Part II. Multiple Chronic Conditions: How Are They Viewed by Medicare?

Part II. Multiple Chronic Conditions: How Are They Viewed by Medicare?

By Terri Lewis, PhD.

(Editor’s Note: Dr. Terri Lewis has been very critical of the CDC for not requiring data collection about chronicity or context of chronic disease. She has been discussing this issue in a series of reports. This is the second of a three-part series.)

As of April 2, 2018, the Center for Medicare Services has adopted modifications to its program requirements for prescribing of opiate medications in the Part D pharmacy program, implementing the recommendations generated by the Center for Disease Control (Guidelines for Chronic Pain, March 16, 2016).  In Part I, I introduced definitions related to this rule change.

Terri Lewis, PhD

What exactly are multiple chronic conditions (MCC) according to the Medicare program?

Medicare tracks hundreds of health conditions that reflect various levels of chronicity.  Beneficiaries may have more than one of these chronic conditions listed alone or in combination with other chronic diseases. Some of these conditions are known to occur together. A Medicare beneficiary is considered to have a chronic condition if the CMS administrative data have a claim indicating that the beneficiary received a service or treatment for a specific condition identified in the Medicare Handbook of Diagnosis Review Groups (DRG).

Hundreds of diseases are tracked within this system, but the 19 most frequently billed chronic conditions are tracked through Medicare administrative claims. Data collected about all conditions is collected as administrative data that has important limitations – in particular, their principal clinical insight comes from ICD-10 diagnostic and associated CPT codes that frequently reflect insufficient attention to case development, are of questionable accuracy, completeness, clinical scope, and meaningfulness. This is a limitation of construction of electronic health records systems which yields primarily ‘count’ or frequency data.


Table 1. 19 Most Frequently Reported Chronic Conditions in CMS Claims Data


Alzheimer’s Disease and Related Dementia Heart Failure
Arthritis (Osteoarthritis and Rheumatoid) Hepatitis (Chronic Viral B & C)
Atrial Fibrillation Hyperlipidemia (High cholesterol)
Autism Spectrum Disorders Hypertension (High blood pressure)
Cancer (Breast, Colorectal, Lung, and Prostate) Ischemic Heart Disease
Chronic Kidney Disease Osteoporosis
Chronic Obstructive Pulmonary Disease Schizophrenia and Other Psychotic Disorders
Depression Stroke

While administrative databases may be useful for descriptive purposes (e.g., exploring variations in regional or demographic treatment patterns), their practical limitations imposed by reliance on this information prevents us from being able to provide credible answers regarding which alternatives offered to patients, treatment technologies, and provider specialties among the available alternatives, work the best for patients. This is because payment for services is not linked to patient outcomes and is compounded by the adoption of an inadequate definition of chronic disease that is hardwired into the data collection system.  Importantly, the CDC has adopted a method of disseminating information about chronic disease incidence and prevalence that omits many chronic conditions from its tracking and reporting systems and makes no mention of duration of the disease or symptoms.  So, missing from this system is information about-

  1. complex causality, with identification of the multiple factors leading to disease onset
  2. a long development period, for which there may be no symptoms in early stages
  3. transitions in the course of disease states from acute to chronic and terminal to chronic status
  4. a prolonged course of illness, which contributes to other health complications
  5. associated functional impairment or disability
  6. disease burden of associated co-morbidities that involve multiple body systems, mental illness, challenges to behavioral health, oral disease, or functional and psychosocial decline

