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www.medium.com/@thomasklinemd_65234/when-does-pain-treatment-become-protected-palliative-care-treatment-339d29024b57
A Medical Office Approach — Clinical and Reimbursement Guidelines
Thomas F. Kline, M.D.,Ph.D. and Carolyn D. Concia, Palliative Care N.P.
The purpose of this paper is to encourage primary care providers to offer palliative care in their practices for patients suffering from intractable pain — of any origin. Palliative care’s evolution, CDC exemptions and reimbursement will be explained. Finally, guidance on how physicians and practitioners can easily start offering palliative care without restrictions on pain medication dosage. You can read more on this post about alleviating pain.
“If we know that pain and suffering can be alleviated, and we do nothing about it, then we ourselves become the tormentors.” — Primo Levi
Palliative care allows more comprehensive and humane treatment as it is exempted from opioid dosage restrictions set by CDC and many states over the past two years. Primary care doctors and practitioners can avoid restrictions if their patients qualify for palliative care. (1)
Pain care becomes palliative care when three criteria are met:
● The underlying disease has no cure
● There is a likelihood the disease will shorten lifespan
● Symptomatic treatment has a high probability of improving the quality of life
EVOLUTION/DEFINITIONS OF PALLIATIVE CARE: WHAT IT IS AND WHAT IT IS NOT
Palliative care is not new. “Palliative care” was created by Balfour Mount, a Canadian-trained physician serving as visiting professor at the first hospice, St. Christopher’s Hospice in London. In 1973, he established a palliative care program at Royal Victoria Hospital in Montreal, the first palliative care program to be integrated in an academic teaching hospital [2]. Palliative care has evolved in scope since that time. (Table 1)
Year
Source and Definition
1990 World Health Organization (WHO): “…The active total care of patients whose disease is not responsive to curative treatment.”
1993 The Oxford Textbook of Palliative Medicine: “The study and management of patients with active, progressive, far-advanced disease for whom the focus of care is the quality of life.”
2007 WHO (revision): “An approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.” (4)
2013 National Consensus Project: “Palliative care means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice.”
EVOLVING DEFINITION OF PALLIATIVE CARE — Table 1 (above)
“The goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies”
– the Oxford Book of Palliative Medicine (3).
DOSAGE RESTRICTIONS WAIVED BY CDC AND MOST STATES
Palliative care exemption for CDC restrictions regarding the prescribing of opioid pain medicine gives providers the freedom to do what is proper to manage pain. Directly from the CDC “Guideline” page one, line one: “This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care.” (1)
Most states provide palliative care exemptions as well. Palliative care is for all prognosis levels, diagnoses and ages groups. The only qualifications are unavailability of a cure and persistent symptoms. It can be CHF with shortness of breath, COPD with intractable coughing, or a person with lupus, arachnoiditis, or advanced arthritis where cure is impossible and treatment focuses on symptoms of pain interfering with the enjoyment of life. It is no different than certifying one of your patients’ needs cardiac care, or comprehensive diabetic care.
Palliative care determinations can be made by licensed providers only. By the same token, people without licenses cannot try to ignore or delete Palliative Care Status (PCS) once in place. Once the PCS is determined, tCDC and state restrictions for opioid prescribing are bypassed.
This allows physicians and practitioners to prescribe what they want, as medically necessary and humane to relieve suffering without interference. Placing any restrictions on palliative care would be tantamount to ignoring CDC and state guideline exemptions and imposing unwarranted restrictions on providers engaged in palliative medical care.
Although the DEA is concerned about “too much” prescribing of pain medicine, the Palliative Care Status, and the DEA definition of prescribing for a “legitimate medical purpose” should help decrease concerns of high and prolonged doses, still legal for any FDA approved opiate, and proper under PCS exemptions.
Practitioners using traditional titration methods to MME levels of 500 or more for many PCS patients are needed to relieve intractable pain still legal for all FDA approved opiates, and of course for exempted PCS patients.
FDA does warn to “heed warnings to watch for addiction and excessive sedation” both of which are rare in proper hands of licensed physicians. As of this writing there is no evidence of addiction occurring after patients are stable on their opiate treatment. Overdoses in non-addicted medical patients are rare as well, at the level of serious side effects of many medications.
Palliative care is not a prescribed program like hospice and does not require the patient to be near end of life, nor to sign up and loose other benefits as occurs in Medicare programs. Palliative Care Status is commonly misunderstood as being available to only those who are at end of life, which is incorrect.
BILLING AND REIMBURSEMENT
Palliative care visits can occur in any setting — hospital, home, or office, not billed as “palliative care” but as standard offices focusing on symptom management, not the disease. Palliative care like any other type of care is billed fee for service using symptom codes instead of or in addiction to disease codes. Symptom codes are fully reimbursed just like disease codes. For example, G89.29 is the ICD-10 code for chronic pain and is fully reimbursable by itself. Painful disease management under a palliative care plan is complex, may involve other team members and is very time consuming. To reimburse for the extra time spent, CMS had provided three mechanisms.
