Hospice & Palliative Care Billing & Coding Guide
Advance care planning 99497, hospice consult vs concurrent care, GV/GW modifiers.
Common Hospice & Palliative Care CPT Codes
Ranked by claim frequency, with current MPFS work RVUs and global periods.
| Code | Description | Work RVU | Total RVU | Global |
|---|---|---|---|---|
| 99497 | Advncd care plan 30 min | 1.50 | 2.60 | XXX |
| 99498 | Advncd care plan addl 30 min | 1.40 | 2.34 | ZZZ |
| 99221 | 1st hosp ip/obs sf/low 40 | 1.63 | 2.23 | XXX |
| 99222 | 1st hosp ip/obs moderate 55 | 2.60 | 3.50 | XXX |
| 99223 | 1st hosp ip/obs high 75 | 3.50 | 4.68 | XXX |
| 99231 | Sbsq hosp ip/obs sf/low 25 | 1.00 | 1.32 | XXX |
| 99232 | Sbsq hosp ip/obs moderate 35 | 1.59 | 2.11 | XXX |
| 99233 | Sbsq hosp ip/obs high 50 | 2.40 | 3.20 | XXX |
| 99238 | Hosp ip/obs dschrg mgmt 30/< | 1.50 | 2.24 | XXX |
| 99239 | Hosp ip/obs dschrg mgmt >30 | 2.15 | 3.19 | XXX |
| 99341 | Home/res vst new sf mdm 15 | 1.00 | 1.47 | XXX |
| 99342 | Home/res vst new low mdm 30 | 1.65 | 2.36 | XXX |
| 99344 | Home/res vst new mod mdm 60 | 2.87 | 4.39 | XXX |
| 99345 | Home/res vst new high mdm 75 | 3.88 | 6.29 | XXX |
| 99347 | Home/res vst est sf mdm 20 | 0.90 | 1.38 | XXX |
| 99348 | Home/res vst est low mdm 30 | 1.50 | 2.36 | XXX |
| 99349 | Home/res vst est mod mdm 40 | 2.44 | 3.96 | XXX |
| 99350 | Home/res vst est high mdm 60 | 3.60 | 5.78 | XXX |
What Hospice & Palliative Care practices are leaving on the table
High-value services that consistently get under-billed across the specialty. Each one is rooted in current 2026 fee schedule and policy updates.
Underutilization of 99483 (cognitive impairment assessment, 3.84 RVU) in Hospice & Palliative Care admissions. Most practices bundle cognitive screening into home visit without separate billing. Opportunity: document MMSE or Montreal Cognitive Assessment at admission; bill 99483 separately if performed as distinct service. Estimated impact: $120-180 per claim (reimbursement varies by payer). Workflow change: add cognitive screening tool to admission template and create separate 99483 encounter line if MDM warrants.
Chronic care management (99490/99491) undercoded when patients have multiple conditions. Many practices bill 99490 (staff-led, 1 RVU) instead of 99491 (physician-led, 1.5 RVU) due to confusion over role definition. Opportunity: clarify billing rules (physician must personally perform >50% of time). Estimated impact: $60-90 per monthly claim if upgraded from 99490 to 99491. Workflow: document physician review/signature on care plan and team communication to support physician-led designation.
99497/99498 (advance care planning) rarely billed by Hospice & Palliative Care despite CMS reimbursement and high complexity. Many practices include this discussion in admission E/M without separate line item. Opportunity: recognize when discussion exceeds 30 minutes and bill 99497 + 99498 add-on in same encounter. Estimated impact: $180-270 per claim (time-based codes, often higher in Hospice setting). Workflow: start timer during goals-of-care conversation, document completion time, and ensure chart note captures specific patient preferences and family involvement.
Modifier 25 underutilization when Hospice physician performs complex medication management review on same day as standard home visit. Many coders default to single E/M code instead of recognizing separately identifiable service. Opportunity: when medication review, symptom assessment, or care plan revision occurs beyond visit scope, bill primary E/M + 99490 or secondary E/M with modifier 25. Estimated impact: $100-150 per additional claim per visit. Workflow: train physicians to time-stamp medication reviews and document decision-making distinct from routine visit to support audit defense.