Given the reliance on the ICD system, variation in adoption of coded definitions across systems and individual users has resulted in the inconsistent collection of patient and public health information that confuses physicians and patients alike and has real implications for those managing chronic diseases or conditions. People with multiple chronic conditions also are at increased risk of poor day-to-day functioning. The failure to gather information within a complete context may cause the process to fail to build a consolidated picture of the chronic disease, its symptom course, and associated and sometimes predictable co-morbidities. For instance, the CDC lists “cancer” as a chronic disease when, in fact, only certain types of cancers (i.e., multiple myeloma) can be viewed in terms of a chronic illness and others are of little long-term consequence. Some forms of cancers have few treatment options and prove fatal in the near term.  Some, but not all, cancer-related conditions generate pain that must be addressed in designing care for patients and there is little to distinguish these care protocols from the treatment needs of other non-cancerous chronic diseases in the current tools. When it comes to the basics of managing pain treatment, nothing is more frustrating to patients in the adoption of treatment protocols for complex illness and pain than the ongoing discourse around the term cancer and whether it constitutes a distinction without a difference in pain care. This contributes to care failure and creates excessive administrative time.  This is of critical clinical importance in managing multiple chronic conditions at the community level.

Having multiple chronic conditions is also associated with substantial personal and public health care costs and as recent analyses have demonstrated, catastrophic illness is associated with financial harms that are associated with increased stressors and early mortality. Approximately 71% of the total health care spending in the United States is associated with care for the Americans with more than one chronic condition. Among Medicare fee-for-service beneficiaries, people with multiple chronic conditions account for 93% of total Medicare spending. People with multiple chronic conditions face substantial out-of-pocket costs of their care, including higher costs for prescription drugs. Changes to prescribing protocols have real world implications for managing costs in a household with limited income.

The impact of this CMS regulatory change has offered little consideration to community conditions that affect actual care management.  Beneficiaries are justifiably concerned about the impact of conflicts between state regulations, Medicare rules and limitations imposed by insurers.  The amount of time necessary to deal with administrative appeals, constraints imposed by availability of insurance coverage (or lack thereof) and for persons who are dually eligible, the integration between Medicare and Medicaid and navigating things like step therapies, is likely to add significant stress to physicians who are working to keep administrative costs low, and users who are unschooled in navigated these changes.

In accordance with the implementation of the Comprehensive Addiction and Recovery Act of 2016 (CARA), Part D sponsors are required to implement drug management programs that result in decreased opioid prescribing volumes. Under such programs, a sponsor can limit at-risk beneficiaries’ access to coverage for frequently abused drugs, including opioids and benzodiazepines, beginning with the 2019 plan year. The clinical guidelines will be used to determine if a beneficiary is potentially at-risk, based on using opioids from multiple prescribers and/or multiple pharmacies.  Sponsors will be allowed to limit an at-risk beneficiary’s access to frequently abused drugs to a selected prescriber(s) and/or pharmacy(ies) (“lock-in”), and through the use of beneficiary-specific point-of-sale (POS) claim edits, which are already permitted under the current policy. Part D sponsors may not implement such limitations unless they have engaged in case management consults with the prescribers of these drugs, and beneficiaries can submit prescriber and pharmacy preferences. The final rule exempts beneficiaries who are being treated for active cancer-related pain, are receiving palliative or end-of-life care or are in hospice or long-term care from drug management programs. At-risk determinations, which include prescriber and pharmacy lock-in, will be subject to the existing disability utilization reviews (DUR) and beneficiary appeals process.

So, for the sake of suggesting a path forward, I want to suggest a thought process for establishing the determination of medical necessity documentation that relies on the exchange of appropriate information between the physician and the patient and occurs at the office level.  Part III will identify a thought process that operates independently of insurance plans or geography. Because persons with complex chronic conditions should plan on annual reviews of medical necessity there is no time like the present to begin to prepare for this conversation.

Let’s Consider the example of Interstitial Cystitis

Below is the framework for the data capture in the ICD-10 lookup system. IC is a noncommunicable disease located in the N group in the ICD-10.  From this information, can you determine anything about severity, or chronicity, or even the impact on one’s daily life for this life changing disease?  To what extent does this disease create disability over time?  Are there indications for pain management or medications required?

