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1 Hospice and Palliative Medicine: Specialties Characterized by Risk and Severity Beth Wolf, MD, CCDS, CPC Health Information Management Medical Director Roper St. Francis Healthcare This is the Full Title of a Session Charleston, SC 1

2 Learning Objectives At the completion of this educational activity, the learner will be able to: Articulate the importance of hospice and palliative medicine in healthcare Differentiate between hospice and palliative medicine Analyze common hospice diagnoses for medical necessity Recognize conditions impacting prognosis Identify documentation strategies for professional service billing 2

3 Disclaimer This material is designed and provided to communicate information about clinical documentation, coding, and compliance in an educational format and manner The author is not providing or offering legal advice, but rather practical and useful information and tools to achieve compliant results in the area of clinical documentation, data quality, and coding Every reasonable effort has been taken to ensure that the educational information provided is accurate and useful Counsel should be consulted on individual legal and compliance questions 3

4 4

5 Polling Question #1 How many personal experiences have you had with serious illness? Zero One Two Three or more 5

6 Hospice and Palliative Medicine: Importance in Healthcare 6

7 Palliative Philosophy of Care... SERIOUS illness PATIENT and FAMILY centered RELIEF from symptoms, pain, and stress QUALITY of life Palliative Care Hospice Provided by a TEAM 7

8 How Are They Different? Palliative Care Any stage Concurrent with lifeprolonging therapy Hospice Prognosis 6 months Must forgo curative treatments Specific insurance benefit Palliative Care Hospice 8

9 Medical Necessity: PROGNOSIS vs. NEED Hospice Eligibility Based on PROGNOSIS Two physicians attest to 6 month life expectancy should the disease(s) follow a natural course Capitated payment program Daily rates Levels: Home, inpatient, respite Palliative Care Consult Based on NEED Ordered by a physician Must give a medical reason for the consultation Billed by the physician Evaluation and management (E/M) codes from Current Procedural Terminology (CPT) 9

10 Who Should Get Palliative Care? Anyone with a potentially life limiting or life threatening condition AND... The surprise question : Surprised if death in next 12 months? Frequent admissions/admission for symptoms Complex care requirements Decline in function, feeding intolerance, or unintended decline in weight Elderly patient, cognitively impaired, with acute hip fracture Metastatic or locally advanced incurable cancer Out of hospital cardiac arrest Admission from long term care facility Current or past hospice program enrollee Limited social support 10

11 Palliative Care Consultation CORE PALLIATIVE TEAM Physician Social worker Chaplain Nurse practitioner PREPARATION Chart review Communication Physicians/bedside RN Ancillary staff/case manager INTRODUCTIONS Customized for each patient/family OBJECTIVE Improve quality of life Set goals and expectations Ensure shared decision making PROCEDURE Listen Listen Listen PLAN Treat Support Coordinate 11

12 Polling Question #2 What is the most common hospice principal diagnosis? Cancer Heart and circulatory disease Dementia Respiratory conditions Stroke 12

13 Most Common HOSPICE Principal Diagnoses Cancer (27.7%) Heart and circulatory (19.3%) Dementia (16.5%) longest length of stay Respiratory (10.9%) Stroke (8.8%) Other (16.7%) Not surprisingly, these are the most common diagnoses seen in palliative medicine consultation 13

14 Patient 1: Gastric Cancer ONCOLOGY H&P: 46 year old female with newly diagnosed stage IV gastric cancer is admitted with N/V. Assessment: 1. Intractable cyclical vomiting with nausea 2. Multiple sites of bowel obstruction Plan: Consult interventional radiology for venting & feeding tube Consult surgery for bowel obstruction Consult palliative care for nausea Begin first cycle of chemotherapy 14

15 Patient 1: Gastric Cancer Palliative Consult What am I being asked to help with specifically? Nausea Any other symptoms? Abdominal pain Sedation from medications Goals/expectations? Patient s understanding of her condition Family s understanding Psychosocial concerns? Single, no local family 15

