity-based billing to reduce errors. Partnering with StarkBilling can bring further success to palliative care medical billing. With its team’s years of experience in medical billing, it can provide expert guidance to streamline your billing process, reduce errors, and maximize reimbursements, enabling you to focus on providing quality care to your patients.

Capture more revenue, and grow your New York procedural-based practice with a specialized medical billing partner that has in-depth knowledge of the coding requirements for all your diverse procedures. Our tailored solutions aim to enhance coding accuracy, reduce denials, and expedite payments. Schedule a free consultation now.