Palliative Care - Medicare Advantage

Policy No: 136
Originally Created: 01/01/2019
Section: Administrative
Last Reviewed: 11/01/2023
Last Revised: 12/01/2022
Approved: 11/09/2023
Effective: 12/01/2023
Policy Applies To: Medicare Advantage

This policy applies only to physicians, facilities and other qualified health care professionals.

Palliative Care
Specialized medical care for people with serious illness. This type of care is focused on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family. Regence considers palliative care appropriate for a wide variety of diagnoses, chronic pain alone does not qualify a member for palliative care.

Palliative care services are specialized medical care for people living with serious illness who may have more focused medical goals depending on their prognosis. Care is focused on providing patients with relief from symptoms, pain and stress of a serious illness regardless of the prognosis. The individual providers that can provide palliative care can include but are not limited to:

• Physician
• APRNs - Includes Clinical Nurse Specialists (CNSs) and Nurse Practitioners (NPs), depending on state regulations on scope of practice
• Physician Assistant

• Social Worker

Acceptable Current Procedural Terminology (CPT®)/Healthcare Common Procedure Coding System (HCPCS)/Rev Codes for facilities

• 90832-90834 and 90837-90840 - Clinical Social Worker Visits. Individual psychotherapy insight oriented.
• 90845-90847 - Psychoanalysis and Family Therapy
• 98960-98962 – Education and Training for patient self-management
• 99071 – Medicine Service
• 99078 – Physician educational services rendered in a group setting
• 99324-99328 and 99334-99337 - Domiciliary or Home visit for counseling
• 99341-99345 and 99347-99350 - Home Visits (Physician/Nurse Practitioner).
• 99354-99355 - Prolonged Psychotherapy Services

• Claim line should also be billed with Z51.5 as the primary ICD-10 code

99497 and 99498 can still be billed as palliative care, regardless of ICD-10, and will be subject to general medical benefits.

Centers for Medicare & Medicaid Services (CMS), 2016. ‘Incident To' Services. MLN Matters Number: SE0441

Centers for Medicare & Medicaid Services (CMS), 2017. Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services. Section 60.4 – Services Incident to a Physician's Service to Homebound Patients Under General Physician Supervision

Noridian Healthcare Solutions, 2022. 'Incident To' Services

Claims and Payment; Claims Submission

Center to Advanced Palliative Care - CAPC

Incident to Services

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.