16 Patient 1: Gastric Cancer Palliative Consult What are the treatment GOALS in advanced gastric cancer? Palliate symptoms Improve quality of life Days outside of the hospital Prolong survival Median survival with supportive care alone vs. with chemo was 4.3 months vs 11 months 16

17 Prognostication Is Part of Every Evaluation Survival estimates are essential for clinician and patient decision making in all phases of a serious illness Accuracy Patient characteristics Clinician characteristics Experience Knowledge of research Clinical intuition 17

18 Patient 1: Gastric Cancer Palliative Consult Factors impacting survival Extent of disease: Metastatic gastric cancer to omentum and right ovary Histologic type: HER2 expression pending Chronic comorbidities Performance status Nutritional status 18

19 Patient 1: Gastric Cancer Palliative Consult Performance Status: ECOG 2 19

20 Karnofsky Performance Status Scale Scale of 100 to 0 (Normal to Death) page 1 of 3 20

21 Karnofsky Performance Status Scale page 2 of 3 21

22 Karnofsky Performance Status Scale page 3 of 3 22

23 Patient 1: Gastric Cancer Palliative Consult Nutritional Status Poor appetite, 40 pound weight loss in the last 4 months BMI 29 23

24 What Does Malnutrition Look Like? 1. It is not always easy to recognize 2. Obese patients can be malnourished 3. Albumen and prealbumin are NOT reliable indicators of malnutrition in acutely ill patients 24

25 Diagnostic Criteria for Malnutrition Know Your System Threshold to Diagnose Some commonly used criteria Energy intake Weight loss unintended 1 month > 5 3 month > 7.5% 6 month > 10% 1 year > 20% Severe Loss of muscle mass/subcutaneous fat BMI Percentage of usual or ideal body weight 25

26 Impact of Treating Malnutrition 30% 50% of hospital patients are malnourished on admission. Through clinical leadership and nutrition therapy, research has shown a 50% reduction in avoidable readmissions, a 25% reduction in pressure ulcer incidence, a 56% reduction in overall complications, and a reduction in LOS by 2.6 days. LOCAL DATA All inpatients: 5.4% Oncology patients: 21% Severe: 10% Mild/moderate: 6% Unspecified: 5% 26

27 Impact of Documenting Severe Malnutrition This report includes data produced by the proprietary 3M TM APR DRG Software. All copyrights in and to the 3M TM APR DRG Classification System and all APR DRG code assignments are owned by 3M. All rights reserved. 27

28 Nutritional Diagnoses Impact Transparency Code Description SOI ROM CC/MC C R63.4 Abnormal weight loss 1 1 none Z68.1 BMI < CC E44.1 Mild malnutrition 2 1 CC E44.0 Moderate malnutrition 3 1 CC R64 Cachexia 2 3 CC E43 Severe malnutrition 4 2 MCC 1=mild 2=moderate 3=major 4=extreme CC = Comorbidity/complication; MCC = Major CC 28

29 Polling Question #3 The prognosis in terminally ill cancer patients is most impacted by: Age Performance status Nutritional status Social support 29

30 Prognosis in Terminally Ill Cancer Patients Best predictor: PERFORMANCE STATUS Independent predictive value: Cognitive failure Weight loss Dysphagia Anorexia Dyspnea TRANSLATING SEVERITY and RISK (Altered mental status) Encephalopathy Delirium Coma Glasgow Coma Scale Cerebral edema Malnutrition Aspiration Respiratory failure Sepsis Pancytopenia Opioid dependence Major depression 30

31 Patient 2: Heart Failure 86 year old male with long standing severe systolic heart failure was admitted 14 days prior with progressive weakness and shortness of breath. Despite maximal medical therapy, he has not improved. His renal function has worsened, he is milrinone dependent, and he just wants to go home. Cardiologist s order: consult palliative care for hospice. 31

32 Hospice Eligibility General Factors Loss of function AND rapidness of decline Nutritional status AND rapidness of change Cognition Hospital utilization Progressive deterioration despite maximal medical therapy Practical factor Is the patient and family at a point where a focus on quality of life and comfort is becoming the preferred goal? Local coverage determinations (LCDs) See references for disease specific factors 32

