What CPT codes are used for palliative care consultations?

Inpatient consultations use 99221-99223 for initial hospital care (Medicare) or 99251-99255 (commercial payers recognizing consultation codes). Subsequent visits use 99231-99233. Advance care planning uses 99497 (first 30 min) and 99498 (each additional 30 min). Hospice care uses terminal care codes. Document complexity of discussions and time spent for accurate coding.

How do I document advance care planning for billing (99497/99498)?

Document: participants (patient, family, healthcare proxy), topics discussed (values, goals, life-sustaining treatment preferences, resuscitation wishes), decisions made, advance directive status, healthcare proxy designation, and total time spent. Face-to-face time with patient/family must be documented. Can be billed with E/M using modifier 25 if separate significant service provided.

What symptom documentation is required for palliative care visits?

Document: standardized symptom assessment (ESAS scale), severity ratings for each symptom (pain, dyspnea, nausea, anxiety, fatigue), current symptom management regimen, effectiveness of interventions, and plan adjustments. Include functional status (Palliative Performance Scale or ECOG). Comprehensive symptom documentation supports medical necessity and quality metrics.

How should goals of care discussions be documented?

Document: patient's understanding of illness/prognosis, patient's expressed values and priorities, treatment preferences discussed (resuscitation, hospitalization, nutrition), decisions made and rationale, who participated in discussion, any disagreements or need for further discussion, and documentation completed (advance directive, POLST). This supports care coordination and legal documentation.

What documentation supports hospice eligibility?

Document: terminal diagnosis with expected prognosis ≤6 months if disease runs normal course, physician certification of life-limiting illness, patient election of comfort-focused care, evidence of disease progression (weight loss, functional decline, laboratory trends), and that curative treatment is no longer desired. Include specific clinical criteria for hospice-eligible diagnoses.

Palliative Care Consult Template - Goals of Care

Palliative Care — Consultation Template

Specialty Palliative Care Updated: 1/3/2026

The Palliative Care Consultation Template is designed for palliative care teams evaluating patients with serious, life-limiting illnesses. This template documents symptom burden (pain, dyspnea, nausea), goals of care discussions, code status (DNR/DNI), advance directives, and psychosocial support needs. It supports interdisciplinary documentation for improving quality of life and aligning treatment with patient values. Ideal for inpatient consults and hospice intake.

Quick-Use Checklist

Use this checklist before finalizing documentation.

Confirm visit context, chief concern, and date/time of service before note completion.

Capture required exam/findings and plan elements that support coding specificity.

Document medical decision making clearly to reduce denials and audit risk.

Visit Information

Date: [Date]
Visit Type: Initial Consult / Follow-up
Reason for Consult: Symptom Management / Goals of Care / Code Status / Family Support
Referring Provider: [Name]

History of Present Illness

Primary Diagnosis: [Terminal or chronic condition] Trajectory: [Recent decline, hospitalizations, functional status change] Current Status: [Hospital day X, current interventions]

Symptom Assessment (ESAS)

Pain: [0-10] [Location, quality, current analgesics]
Dyspnea: [Severity, at rest vs exertion, O2 needs]
Nausea/Vomiting: [Frequency, triggers]
Anxiety/Depression: [Mood, existential distress]
Consipation/Bowels: [Last BM, regimen]
Appetite/Intake: [Poor, percentage of meals]
Delirium/Confusion: [Present / Absent]

Psychosocial / Spiritual

Caregivers: [Who is at bedside/home?] Understanding of Illness: [Patient/Family awareness of prognosis] Values: [What matters most? Independence, time with family, avoiding pain] Spiritual Needs: [Chaplaincy referral needed?]

Medical Review

Pertinent Meds: [Opioids, Benzos, Antiemetics] Treatments: [Chemo, Dialysis, Vent, Pressors - discussions on utility]

Physical Exam

General: Cachectic / Comfortable / Distressed Resp: Effort, secretions (death rattle) Abd: Distension, tenderness Ext: Edema, mottling

Goals of Care Discussion

Participants: [Patient, Family members, Staff] Discussion Content:

Reviewed medical status and likely prognosis.
Explored patient values: [Quality vs Quantity of life]
Discussed Code Status options.

Decisions Made:

Code Status: Full Code / DNR / DNI / Comfort Measures Only
Transfer: Hospitalize / Do Not Hospitalize / Hospice Referral
Artificial Nutrition/Hydration: Wanted / Not Wanted

Assessment & Plan

Impression: Patient with [Condition] approaching [End of life / Transition point]. Symptom Plan:

Pain: Adjust [Morphine/Dilaudid] to [Dose].
Dyspnea: Initiated [OPIOID/BENZO] protocol.
Secretions: [Glycopyrrolate/Scopolamine].

Discharge Planning:

Referral to [Hospice Agency] initiated.
Anticipated discharge to [Home/Facility].

Follow-up:

Daily support for patient/family.