Diseases of the genitourinary system N00-N99 >

Type 2 Excludes

certain conditions originating in the perinatal period (P04-P96)

certain infectious and parasitic diseases (A00-B99)

complications of pregnancy, childbirth and the puerperium (O00-O9A)

congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)

endocrine, nutritional and metabolic diseases (E00-E88)

injury, poisoning and certain other consequences of external causes (S00-T88)

neoplasms (C00-D49)

symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)


N00-N08  Glomerular diseases

N10-N16  Renal tubulo-interstitial diseases

N17-N19  Acute kidney failure and chronic kidney disease

N20-N23  Urolithiasis

N25-N29  Other disorders of kidney and ureter

N30-N39  Other diseases of the urinary system

N40-N53  Diseases of male genital organs

N60-N65  Disorders of breast

N70-N77  Inflammatory diseases of female pelvic organs

N80-N98  Noninflammatory disorders of female genital tract

N99-N99  Intraoperative and postprocedural complications and disorders of genitourinary system, not elsewhere classified

As you can see, there are limitations to the way disease information is collected. These limitations have implication for decisions about treatment, prescribing, and chronicity of disease. The lack of contextual information may make the disability utilization review process unnecessarily difficult due to lack of important interpretive information to support the decisions you make with your physician.  In Part III we will consider a thought process for gathering the necessary information that must be available in your medical records to support medical necessity for impact of disability, treatment planning and prescribing.


Gerteis J, Izrael D, Deitz D, LeRoy L, Ricciardi R, Miller T, Basu J. Multiple Chronic Conditions Chartbook.[PDF – 10.62 MB] AHRQ Publications No, Q14-0038. Rockville, MD: Agency for Healthcare Research and Quality; 2014. Accessed November 18, 2014.

ICD-10 Codes online lookup.

Multiple Chronic Conditions—A Strategic Framework: Optimum Health and Quality of Life for Individuals with Multiple Chronic Conditions. [PDF – 234.43 KB] Washington, DC: US Dept. of Health and Human Services; 2010. Accessed November 18, 2014

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Authored by: Terri A Lewis, PhD.

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For a solution to most acute and chronic traumatically induced spine pain see my website and click on video and on manipulation.

Terri Lewis

Plain English version:

Each disease that is billed to Medicare or Medicaid has an ICD-10 diagnostic code, associated CPT codes (Procedures and/or tests associated with each ICD-10 code), and is parked into a group of diseases that tend to occur together (disability related group).

Individuals who use opioids now, alone or with other medications, will have work with their physician and Part D carrier to obtain prescriptions on the drug formulary just as now.

Individuals who are using doses of opioids now, that are 90 MME or over and alone or in other combinations, will have to prove that the disease(s) for which they are receiving these medications are best treated by higher doses based on what is called ‘medical necessity criteria.’ See Part III in my series.

If you live in a state with palliative care regulations in place, you may want to shift your medical plan into a palliative care protocol which facilitates integrated services that include support for higher dosing with opioids alone or in combination with other medications.

If your state does not have palliative care regulations in place, your need for services associated with palliative care will be made through the documentation and codes in your medical record – that will include documentation of multiple chronic conditions (ICD-10), tests and services (CPT), and related chronic conditions (Disability related groups -DRG).

The new regulations will go into place in 2019.

Your physician must annually make the case that your treatment needs are best served by higher doses of opioids, alone or in combination with other drugs, based on information collected at the time of your annual review and recorded in your electronic health record (EHR).

This is not going to get easier. Now is the time to prepare for this process.

Start learning how to read your evidence of benefits (EOB). What codes show up on your claims paid documentation?

Ask your physician to review your medical records with you. (See Part III in my series).

