HCPCS Level II S0311: Comprehensive Advanced Illness Care Management, Monthly - OpenPayer

Summary & Overview

HCPCS Level II S0311: Comprehensive Advanced Illness Care Management, Monthly

HCPCS Level II code S0311 denotes monthly comprehensive management and care coordination for patients with advanced illness. The code captures longitudinal services that integrate symptom management, care planning, and coordination across providers and settings, addressing complex clinical and psychosocial needs. As population aging and chronic disease burdens increase, a nationally recognized billing pathway for comprehensive advanced-illness management informs access to interdisciplinary support and resource alignment.

Key payers in this review include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of how S0311 is defined, payer coverage patterns and gaps, benchmarks where available, and the clinical context for use—emphasizing service components, typical sites of care, and operational considerations for monthly delivery. The publication highlights policy developments and coding guidance that affect reimbursement and utilization for advanced-illness care coordination, and it outlines areas where data are limited or evolving. This summary is intended to orient payers, providers, and policy stakeholders to the role of S0311 in supporting comprehensive, patient-centered management for individuals with advanced illness.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareS0311HCPCS Level IIadvanced illness carecare coordinationchronic disease managementpalliative care servicesmonthly care managementlongitudinal care

Billing Code Overview

HCPCS Level II code S0311 describes comprehensive management and care coordination for advanced illness, per calendar month. The service represents ongoing, longitudinal care that focuses on managing complex symptoms, coordinating multidisciplinary services, and aligning treatment with patient goals for individuals with advanced or progressive illnesses.

Service Type: Care management and coordination services for advanced illness

Typical Site of Service: Home or community-based settings and outpatient care environments where longitudinal care coordination is delivered

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A 78-year-old patient with stage IV congestive heart failure and metastatic non-small cell lung cancer is enrolled in an advanced illness care program. The patient has frequent symptom burden (dyspnea, pain, fatigue), multiple medications, and complex social needs. Monthly care coordination is provided by an interdisciplinary advanced illness management team led by a physician or nurse practitioner, including a nurse care manager, social worker, and palliative care clinician.

During a typical month the team performs a comprehensive assessment, documents goals-of-care discussions, adjusts medications for symptom control, coordinates home health and durable medical equipment, communicates with the patient’s primary care physician and oncologist, organizes hospice referrals when appropriate, and completes required regulatory and billing documentation. The service is billed once per calendar month using S0311 for the professional oversight and ongoing case management of the patient’s advanced illness.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when the work required to provide `S0311` is substantially greater than typically required (document intensity/time).

HCPCS S9443: Lactation Classes by Non-Physician Provider, Per Session

HCPCS-S3842-GENETIC-TESTING-VON-HIPPEL-LINDAU

HCPCS Level II S3842: Genetic Testing for von Hippel-Lindau Disease

HCPCS-S5565-INSULIN-CARTRIDGE-150-UNITS-PEN-DEVICE

HCPCS S5565: Insulin Cartridge, 150 Units

HCPCS-S9989-SERVICES-OUTSIDE-UNITED-STATES

HCPCS S9989: Services Provided Outside the United States

HCPCS-S5502-HOME-INFUSION-CATHETER-CARE-IMPLANTED-ACCESS

HCPCS S5502: Home Infusion Catheter Care for Implanted Access Device

HCPCS-LEVEL-II-S9024-PARANASAL-SINUS-ULTRASOUND

HCPCS Level II S9024: Paranasal Sinus Ultrasound

HCPCS-S4995-SMOKING-CESSATION-GUM-NICOTINE-REPLACEMENT

HCPCS Level II S4995: Smoking Cessation Gum

HCPCS-S0315-DISEASE-MANAGEMENT-INITIAL-ASSESSMENT

HCPCS S0315: Disease Management Program, Initial Assessment and Initiation

HCPCS-S0157-BECAPLERMIN-GEL-TOPICAL-WOUND-CARE-0-01-0-5GM

HCPCS S0157: Becaplermin Gel 0.01%, 0.5 gm

HCPCS-S2205-MINIMALLY-INVASIVE-DIRECT-CORONARY-ARTERY-BYPASS-SINGLE-ARTERIAL-GRAFT

HCPCS S2205: Minimally Invasive Direct Coronary Artery Bypass, Single Arterial Graft

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Taxonomy Code	Specialty	Notes
207P00000X	Internal Medicine	Common physician specialty managing longitudinal advanced illness care and coordination.
208D00000X	Palliative Medicine	Specialist providing symptom management, goals-of-care discussions, and hospice coordination.
363L00000X	Nurse Practitioner	Advanced practice clinicians who frequently deliver and document monthly comprehensive management services.
207Q00000X	Family Medicine	Primary care physicians often coordinate advanced illness management in outpatient or home settings.
173E00000X	Home Health Care	Agencies and clinicians providing home-based nursing and coordination services tied to `S0311`.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`E11.9`	Type 2 diabetes mellitus without complications	Common comorbidity requiring medication and care coordination in advanced illness management.
`I50.9`	Heart failure, unspecified	Frequent reason for advanced illness management due to symptom burden and recurrent admissions.
`C34.90`	Malignant neoplasm of unspecified part of unspecified bronchus or lung, unspecified	Active metastatic cancer commonly triggers comprehensive advanced illness care coordination.
`J96.00`	Acute respiratory failure, unspecified whether with hypoxia or hypercapnia	Relevant when symptom management and complex decision-making are required in advanced illness.
`F03.90`	Unspecified dementia without behavioral disturbance	Cognitive impairment alters goals-of-care discussions and care coordination in advanced illness.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99497`	Advance care planning including the explanation and discussion of advance directives, first 30 minutes	Often performed during monthly management to document goals-of-care and advance directives relevant to `S0311`.
`99406`	Smoking and tobacco use cessation counseling visit, intermediate, greater than 3 minutes up to 10 minutes	May be provided as part of counseling within the comprehensive care plan during the month.
`99495`	Transitional care management services with moderate complexity medical decision making, face-to-face within 14 days	Performed when the patient transitions from hospital to home and advanced illness coordination under `S0311` is part of the transition.
`99354`	Prolonged service in the office or other outpatient setting, first hour (with direct patient care)	Used when monthly coordination requires prolonged face-to-face time beyond typical E/M visit durations during the month.
`99490`	Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month	Commonly furnished alongside `S0311` when chronic care management activities overlap with advanced illness care coordination.

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