I apologize if this isn’t the right forum in which to ask this question – I couldn’t quite decide if I should post here or the Inpatient forum – but one of the groups for which I code added a LCSW in the palliative care setting. I am new to this kind of coding, and don’t quite see where the services being performed line up to the CPTs that I am being told should be used for LCSW’s services. Here’s a fairly typical example of the kind of note that we are seeing with all the PHI scrubbed out:

"Met with daughter and patient at bedside. Daughter hoping for SNF. We discussed reasonable expectations, daughter understands that patient will not walk again, she would like her to be able to transfer bed to potty and wheelchair if possible. She is struggling because pt is stubborn and does not like having mobility restrictions. We provided supportive counseling and emotional support, she is experiencing some caregiver burnout as she works full time and take care of patient all the rest of the time. Pt sundowns daily and has increased agitation, does not like having an aid or for her daughter to assist her with ADLs. Daughter reports pt usually does not recognize her, describes patient actively hallucinating (seeing her parents, searching for them). Dr feels patient has dementia after his assessment.

LCSW questioned patient’s daughter about experiences with X Hospice. She reports patient has been with them almost a year and she had no issues until recently when pt had a kidney infection and they would not do a UA to test for it or treat it. She also had issues prior to this admission, reports they refused to let her revoke hospice for almost 24 hours while pt was in pain at home.

We will continue to follow and provide supportive counseling to patient’s daughter. If patient does not progress in therapy and has further decline or readmission, hospice may again be appropriate. For now we agree with plan to try rehab. Palliative care following."

I had been looking at the 96150-96155 CPTs but most of the patients are similar to the one above, where they are not alert/oriented enough to truly participate, and I don’t think any of the other CPTs really fit either. Is that sort of service actually billable? Can anybody point me in the right direction? Thank you!