Code pairs that auto-bundle to CO-97
From the National Correct Coding Initiative for Hospice & Palliative Care. The rationale tells you when a modifier legitimately bypasses the edit and when it cannot.
99491 (physician-led chronic care management) bundles with 99490 (staff-led CCM) in the same calendar month. They share the same 20-minute threshold and cannot both be billed. Use 99491 only if physician personally performs work.
99497 and 99498 are time-paired codes (30 min initial, 30 min add-on). Both require documentation of advance care planning discussion. Cannot bill 99497 twice or 99498 without first billing 99497 in the same month.
99345 (new patient home visit, high MDM) bundles with 99483 (cognitive impairment assessment) when the same patient is seen the same day. 99345 is the primary service; 99483 is redundant. Append modifier 59 only if cognitive assessment is distinct from the home visit E/M.
99238 (discharge management) cannot be billed with 99231 (subsequent hospital visit) on the same day. 99238 is the appropriate code when discharge occurs; using both inflates service count and triggers RAC review.
Modifier Guidance for Hospice & Palliative Care
When each modifier legitimately applies in this specialty, with denial-pattern context and audit-defense documentation.
Modifier 25 applies when a significant, separately identifiable E/M is performed on the same day as a non-E/M service. In Hospice & Palliative Care, example: patient admitted to inpatient unit (99223 as first visit) and same day physician performs complex medication review and symptom assessment beyond the admission visit scope, billed as 99223-25 with 99490 or separate E/M with thorough documentation of distinct time and medical decision-making.
Modifier 59 or X-modifiers (XS, XU) indicate distinct procedural services normally bundled are performed separately. In Hospice context, rarely applicable since most codes are E/M only. If used, requires explicit chart note stating service is unrelated or performed on distinct anatomical area/structure. RACs scrutinize 59 heavily; ensure documentation timestamps and clinical necessity are explicit.
Modifier GP designates services delivered under outpatient physical therapy plan of care. In Hospice & Palliative Care, this applies when PT services are billed alongside physician E/M on same day (comfort care, mobility assessment, pain management through movement). PT must have its own documented plan and physician E/M must be separately identifiable to support concurrent billing.
Modifier 95 indicates synchronous telemedicine via real-time audio/video. Hospice & Palliative Care increasingly uses telehealth for follow-up visits and family meetings. Append 95 to the E/M code (e.g., 99348-95) when visit is conducted remotely. Ensure EMR documents platform used, patient/provider location, and synchronous interaction confirmed.
Modifier KX certifies that medical policy requirements for the service have been met. Some payers require KX on high-frequency codes like 99491 or 99483 to confirm medical necessity and care plan documentation exist. Check payer contracts; Medicare rarely requires KX but UHC and Anthem may demand it for chronic care management codes.
Documentation requirements
What needs to live in the encounter note for these codes to survive a payer audit.
- Time stamp for each E/M visit (start/stop) to defend time-based code selection (99490/99491 minimum time thresholds, 99497/99498 30-minute increments) and support audit defense if challenged on code level.
- Medical decision-making summary (problem list, assessment, plan per encounter level) to substantiate complexity level claimed (straightforward, low, moderate, high) for 99221-99223 and 99341-99350 audits.
- Coordination of care documentation showing communication with other providers, family, or care team when billing 99490/99491 to demonstrate active care management and justify monthly billing.
- Advance care planning discussion summary (goals of care, preferences, surrogate decision-maker identified) linked to 99497/99498 claims; missing this is the #1 denial reason for these codes.
- Patient/family consent or acknowledgment of telehealth (if applicable) and confirmation of synchronous interaction to support modifier 95 coding and fend off retrospective denials for non-face-to-face claims.
- Cognitive assessment results or documented impairment rationale when billing 99483 to prevent bundling denial with concurrent E/M; must show distinct cognitive screening or evaluation beyond standard history/exam.
OIG and audit triggers in Hospice & Palliative Care
Patterns that show up in OIG Work Plans, RAC audits, and CERT improper payment reviews. Build internal compliance checks around these.
