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Physician Reimbursement for Critical Care Services Integrating Palliative Care for Patients Who Are Critically IllReimbursement for ICU Palliative Care

Dana R. Lustbader, MD; Judith E. Nelson, MD, JD, FCCP; David E. Weissman, MD; Ross M. Hays, MD; Anne C. Mosenthal, MD; Colleen Mulkerin, MSW, LCSW; Kathleen A. Puntillo, RN, DNSc; Daniel E. Ray, MD, FCCP; Rick Bassett, MSN, RN, APRN, ACNS-BC, CCRN; Renee D. Boss, MD; Karen J. Brasel, MD, MPH; Margaret L. Campbell, PhD, RN; Therese B. Cortez, MSN, NP, ACHPN; J. Randall Curtis, MD, MPH, FCCP;; for The IPAL-ICU Project
Author and Funding Information

From the Division of Palliative Medicine (Dr Lustbader), North Shore University Hospital, Manhasset, NY; the Department of Medicine (Dr Nelson), Mount Sinai School of Medicine, New York, NY; the Department of Internal Medicine (Dr Weissman), Medical College of Wisconsin Milwaukee, WI; the Department of Pediatrics (Dr Hays), Seattle Children’s Hospital, Seattle, WA; the Division of Critical Care and Palliative Care (Dr Mosenthal), University of Medicine and Dentistry, Newark, NJ; the Department of Palliative Medicine (Ms Mulkerin), Hartford Hospital, Hartford, CT; the School of Nursing (Dr Puntillo), University of California, San Francisco, San Francisco, CA; the Critical Care Department (Dr Ray), Lehigh Valley Health Network, Allentown, PA; St. Luke’s Hospital (Mr Bassett), Boise, ID; the Department of Pediatrics (Dr Boss), Johns Hopkins Hospital, Baltimore, MA; the Department of Surgery (Dr Brasel), Froedtert Hospital, Milwaukee, WI; the Department of Nursing (Dr Campbell), Detroit Receiving Hospital, Detroit, MI; the Department of Palliative Care (Ms Cortez), Veterans Integrated Service Network 3, New York, NY; and the Division of Pulmonary and Critical Care Medicine (Dr Curtis), Harborview Medical Center, Seattle, WA.

Correspondence to: Dana R. Lustbader MD, Hofstra North Shore-LIJ School of Medicine, Palliative Medicine, Critical Care Medicine, North Shore University Hospital, 300 Community Dr, Manhasset, NY 11030; e-mail: Lustbader@nshs.edu


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2012 American College of Chest Physicians


Chest. 2012;141(3):787-792. doi:10.1378/chest.11-2012
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Patients with advanced illness often spend time in an ICU, while nearly one-third of patients with advanced cancer who receive Medicare die in hospitals, often with failed ICU care. For most, death occurs following the withdrawal or withholding of life-sustaining treatments. The integration of palliative care is essential for high-quality critical care. Although palliative care specialists are becoming increasingly available, intensivists and other physicians are also expected to provide basic palliative care, including symptom treatment and communication about goals of care. Patients who are critically ill are often unable to make decisions about their care. In these situations, physicians must meet with family members or other surrogates to determine appropriate medical treatments. These meetings require clinical expertise to ensure that patient values are explored for medical decision making about therapeutic options, including palliative care. Meetings with families take time. Issues related to the disease process, prognosis, and treatment plan are complex, and decisions about the use or limitation of intensive care therapies have life-or-death implications. Inadequate reimbursement for physician services may be a barrier to the optimal delivery of high-quality palliative care, including effective communication. Appropriate documentation of time spent integrating palliative and critical care for patients who are critically ill can be consistent with the Current Procedural Terminology codes (99291 and 99292) for critical care services. The purpose of this article is to help intensivists and other providers understand the circumstances in which integration of palliative and critical care meets the definition of critical care services for billing purposes.


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