ateness of diagnostic, procedure, and other payment-related classification schemes that were originally developed for adult services. These schemes include DRGs for hospital payment and an RBRVS for physician payment. Many private payers and Medicaid programs have adopted these classification schemes (although not necessarily the level of payment associated with them). Given the confusion about billing for palliative care services and the frequent denials of payment for improper coding or documentation, access to care may also be improved by providing clearer guidance about accurate coding and documentation of covered palliative services. Although providers faced with claims denials and hassles may sometimes render services without billing for them, they may also opt not to provide the services or to avoid patients that need such services.

Recommendation: Federal and state Medicaid agencies, pediatric organizations, and private insurers should cooperate to (1) define diagnosis and, as appropriate, severity criteria for eligibility for expanded benefits for palliative, hospice, and bereavement services; (2) examine the appropriateness for reimbursing pediatric palliative and end-of-life care of diagnostic, procedure, and other classification systems that were developed for reimbursement of adult services; and (3) develop guidance for practitioners and administrative staff about accurate, consistent coding and documenting of palliative, end-of-life, and bereavement services.

Again, these recommendations target only a subset of financial barriers to competent and reliably available palliative, end-of-life, and bereavement care. Uninsurance, underinsurance, certain managed care requirements, and radically low levels of provider payment also constitute significant barriers. Reducing or removing these barriers will require far more comprehensive changes in policies.

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