Billing by time: If more than 50% of the visit is concerned with “counseling and/or coordination of care”, time itself controls the visit parameters, obviating cumbersome the AMA “2 of 3” CPT guideline rules for standard office billing codes. It allows the primary care professional the extra time needed when with complex palliative care patients without worry as to how many body parts are examined. The time spent must be in the presence of the patient, family member, for “counseling and coordination of care” For example, a level 5 established patient is set at 40 minutes. If 25 minutes is spent with coordination of care, by calling the pharmacist during the visit, and coordinating care with the patient, time will then override the clinical coding rules. (5)
If you are supervising a palliative care certified person at home under Medicare home health services, you can bill separately for non-face to face time through the Home Care Plan Oversight code series G0180 (which pays about $100). This cognitive time will cover phone calls to pharmacists, home health nurses, colleagues, reviewing labs/x-rays/consults, etc. and is important reimbursement for complex Home Health Agency homebound palliative care patients.
If your patient is not covered by home health, the same type of non-face to face time can be billed using the newer Chronic Care Management (CCM) code series 99490. These charges begin with 15 minutes paying about $50 and are unlimited for further documented time spent with, for example pharmacies, prior authorizations, phone calls from member of the palliative care teams, etc. Some of the glitches have been worked out this last year. Substantial recoupment of time with complex palliative care disease can be billed. Details are at: CMS FAQs for CCM (6)
Patients with dementia and cognitive impairments frequently exhibit maladaptive behaviors when pain is overlooked. Some physicians have the patients undergo brief trials of low dose pain medication to empirically diagnosis the pain as cause of changes in behavior. If pain is diagnosed and there’s no cure for the underlying cause, billing would be the same fee for service palliative care as other patients. The patient would be eligible for the new code G0505, a $200 cognitive assessment. Older palliative care patients with or without dementia would be free of imposed restrictions on their pain care and need not be forced off as is occurring in many states such as Washington State, and others.
Exemption is Exemption.
If a pain patient is suicidal, proper pain treatment will usually treat the problem and becomes a suicide prevention tool. If additional psychological counseling for the suicidal ideations, or other problems is needed, this can be added to the office visit using the 90837 series codes.
Commercial Insurances generally follow the Medicare standard. The Palliative Care Plan needs to be developed and documented like any other care plan. It can be supplemented with other services, or not, at the discretion of the licensed professional certifying the patient. Other services requiring Chronic Care Management (CCM) time can include therapists, nurses, home care agencies, and even palliative radiation for painful tumors (not allowable under hospice rules).
It is these complex palliative care pain and other symptomatic patients, young or old, that CMS is finally providing reimbursements for non-face to face or “cognitive” work time for all the primary care practitioners willing to accept and treat complex and challenging patients and be paid for it.
WHAT CAN I DO TO START HELPING MY PATIENTS?
1. Offering office palliative care is the first and most important step in returning care to first line practitioners and returning compassionate medical care to the office.
2. Provide a “Palliative Care Certificate” which can be generated by the licensed practitioner including a certifying statement the patient has the triad for palliative care: no cure, condition existing more than 6 months, and the need of symptom treatment. (Please see attachment for an example certificate).
3. Add the words, “palliative care” to your prescriptions so the pharmacist understands the patient’s severity and chronicity of the illness and has Palliative Care Status. Provide the patient and pharmacist with a copy of the certificate.
4. Encourage your patients to be part of the solution. Get them involved in their own care in fact- finding, keeping a diary, setting goals, and communicating routinely. They can help with documenting the time spent on the phone with you, etc. These Discussions are billable under time coding and CCM. Tell the patient what is going on, they love to help.
5. Learn coding for improved reimbursements for non-face to face time needed for complex, time consuming patients. Many patients are looking for competent, caring practitioners willing to handle the challenge complex illnesses after being cast aside in the last 18 months as “too troublesome” or “too DEA risky”.
The Palliative care certification allows freedom for primary care practitioners to treat with full doses of pain medications, bringing back old-fashioned compassion to our first job — relieving pain. At the same time being properly reimbursed for extra time to do our job as real doctors and practitioners unfettered by those without licenses trying to control the practice of medicine.
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There is NO COMMERCIALLY AVAILABLE ORAL FENTANYL available in the USA.. This would suggest that Prince obtained his “Fentanyl” from some ILLEGAL SOURCE that produced some “FENTANYL ” in a solid oral dosage form. Notice in this report they only talk about “FENTANYL” there is one single legal Fentanyl in the USA and that is Fentanyl Citrate but.. there is some 18 different ILLEGAL FENTANYL ANALOGS coming in from China and Mexico. Whose agenda is it to confuse the public about all of these OD’s being caused by the ILLEGAL FENTANYL ANALOGS and leading them to believe that it is the same Fentanyl that is legally prescribed in this country ?