33 Heart Failure: Findings Linked to Worse Prognosis New York Heart Association (NYHA) Class IV Symptoms at rest If unable to tolerate an ACE inhibitor, 6 month mortality rate of 44% (12 month mortality rate of 64%) Left ventricular ejection fraction < 20% Cheyne Stokes breathing Weight loss (called cardiac cachexia if severe) Stage III or greater CKD Acute kidney injury Hyponatremia Comorbidities: Coronary artery disease, diabetes, depression, obstructive sleep apnea 33

34 Survival Prediction Models Potential benefits Realistic expectations Resource allocation Burden vs. benefit discussions Facilitates goal setting Potential limitations Derived from a population Compliance, preference, or attitudes are not incorporated New therapies may make models obsolete Uncertainty in applying the model to an individual is difficult to explain Scores may replace informed and compassionate conversations 34

35 Patient 2: Heart Failure Hospice Eligibility Statement 86 year old male with COPD, CAD, dilated cardiomyopathy, and end stage systolic HF has an EF of < 20%. His GFR has dropped below 30 ml/dl (likely cardiorenal syndrome) and he is milrinone dependent to keep him out of cardiogenic shock. He is on maximal medical Rx. Function: He has gone from a KPS of 50 to 30 in the last 2 weeks. He has dyspnea at rest and occasional chest tightness. He requires assistance with all ADLs except feeding. He sleeps for several hours a day and has had witnessed Cheyne Stokes respirations. Severe malnutrition: Despite fluid retention, he has lost 10 pounds in the last month (150 down to 140 6%). Liberalizing diet. Goal: He desires a comfort focus and to be at home. Prognosis: If his heart failure progresses as expected, he has a > 50% chance of dying in the next 6 months. 35

36 Patient 3: Alzheimer s Dementia 75 year old female with moderate to severe dementia fell at home and fractured her right hip. Palliative care was consulted per protocol because of the fragility fracture. Palliative care consult history She requires assistance with bathing, dressing, and toileting. She wanders and must be supervised 24/7. She is incontinent of urine. She has O2 dependent COPD and frequent bronchitis. Three months ago she was restricted to nectar thick liquids to reduce aspiration risk. She has lost 12 pounds in the last month (105 93). Palliative care plan DNR written (family already had made that decision) Goal of surgery: pain control, facilitate ambulation Minimize risk of delirium and aspiration 36

37 Dementia With Hip Fracture: Palliative Consult Documentation Impact 37

38 Hospice Eligibility: Alzheimer s Disease & Related Disorders FAST (Functional Assessment Staging Scale) Stage 6: Decreased ability to dress, bathe, and toilet independently Stage 7: Loss of speech, locomotion, and consciousness 7a: Ability to speak limited (1 to 5 words a day) 7b: All intelligible vocabulary lost 7c: Non ambulatory 7d: Unable to sit up independently 7e: Unable to smile 7f: Unable to hold head up Comorbidities related to dementia that impact prognosis: Aspiration pneumonia Pyelonephritis or other upper UTI Septicemia Pressure ulcer, multiple, stage 3 or 4 Weight loss of > 10% during the previous 6 months 38

39 Patient 3: Alzheimer s Dementia (day 2) She underwent surgical hip repair. Early the next morning she developed hypoxia and acute respiratory distress felt 2/2 aspiration. She was placed on 100% oxygen via NRB and then BIPAP to keep sats > 90%. Palliative care was asked to see the patient urgently to help establish treatment parameters and goals. Based on the patient s advance directive, the family requested that she not be moved to the ICU. After clear delineation of the patient s wishes by the family, it was decided to remove the BIPAP and focus on comfort, with the expected outcome of death. 39

40 Dementia With Hip Fracture: Follow up Visit Documentation Impact 40

41 Hospice and Palliative Medicine: Professional Billing 41

42 Inpatient Evaluation and Management (E/M) Options (aka CPT Codes) Component based E/M visits Based on complexity of medical decision making Requires specific history and physical elements Time based E/M visits (same codes, different rules) Every E/M code has an expected duration of time Total time must be on the unit/floor If > 50% of total time spent counseling/coordinating care Prolonged visits Added on to E/M visits (above and beyond expected time) ENTIRE time must be face to face with the patient Critical care visits Family discussions needed for significant decisions 42

