Date of Award


Degree Name

Nursing (D.N.P.)


College of Nursing


Background and Objectives: Home palliative care services are challenging to bill due to the complexity of services and competing time demands. Objectives and protocol were developed to guide coding and billing to increase Relative Value Unit generation and improve financial sustainability.

Design: A quality improvement project.

Setting: A home-based palliative care program in one health system in the Midwest.

Participants: Participants included 7 nurse practitioners.

Intervention: Coding protocol were developed, providers were educated, electronic health record audits were conducted to collect data on improvement, and feedback provided to prompt improvement.

Measurement and Analysis: Documentation of advanced care planning and billing, visits by discipline, and revenue generation and codes utilized were examined. Observation of advanced care planning conversations occurred during home visits. Provider education knowledge and satisfaction were surveyed. Descriptive statistics and chi-square or simple t-tests were used.

Results: Number of nurse practitioners increased (2 to 7) during implementation. Clinician knowledge increased a mean of 2.0 (2.7-4.7 [of 5]) after education; and 100% were satisfied. There were 16.7% (n=60) initial visits examined prior to implementation and 83.3% (n=55) after. Improved advanced care planning length (2.3-minutes; [18.5 to 20.8]), documentation (18.3% [61.7% to 80%]), and billing (36% [16.7% to 52.7%]) occurred as a result of the project. Return on investment for this project totaled $62,537.

Conclusion: Billing and coding practices can be improved through use of coding protocol, education, and audit and feedback to support financial sustainability. As a result of accurate coding, increased reimbursement for services provided can occur.