Alan Edwards

According to part 2, politics and enormous complexity with holes is now in place within and without medicare. In 2019, things will worsen.
I appreciate your efforts and knowledge. It is a forewarning that things may worsen, creating anxiety, depression and early death for many of us. My daily functionality has declined to nearly zero since March of 2016. Cerebral Palsy due to malpractice after birth, arthritis and 15 diagnoses with associated complex pain have me housebound. I am now financially crippled by the expense of medical treatments without opioids and their inefficacy. Their grand data gathering should now include early death and suicide caused by their policies. Very depressing and yes, I wish you were in authority.

stephanie logan

I have endometriosis Adhesion related disorder and fibromyalgia. What I’ve gotten from your writings on Medicare policy is every patient will have to show proof of disease in order to get Medicare to cover therapy in relation to said disease? I’m trying real hard to follow here. I have had over 12 surgery’s for the first two diseases above. I almost died twice. Most of my records are so old I can not even get copies. I’ve tried to get copies of the surgery’s. I’m told hospital only has past 10 years! I have many scars from all surgery’s. I’m in a different state now. While on my oipiod pain medication I was able to garden, stain glass art, walk, take care of my family’s bill, taxes ect. My medicine was cut in half. Now I spend 75% of my time curled up in a fetal position. My blood pressure is climbing higher and higher do to pain. I’ve never had high blood pressure until now. I was on one dose for 20 years and I was given just enough quality of life. I still suffored. Nothing like now. I have tried all alternative therapy that I paid out of pocket for. Are you saying at my age I have to jump through hoops to get pain relief that works on me oipiods? I do not have the energy. This WILL KILL ME. If things do not turn around my husband two sons are going to loose there mother and wife. Please help me and those who are walking the fine line of having there quality of life taken from us. P.S. please write in lamin terms.


Debbie, think that is mighty close to 3900 mg. daily recommended dosage of extended tylenol. Yep, no care for your liver, nor your pain is what I gather from such a cockamamie order. I would be livid!

By the way, my mama’s dog has bulging disk. You will never believe what the vet gave him, Gambapentin!!!!! Even the vets are now giving horribly dangerous meds instead of safer pain meds!! What, the dog will become addicted? Holy crap what mess,……….at least she will be able to legally end his pain if time doesn’t heal him. Compassion is missing from USA medicine completely, no matter your species..


I cannot figure out what comorbitities have to do with narcotic prescription policies, other than as a corollary note. Is this new policy not prescription related? The aforementioned articles confuses the subject AND the readers.
Circular talk and confusion reign supreme if these articles reflect the wording of the new policy. Hell, only the writer can understand what was written, though I am doubtful of that myself. Completely astounded only two of us have commented on not understanding what the point of these articles really is!

Karen C.

Truly dizzying. I have RSD/CRPS as well as other painful diseases. Can you give any input on what someone with RSD/CRPS will be up against? Thanks so very much for all your hard work for us. We love you Terri. 🙂

Robert the victim

To the Author may I suggest as a future article you inquire into patient care in Charlottesville, Virginia. I personally have known nothing but harm at REDACTED Hospital and REDACTED Hospital whenever I have gone to them since my December 2013 stroke. One asks for a patient advocate for help and you either get an individual willing to disregard you and protect the doctors and hospital or the individual is in stealth mode because you never see them. One continually sees ads for patient advocates needed at both hospitals. No patient advocacy firms practice in Charlottesville nor will the ones in Richmond, Lynchburg or Washington, D.C. be able to help you once they here “Charlottesviie, Virginia.” I can only opine it is the lack of guantative funds here vs there. The only online patient care advocacy I found willing to charge me money under the excuse of help turned out to be a Republican money fund branching out seeking more money. You will hear either advocay or money fund if you call them The headman was silver tongued and their vaulted legal prowress protects and aids their firm not paying patients. In my opinion the firm sounded much like REDACTED llc. After experiencing them in action I am only offerring my opinion. I am still seeking any help. You may contact me via email but I am not sure when next I will be able to hold and use a stylus. Be Well and sorry for the misspellings. An article on how to receive help rather than harm at a Charlottesville hospital would make an interesting, useful read. Again thank you for the informative article