43 Patient 1: Gastric Cancer Initial inpatient consultation Total time 60 minutes on the unit 35 minutes spent coordinating care High complexity medical decision making E/M Code Medical Decision Making Time Threshold Relative Value Units Approx Dollar Value Low 30 min 1.92 $ Moderate 50 min 2.61 $ High 70 min 3.86 $206 43

44 Polling Question #4 Gastric cancer initial consult. High medical decision making. 60 minute visit, of which 35 was spent counseling and coordinating care. How would you bill? Component based E/M code Time based E/M code Prolonged visit E/M code Critical care E/M code 44

45 Common Inpatient Coding Mistake in Palliative Medicine: Billing Exclusively on Time Often visits can qualify for either type of billing. Make sure to represent (and document) the work accurately. E/M Code Medical Decision Making Time Threshold Relative Value Unit Approx Dollar Value Low 30 min 1.92 $ Moderate 50 min 2.61 $ High 70 min 3.86 $200 ANSWER: Component (bulleted) documentation High medical decision making (complexity) Comprehensive history and exam 45

46 Medical Decision Making: High Complexity Requirements ONE: Significance of problem Risk of mortality or serious morbidity IV controlled substances or other high risk medications (methadone) DNR decision or de escalation of care because of prognosis TWO: Intensity of work Extensive management options One new significant problem needing additional w/u, or two continuing chronic problems inadequately controlled Extensive data/records/tests results reviewed THREE: History and exam documentation Initial consults require both a comprehensive history and an exam Follow up visits: either a detailed interval history or a detailed exam 46

47 Patient 2: Heart Failure Prolonged F/U Visit Start: 3 pm Stop: 4:15 pm Total: 75 min (65 minutes w/patient and wife at bedside) 99233: Level 3 follow up visit (based on TIME 35 min) All work must be done on the unit/floor > 50% of the time must be spent on counseling/coordinating care I spent 35 minutes at the bedside and on the unit, of which [at least 18] minutes was spent counseling and coordinating care as described : PROLONGED face to face visit first hour (can count for full hour once you hit the 30 minute mark) All time must be face to face with the patient I spent an additional [at least 30, up to 74] minutes on the unit face toface with the [patient or incapacitated patient's surrogate] discussing prognosis and goals as well as counseling and coordinating care. 47

48 Patient 3: Dementia With Hip Fracture Follow up inpatient visit the day she acutely decompensated and died High complexity medical decision making Total visit time 65 minutes 20 minutes at bedside examining patient and talking to husband F2F 10 minutes call with daughter (from RN station) coordinating care 20 minutes at bedside with husband and daughter discussing goals F2F 15 minutes at the RN station writing my note while respiratory therapy removed the BIPAP 48

49 Polling Question #5 Dementia with hip fracture follow up. Total visit time 65 minutes: 40 minutes face to face with surrogates/patient. How would you bill? Component based E/M code Time based E/M code Prolonged visit E/M code Critical care E/M code 49

50 Critical Care Service Can Be Billed Outside of the ICU Total time of 65 minutes gives me 2 options... RVU Relative Value Unit 50

51 Critical Care Billing Requirements Patient must have at least one organ failure and be at risk for life threatening deterioration Time is KEY COMPONENT does not need to be continuous (document the times) Provider immediately available to patient 51

52 Critical Care for Family Discussions Documentation The critical and unstable nature of the patient s condition Patient s incapacity to participate in decision making Discussion is necessary for making significant decisions All other family discussions, no matter how lengthy, may not be counted toward critical care Most common examples in my practice Compassionate extubation (ventilator withdrawal) De escalation of care in a critically ill patient Removal of BIPAP/high flow oxygen on a non ICU patient Brain death determination 52

53 Evaluation & Management CPT Codes CRITICAL CAARE Time at bedside/unit Time (min) INITIAL IP CONSULT F/U IP VISIT PROLONGED VISIT (time must be face to face with the patient) Work RVUs (prolonged visit: additional min F2F time) (prolonged visit: additional min F2F time) x (additional min F2F time) x x 2 (additional min F2F time) (additional min F2F time)

