Radio recap: Hospice and palliative medicine

At this year’s annual ACDIS conference, Beth Wolf, MD, CCDS, CPC, medical director of HIM at Roper Saint Francis Healthcare in Charleston, South Carolina, will take the stage in the expansion and innovation track to share about CDI specialists’ role in reviewing hospice and palliative care records. Earlier this week, ACDIS Director Brian Murphy invited Wolf onto ACDIS Radio to provide a peek into her presentation.

“Hospice and palliative care focuses on providing relief for the symptoms and stress of a serious illness,” said Wolf on the episode. “The goal is to improve the quality of life for the patient and the family. Palliative care services are based on need, like our traditional medical necessity. Hospice care is based on prognosis.”

With these seriously or terminally ill patients in both populations, there are a number of documentation concerns that apply, Wolf said.

“Many patients in the hospital have life-limiting or life-threatening illnesses and complex care requirements but are not being seen by palliative care specialists,” she said. “It’s important to recognize the patient characteristics and not just focus on whether or not a palliative care specialist has been consulted.”

These patients, Wolf said, often need many different specialists and care givers’ involvement which complicates CDI efforts.

“We know that the more people in the chart, the more opportunity for conflicting and ambiguous documentation,” she said. “CDI as they follow the story along can really help with concurrent corrections and really make it so our coder colleagues, after discharge, have an easier time codifying the story.” 

CDI professionals also need to be on the lookout for diagnoses that may no longer be treated during hospice care, as these still increase the patient’s complexity and the amount of care necessitated. 

“In particular, things like respiratory failure and encephalopathy. Just because we’re not using BiPAP or giving fluids to correct the decline in creatine doesn’t mean that these diagnoses shouldn’t be documented and final coded to impact the severity of illness [SOI] and risk of mortality [ROM],” she said.

Not only can CDI specialists ensure that these larger, end-of-life diagnoses are accurately captured, but they can also help with capture some of the less severe diagnoses that affect the SOI/ROM, she said.

Specifically, nutritional and functional status are frequently missed in these populations, according to Wolf. “I tell [the CDI specialists] that palliative care patients are malnourished until proven otherwise.”

CDI professionals need to closely investigate the patients record to formulate a query regarding their nutritional status, even to the point of triggering a nutritional consult, Wolf said.

Functional status, said Wolf, can be a bit trickier because the coding language does not always match the necessary specificity for these patients’ conditions.

“CDI is in a unique position to recognize common functional scales in palliative care and tease out information that could be used in queries to capture codeable diagnoses,” she said.

While the opportunities may be ripe for the CDI picking in these patient populations, CDI specialists will still encounter the trouble of physician engagement, Wolf said. Her suggestion for getting in the door is to lead with information about their evaluation and management (E/M) billing.

“Probably the most important thing about level of billing is medical decision making. And that’s in the assessment and plan and it’s related to the number of problems, the severity of problems, and the complexity of the problems,” she said.

On top of that, each level of E/M billing has an expected amount of time to go along with it. Physicians, Wolf said, can bill Medicare based on time if more than 50% of the visit was spent consulting and/or coordinating care. This is a great opportunity for CDI specialists to provide some education and gain buy-in.

“Palliative care visits, in particular, involve complex, shared decision making, extensive communication between care givers, and I’m often able to meet those time-based criteria,” she said.  

CDI specialists can also make headway by educating physicians on the use of critical care codes, Wolf said. “Most of us don’t really think of providing palliative care as providing critical care,” she said.

“Critical care codes for family discussions are a legitimate assignment if the patient has at least one organ failure and is at risk for life threatening deterioration,” she said. “The patient must also lack the capacity to participate in active decision making.”

Editor’s note: To listen to the entire episode of ACDIS Radio from Wednesday, March 28, click here. The ACDIS conference takes place May 21-24 at the Henry B. Gonzalez Convention Center in San Antonio, Texas. Click here for more information.