New Policy Guidance for Palliative Care

December 29, 2017

In November, 2017, the Department of Health Care Services (DHCS) issued the new SB 1004 Medi-Cal Palliative Care Policy as required by Senate Bill 1004 (Hernandez, Chapter 574, Statutes of 2014). This policy is effective for dates of service on or after January 1, 2018.

Medi-Cal providers may render medically necessary palliative care services for recipients who meet both the general eligibility criteria and disease-specific eligibility criteria identified in the November 2017 SB 1004 Medi-Cal Palliative Care Policy, for at least one of the following diagnoses:

  • Congestive heart failure
  • Chronic obstructive pulmonary disease
  • Advanced cancer
  • Liver disease

Medi-Cal covered palliative care services rendered in an inpatient setting, outpatient setting or in the patient’s home include advance care planning, palliative care assessment and consultation, pain and symptom management, mental health services, discharge planning, caregiver assessment/support, plan of care, care coordination and a palliative care team. DHCS recommends recipients have access to chaplain services, although chaplain services are not separately reimbursable under Medi-Cal.

Medi-Cal will implement system changes to allow providers identified in SB 1004, as allowable providers of palliative care services. These system changes will be retroactive to January 1, 2018. Providers will be able to use the following existing billing codes when submitting claims for palliative care services.

Palliative Care Service Billing Codes
Advance Care Planning (Inpatient/Outpatient [I/O] and Hospital [H]) Evaluation and Management (E&M) codes 99497 (reimbursable twice a year before Treatment Authorization Request [TAR] override) & 99498 (reimbursable once a year before TAR override)
Palliative Care Assessment and Consultation (I/O) E&M codes for counseling
Palliative Care Assessment and Consultation (H) E&M codes 99341 – 99350 for MD/NP, or Home health for RN/LPN
Pain and Symptom Management (I/O) Prescription drugs, physical therapy (TAR)
Pain and Symptom Management (H) Home health physical therapy
Mental Health Services, Discharge Planning (I/O) Individual and group psychotherapy, hospital or Nursing Facility Level B discharge planning
Mental Health Services and Caregiver Assessment/Support (H) Medical social services within home health
Plan of Care (I/O) E&M codes
Plan of Care (H) Home health or E&M codes 99341 – 99350
Care Coordination (I/O) E&M codes
Care Coordination (H) Home health or E&M codes 99341 – 99350
Palliative Care Team (I/O) E&M codes 99366 and 99368
Palliative Care Team (H) Home health or E&M codes 99341 – 99350