54 Key Points Both have specialty trained teams that focus on improving quality of life in serious illness by addressing patient and family needs Hospice care services based on PROGNOSIS (specific insurance benefit) Palliative care services based on NEED (provided along with curative therapy) Two important factors impacting prognosis in hospice and palliative care patients Nutritional status (impacts SOI/ROM and DRG) Functional status (harder to capture in ICD) 54

55 References Slide 10: Weissman DE, Meier DE. Identifying patients in need of a palliative care assessment in the hospital setting. J Palliat Med 2011; 14:17. Slide 13: NHPCO Facts and Figures: Hospice Care in America. Alexandria, VA: National Hospice and Palliative Care Organization, September Slide 16: Wagner AD, Syn NL, Moehler M, Grothe W, Yong WP, Tai BC, Ho J, Unverzagt S. Chemotherapy for advanced gastric cancer. Cochrane Database Sys Rev 2017;8:CD Epub 2017 Aug 29. Slide 26: Matarese L and Charney P. Capturing the elusive diagnosis of malnutrition. Nutr Clin Prac 2017;32(1): Snider JT et al. JPEN J Parenter Enteral Nutr 2014;38(2 Suppl):77S 85S. Somanchi M, Tao X, Mullin G. The facilitated early enteral and dietary management effectiveness trial in hospitalized patients with malnutrition. JPEN 2011;35:

56 References Slide 26 (cont): Tappenden KA, Quatrara B, Parkhurst ML, et al. Critical role of nutrition in improving quality of care: An interdisciplinary call to action to address adult hospital malnutrition. J Acad Nutr Diet 2013;113: Slide 31: Vigano A, Dorgan M, Buckingham J, Bruera E, Suarex Almazor ME. Survival prediction in terminal cancer patients: A systemic review of the medical literature. Palliat Med 2000;14(5):363. Slide 33: CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe CHF. N Engl J Med 1987;316(23):1429. Anker SD et al. Prognostic importance of weight loss in chronic heart failure and the effect of treatment with ACE inhibitors: An observational study. Lancet 2003;361(9363):1077. Chertow GM et al. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. Amer Soc Nephrology 2005;16: doi: /asn Krumholz HM et al. Correlates and impact on outcomes of worsening renal function in patients 65 years of age with heart failure. The American Journal of Cardiology 2000;85(9): Slide 35: Goldberg LR, Jessup M. A time to be born and a time to die. Circulation 2007;116(4):360. Slide 46: Jones MD, Bull MD, Acevedo K. Top ten inpatient palliative medicine billing and coding mistakes (and how to fix them this week). J Palliat Med 2015;18(3):

57 Helpful Resources Center to Advance Palliative Care (CAPC) DEPARTMENT OF HEALTH AND HUMAN SERVICES. Centers for Medicare & Medicaid Services. 42 CFR Part 418 [CMS 1675 F] RIN 0938 AT00. Medicare Program; FY 2018 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements /pdf/ pdf Medicare Claims Processing Manual. Chapter 12 Physician/Nonphysician Practitioners and Guidance/Guidance/Manuals/downloads/clm104c12.pdf CMS Prolonged Services (Codes ) MLN and Education/Medicare Learning Network MLN/MLNMattersArticles/downloads/mm5972.pdf Medicare Learning Network (MLN) Hospice Payment Booklet and Education/Medicare Learning Network MLN/MLNProducts/Downloads/hospice_pay_sys_fs.pdf International Classification of Function (ICF) 57

58 Medicare: Palmetto Government Benefits Administrators (GBA) Hospice Information Type/Hospice Center.html Palmetto local coverage determinations (LCDs) Hospice HIV disease Hospice Liver disease Hospice Neurological conditions Hospice Renal care Hospice Alzheimer's disease and related disorders Hospice Cardiopulmonary conditions Beyond basics: Cardiopulmonary Hospice: Documenting weight loss for beneficiaries with nonneoplastic conditions 58

59 Thank you. Questions? In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide. 59