Robert the victim

A 2nd comment I wish to add is medicare mistreats its patients. After my stroke medicare insisted that I personally had to fill out 30 day blood sugar reports and send them into Medtronic, the maker of my pump and pump neccessities like reservoirs to hold insulin in the pump and infusion devices for pump to administer insulin to the user, because I use an insulin pump and Medicare insists on it being done. Hmm holding a pen or stylus so I can text or write is not a daily possibility yet and it is a lengthy ordeal and struggle when I can hold on to something. The fact that Medicare pays less for insulin used in a pump opposed to insulin given by shot forces me to get my insulin to stay alive at a pharmacy store building since no mailorder pharmacy will touch it. The fact I need physical aid from my wife to get to a pharmacy and then need an electronic cart to get to the pharmacist there becuse of post stroke/mediation abilities is one of those by-line none relevent matters that only need be poo -pooed to and forgotten. Insulin used in shots pays more from Medicare so many mailorder pharmacies will help there. Alas thanks to the harmful affects of Lipitor confusion still haunts me and there are still holes in my memory that I still struggle to heal from even over 5 years after the incident with slow limited results mean that on shots I cannot remember my last shot or whether it was short or long acting insulin. At times I cannot figure out how much insulin is still active nor how much insulin I need for what food I am about to ingest as a bolus dose. A pump records, remembers, give it the carbs of the food and you should get x amount of humolog insulin as a bolus does for food and keep the pump attached you get y amount of basal dose insulin administered daily to keep your body working. Too bad about the confusion and loss of memory from Lipitor because then you could get mailorder insulin to stay alive and not have to deal with the huddles of physically getting to a pharmacy while you are only able to move/control half your body. How will the corporate and medical as well as political communities twist things to insist that the increased amount of screaming patients/victims are not the result of the poorly applied enactment of this hurtful policy in 2019? Afterall screaming people make for better and peaceful communities- right?
To the author I say thank you for bringing the world this needed information and please continue to do so.

Robert the victim

Hmmm, as a stroke survivor with diabetes and great pain at times I view this restriction of pain meds as those in power can show a bottom line nothing else matters. The fact that this medicare recipient survivor screams in pain daily will be argude but we reduced opiods usage – his sreaming must be some inconsequensional by-line like he is just losing his mind with age, or the mass forcing of elderly, disabled onto Lipitor many years ago just coincided with more patients devloping alzheimer’s symptoms rather than the medication was causing the symptoms. Having survived the harmful affects of Lipitor to myself I still get Drs insisting give the Lipitor is important if a stroke hapoened no matter what caused the stroke. The patient yelling ” No, Bad. Harms” are immaterial what matters is giving him the drug to help the company’s bottom line and I get my yearly perk for administering the drug – just disregard the side affects like massive confusion and great loss of memory. Stop taking the drug and it is out of body within 72 hours. Problem is the harm done the patient is not gone even years later. So whst twist are the political and medical communities going to use to explain all the screaming patients after the 2019 enactment of this policy? The affects on the patirnts and their qualty of life is not relevent to any important bottom line for either community especially if Medicare is involved!

David W Cole

Thank you Terri!
I think it’s time we put you in charge of CMS. It’s obvious we have a bunch of educated idiots with no common sense there now.

Debbie Gray

My physician just prescribed
6 – 600 mg of … Extended 8 hr Tylenol per day!!!!!!! Refused to prescribe instant pain relief !!! So now eat my liver up!!!!!!!
ACETAMINOPHEN !!!!!!!!!!!!!!
That’s over approx 3600 mg !!!

Audrey L Liebl

Thank you so much for writing this series of articles. Being subjected to a forced taper myself, I’ve been looking and looking for what information I need in my medical records and/or specialists I may need to see; these articles are so important as a guideline for what I and other patients need to do as we get caught in the bureaucracy.

I was wondering if you had any insights into the Medicaid system. I know it varies state by state – I’m in MA, so if you could point me in the right direction as to what needs to be documented, I would be greatly appreciative and would be able to help others navigate their own state’s rules and regs.
Again, thank you! 🦋❤️🐾