Part III: Multiple Chronic Conditions: Patient & Physician Confirm Medical Necessity for Palliative Care

Part III: Multiple Chronic Conditions: Patient & Physician Confirm Medical Necessity for Palliative Care

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 third of a three-part series.)

Terri Lewis, PhD

Prior to undertaking the necessary work against this set of activities, review Parts I and II of this series. Review definitions, and give more than passing glance at the ICD-10 lookup system online.  Following, is a list of steps that you can take with your physicians and care teams to prepare for a disability utilization review.  For more information, refer back to Parts I and II in this series. Generally, these tasks should be organized in the order in which they are listed here. Remember, medical necessity relies on the integration of medical information about your multiple chronic conditions (MCC) integrated with contextual information that describes the impact of these diseases on your daily life – impairment, disability, chronicity, time, and expectations for disease progression.

  1. Update your releases of information and designate a care partner who will stick with you throughout this process. This should be somebody that you can authorize to act on your behalf to assist – a family member, friend, neighbor, or organizational representative.
  2. You are entitled to one complete set of medical records annually from each of your treating providers. Make a request in writing. I recommend you request three years of medical and pharmacy records in order to track changes in your records over time. For each medical provider that you have used in the prior three year period, make a request for your entire medical record or records.  Gathering them as electronic records on a CD is likely to be less expensive and more versatile. Log into your insurance company account and print your evidence of benefits (EOBs) for the same period as your records.
  3. Sit down with your care partner and review your records. Match your records by date to billings and claims notices (evidence of benefits – EOBs).
  4. Identify the following information:
    1. ICD-9 or 10 diagnostic codes that define the conditions for which claims have been submitted[1]
    2. For each ICD code, find the CPT codes that are associated with the diagnosis code – these are likely to be found on your evidence of benefit (EOB) associated with each of your medical visits
  5. Look at the clinical notes that support each diagnosis code for the dates submitted.
    1. For each ICD-10 and CPT code, what is the first date of diagnosis?
    2. What is the examination that was conducted?
    3. Are there referrals to specialists associated with the ICD code?
    4. Are there additional physicians or other providers who provide treatment to you for this diagnosis code?
    5. What medications have been prescribed to your for each ICD-10 diagnosis? Ask-
      1. Why are you prescribing it?
      2. Is it working?
      3. Is there any possible interaction with existing medications or foods?
      4. How should I store and take it?
      5. Are there potential side effects?
      6. Do I ever stop taking it? What about epiration?
      7. Any non-prescription alternatives?
      8. What if I miss a dose?
    6. Which medications have been discontinued for lack of efficacy?
    7. What tests, or treatment services have you received for this ICD code?
    8. Are you about the same, getting worse, or better?
  6. Are your records correct?
    1. Are there errors?
    2. Is the information incomplete? Missing or wrong references to diagnoses?
    3. Is somebody else’s information in your medical record?
    4. Do your EOBs match the dates for the visits in your medical record?
  7. Make an appointment with your clinician to review your records and update the clinical notes. Look for the information that must be present to support medical necessity.
    1. Physical examination
      1. History of presenting problem(s)
      2. History of prior medical care
      3. Availability of social and/or family supports
      4. Physical examination
      5. General level of functioning
  8. Past medical, family and social history (PFS)
    1. Past Medical History
    2. Family History
    3. Social History
  9. History of present illness criteria (HPI)
    1. Past Medical History
    2. Family History
    3. Social History
    4. Duration
    5. Context – what happened, how are you affected?
    6. Modifying Factors
    7. Disease Signs and Symptoms
  10. Review of body systems (must match your ICD-10 codes)
    1. Constitutional – General health
    2. Eyes
    3. Ears/Nose/Mouth/Throat
    4. Cardiovascular
    5. Respiratory
    6. Gastrointestinal
    7. Genitourinary
    8. Musculoskeletal
    9. Skin
    10. Neurological
    11. Psychiatric
    12. Endocrine
    13. Hematologic/Lymphatic
    14. Allergic/Immunologic
  11. Assess reports of pain associated with each body system
    1. ICD10 (where Substance Use Disorder is potentially co-morbid, review pain symptom criteria in F11.0)
    2. Characterize reports of pain against R-52 codes (locate affected body parts),
    3. Other clinical findings criteria
    4. Review http://www.icd10data.com/ICD10CM/Codes/R00-R99/R50-R69/R52-/R52
  12. Account for the impact of widespread chronic pain on activities of daily living
    1. ICF Core sets (https://www.icf-core-sets.org/en/page0.php)
    2. General, Rehabilitation, Chronic widespread pain, other
    3. Chronic widespread pain, other
    4. Determine levels of severity 1-4, +
    5. Develop profile based on body systems, ICD, CPT codes
  13. Rule in/out risks versus benefits for substance abuse, misuse -REMS criteria
  14. Confirm medical necessity for treatment
    1. Rule in, out SUDS, OUD diagnosis
    2. Characterize reports of pain
    3. Confirm impact of pain for each body system involved
    4. Rule in, out need for various forms of treatment and prescribing based on medical necessity criteria based on body systems
  15. Create or review the care and treatment plan
    1. Discuss the conditions that need ongoing care coordination
    2. Identify potential treatment, contraindications, off label, experimental treatment options, appeals to be made
    3. Discuss nonpharmaceutical & pharmaceutical interventions
    4. Discuss the need for psychological first aid and development of coping skills, family strategies, education
    5. Discuss adverse events, results, outcomes, impact of treatment choices, measures, what you do or don’t want done to you
    6. Create a plan for patient REMS education and communication
    7. Discuss legal and regulatory constraints, responsibilities of attendant palliative care diagnosis
    8. Discuss referrals and external partners to care plan
  16. Document decisions in electronic health records
    1. For each ICD-10 Code
    2. For each ICD-10 code, document CPT codes
    3. For each ICD-10 codes that describe conditions that may be occurring together (document disability review groups [DRG])
    4. For each ICD-10 code identify referrals, other services, or equipment
    5. For each ICD-10 code identify associated pharmacy supplies
    6. Identify the frequency of review for treatment plan (at least annually)
  17. Determine shared outcome measures of effectiveness based on client values and resources
    1. Working alliance
    2. Informed consent
    3. Frequency of communication
    4. Emergency instructions
    5. Instructions that must be communicated to others
    6. Advanced directives, medical designees
    7. HIPAA releases and communications to care partners
    8. Complete a certification of necessity for palliative care based on medical necessity and put it into the medical record with copy to patient and pharmacy (see Dr. Thomas Kline’s model for a Palliative Care Certificate at https://medium.com/@thomasklinemd_65234/palliative-care-certificate-form-to-accompany-article-when-does-pain-treatment-become-palliative-f5ab526188cb)
    9. Review Medicare appeal criteria at https://www.cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev/index.html

