Sourcebook : 9.2 Medicare Payments for Physician Services : 9.2.1 Case Study - Northwestern Memorial Hospital

Chicago's Northwestern Memorial Hospital offers a palliative care consultation service in its acute care facility. The palliative care team comprises a nurse, attending physicians, rotating fellows, medical residents, and medical students. The full consultation - for example, talking with the patient's family members or other loved ones - could take several visits. Comprehensive results of the consultation are recorded in the patient's medical record; the team makes its recommendations surrounding a treatment plan directly to the attending physician.

To avoid the suggestion that the patient did not need hospital services, consultants do not discuss hospice services in the chart notes, unless hospice will clearly be part of a discharge plan. If there is need to clarify or justify the acuity needs of the patient, the consultant makes this explicit in the note. For example, intensive nursing care and frequent physician assessments often require an inpatient hospital setting.

Billing Patterns For Palliative Care at Northwestern

Northwestern Memorial Hospital reports that during one fiscal year, the four attending physicians on the team billed initial consults almost entirely with the code 99254 which is a level 4 visit consisting of a complete history, a comprehensive exam, and moderate level of medical decision-making (a total of 275 times).
Forty-nine percent of the billed charges were collected.
Repeated visits were billed as subsequent care codes not as follow-up consultation codes, since the consult team is usually managing symptoms or providing direct care.

For organizations making their first attempt at offering a palliative care service, the consult model may be a good place to start. It provides a basis for educating patients, other physicians, and family members about the purpose of palliative care. This model has very few overhead costs. A dedicated multidisciplinary palliative care team and an organizational structure within which it can operate are all that is needed. Often the effects on improving services are well worth the risks of denials or of simply not being able to bill enough to fund the program, at least for a while.

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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.

For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].