OIG Work Plan FY2025 targeting Hospice & Palliative Care billing for concurrent E/M and care management codes (99490/99491 bundled improperly with office visits). Audit focus: same calendar month billing of both codes on same patient. Defense: maintain separate care plan documentation showing staff-led vs. physician-led components and distinct calendar months.
RAC pattern on 99497/99498 (advance care planning) denying claims lacking documented advance directive discussion or goals-of-care conversation. Audits often reject claims with vague documentation like 'discussed prognosis' without specific patient preferences recorded. Defense: create template capturing surrogate ID, specific wishes (CPR/intubation/comfort-focused), and patient understanding confirmed.
CMS LCD scrutiny on 99483 (cognitive impairment) when billed with home visit codes (99345/99350) same day without distinct cognitive screening tool or separate assessment note. Bundling denials spike when chart shows single visit note covering both E/M and cognition. Defense: separate progress note section for 99483 showing MMSE, SLUMS, or clock-draw score with interpretation.
Commercial payer (UHC, Anthem, Cigna) denial of 99491 when no monthly team communication documentation exists. Payers interpret 'chronic care management' as requiring evidence of staff coordination and physician oversight. Claim rejection rate 15-22% when case manager notes missing. Defense: attach team meeting summary or care coordinator note showing touchpoints with patient/family and physician review.
Payer-specific billing notes
Where the major payers diverge from generic Medicare rules in Hospice & Palliative Care.
ME Medicare +
CMS LCD L33822 (Hospice and Palliative Care E/M Services) covers 99221-99223, 99231-99233, 99238-99239 for inpatient settings and 99341-99350 for home/residence visits with no restrictive frequency limits. 99490/99491 and 99497/99498 are covered under separate CPT guidelines with monthly time thresholds (20 min, 30 min respectively). No prior auth required. FY2026 changes: CMS emphasized documentation of team-based care and distinct cognitive assessment; expect increased medical review targeting bundling patterns.
UN UnitedHealthcare +
UHC medical policy 2025 requires prior authorization for chronic care management (99490/99491) when patient is also receiving concurrent Hospice services; auto-denies dual billing. Home visit codes (99341-99350) require documented medical necessity and ICD-10 diagnosis tied to palliative/comfort care. UHC Optum delegations vary by state. Advance care planning codes (99497/99498) require documented advanced directive form or state-compliant goals-of-care template attached to claim.
AN Anthem +
Anthem Blue Cross medical policy (varies by state Blue plan) covers 99221-99223 and 99231-99233 for inpatient Hospice admissions but caps 99238/99239 discharge codes at one per admission. Home visit codes require care coordinator or nurse assessment note supporting physician visit. Anthem's AIM (Automation in Motion) system auto-denies 99490 + 99491 same month; prior auth must specify which code will be billed. No modifier 25 bypass for concurrent E/M + CCM.
CI Cigna +
Cigna medical policy covers Hospice & Palliative Care E/M codes with standard CMS RVU reimbursement; no specific LCD restrictions. eviCore does not typically manage Hospice E/M prior authorization. Cigna's interpretation of 99497/99498 requires that conversation occur in real time (not telehealth recap call); attach visit note timestamp. Cognitive assessment (99483) requires ICD-10 diagnosis code confirming dementia or neurocognitive disorder; codes without that linkage auto-deny.
Standard Hospice & Palliative Care coding workflow
Step 1: At visit start, confirm patient status (new vs. established, location, setting: home/residence, hospital inpatient, observation). Step 2: Document time spent and medical decision-making level (straightforward/low/moderate/high) with specific clinical elements. Step 3: Identify if concurrent services apply (CCM, advance care planning, cognitive assessment) and check bundling logic against same-day rules. Step 4: Assign primary E/M code and determine if modifiers 25, 59, 95, or specialty modifiers (GP/GO/GN) apply; verify payer requirements for KX or ABN. Step 5: Link all claim line items to corresponding chart documentation, including time stamps and clinical justification; submit with supporting notes flagged for auditor review if codes appear high-frequency or bundling-adjacent.
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Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on May 31, 2026.
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