To ensure a smooth transition to continued prescribing under the 2019 CMS rule changes, it is necessary to confirm that your continued program of care is medically necessary.  Criteria for determination of medical necessity from state to state is found on this link: https://nashp.org/medical-necessity/. Whether your state has palliative care reflected in your state pain regulations or you have to rely on the Medicare coding system based on ICD codes, your records must be correct, and current.  And they will need to reviewed annually.  This is also a terrific time to think about your own values and wishes for how you will interact with services. Involve your care partners and physicians in your planning.  Review your insurance plans, speak with representatives from community located health care organizations.

Resources for Health Planning

https://getpalliativecare.org/whatis/disease-types/

http://www.ncsl.org/research/health/the-medical-home-model-of-care.aspx

https://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf

https://www.magellanprovider.com/media/1771/mnc.pdf

https://nashp.org/medical-necessity/

https://www.privacyrights.org/consumer-guides/hipaa-privacy-rule-patients-rights

[1] On October 1, 2015 the conversion from the 9th version of the International Classification of Diseases (ICD-9-CM) to version 10 (ICD-10-CM) occurred. Regardless of when a claim was submitted for payment, services that occurred prior to October 1, 2015, use ICD-9 codes. Chronic conditions identified in 2015 are based upon ICD-9 codes for the first ¾ of the year (January-September) and ICD-10 codes for the last quarter of the year (October-December).

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Authored by: Terri A Lewis, PhD.

