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Improving Palliative Care for Cancer
reimburse them, despite the example given in the CPT 2000 appendix citing the use of these codes to counsel family members without the presence of the patient. Therefore lengthy counseling time is not being reimbursed at all. COG PIs reported as follows: 77 percent do not bill these because they will not be reimbursed; 23 percent do bill them, reporting amounts paid as low as $10.00–30.00.
Lack of reimbursement or poor reimbursement for the prolonged services codes is a serious problem for pediatrics, but the total nonreimbursement of non-face-to-face time codes is an even greater problem for several reasons. First, the parents of seriously ill children often wish to discuss treatment issues—particularly issues regarding the possible death of the child—without their child present. Second, when the child is an infant or toddler, his or her face-to-face presence is irrelevant to the discussions, and children most often are not present for medically complex conversations. Third, interdisciplinary team management is discouraged by this system. Often, when the physician is with the parents, child life or social work staff are counseling the child patient. There are no codes for the latter staff to charge, so their services are bundled into the physician or team services. As a result, the charges that providers code must support the services of the entire team working with the child and family. The American Academy of Hospice and Palliative Medicine training guide for physicians (Storey and Knight, 1996) states that current reimbursement systems “discourage significant patient-physician interaction by selectively reimbursing for brief, procedure-related visits.”
Representative examples from the practices of the authors are presented described below.
A young girl with a brain tumor had a suspicious lesion on magnetic resonance imaging (MRI) at the end of therapy. The child was scheduled for a biopsy, under anesthesia; the oncology pediatric nurse practitioner did the history and physical that morning. The neurosurgeon performed the biopsy and frozen section confirmed the malignancy that day. An hour later, the pediatric oncologist spent 90 minutes with the parents, reviewing the biopsy results, discussing their sadness and fear, and going over with them the treatment options as well as strategizing about how to tell the 10-year-old child. The oncology billing office stated that there was no way for the pediatric oncologist to bill for this time. It was not face-to-face with the patient, and 99238 or 99239 codes are denied in that state. Codes 99354– 99357 could not be used as extended time codes, since the oncologist had not done the history and physical and thus, had not had any face-to-face contact with the child, which is required for those codes. Thus, 90 minutes of time, highly valued by the family, was not reimbursed at all.
A hospital visit of intermediate complexity, which included assess-