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14 Comments on "Part III: Multiple Chronic Conditions: Patient & Physician Confirm Medical Necessity for Palliative Care"

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Thank you Dr Lewis for the interpretation of the new CMS. I am sorry to say that in most cases with doctors using new computer systems, my information is gone. In order to recreate it I would need to have all tests done over. This appears to be more hoops to jump through in the off chance I might be approved for pain medication through my doctor. Then I have to get through my insurance plan and the pharmacist. I am going an alternate route.
You can not believe all I have done over the years (20) to get relief for pain, Nothing compares to the past year.Every month a reduction in medication, an increase in pain, a reduction in mobility. Every month, fearful my doctor will cut me off, every month afraid insurance won’t pay or the pharmacist will decide I am addicted and scream it out to other customers. I am done with the degradation, humiliation, the instructions that need translation and even those need translation. No more. I am following others and saying no more!

THANK YOU!! That list is much easier to understand. Not so easy to accomplish, but at least I have a goal to work towards. Thank you again Dr. Terri!

I wish I had someone like you suggest to help.

Now, one more thing….why is this necessary(in plain english),?

I swear before all this [edit] started with me I was intelligent…now even reading the slightest complicated thing and comprehending it is very difficult. My analytical skills have taken vacay without my permission. Does anyone else have this problem now? Hell,for fun I learned animal law, wrote articles and fought for constitutional property rights. Just the idea exhausts me at This point.

Teresa

I keep listening to all these professionals talk and talk what we all should do is stand up together as one . Talking isn’t doing anything to solve our problems. We are dying losing everything!!! There are millions of us in this situation and they don’t care so let’s make them instead of asking them for help that’s not coming .

Dr Lewis! Thank you! I read all of your posts, even comments. I love how you tell it like it is. I have learned so much from you so that I can converse with my docs. I’ve been on a long chronic pain journey and each level I’m at you can speak to. Some readers are not far enough along to understand what you’re documenting. They can’t pick up what you’re putting down OR smell what you’re cooking.

Thank you, Dr. Lewis. I am overwhelmed with all of this and I am not only associated with ATIP but have had both my private insurance long-term disability and Social Security Disability Insurance benefits cut off (each at a different time over the last 27 years) and had to hire lawyers and fight for a year to get it reinstated. I understand the frustration that some readers may feel upon the realization of all that should be done before 2019, but I hope all will also understand that Dr. Lewis is giving great advice, and instructions, that will be of tremendous benefit, if followed.

We have 7.5 months to either follow her advice & instructions or wait to see what will happen. It would be much better to be prepared to deal with what will happen than to wait & see. We all have an important choice to make.

Plain English version:

Try to talk someone into working through this process with you.
If somebody isn’t available, ask for someone in your physician’s office to work through this with you.
Request your medical records (clinical notes, tests, procedures).
Request your pharmacy records (prescription history).
Review your medical and pharmacy records.
Identify all of the conditions for which you are treated – list all the diagnosis codes.
For each diagnosis, identify all the treatments, tests and procedures, and drugs associated with each diagnosis code.
Identify all the ways in which you are helped by your treatment routine.
Identify how you measure progress.
Identify all the ways in which you would be harmed if your treatment routine was modified or removed.
Describe how your treatment routine allows you to interact with your family and friends, community, and other aspects of your life.
What are your goals for care?
What is the relationship of your goals to your treatment plan and to the medications that help you manage your disease(s)?
Do you need multiple services – are they represented in your records?
Will you need multiple coordinated services delivered over a long period of time?
Have you been screened for and educated about the proper use of the medications you take?
Do you full understand your illnesses and know what to do in an emergency?
Have you given consent for the treatments you receive?
Do you feel confident in your care providers?
Do they understand your goals, wishes, needs, values?
In an emergency is there someone who can be designated to speak to your physicians and given consent for care if need be?
Is all of this information contained in your records.

Remember, if it isn’t written down, it never happened. And that will be a great big fat headache for you and your doctor. And it may result in changes you don’t like or want.

If most pain patients could do all the paperwork and run the 100 yard dash, we would not need pain management care. Pain management patients have a far worsened life now. It was bad enough when the word opioid or opiate medication was not nationally taboo. We have to live with the stigma of pain management medication “prescribed” everyday and dot/gov does NOT have the “right” to take away medication that has been documented as successfully used, responsibly prescribed along with a full cavity “search” at every pain managment agency just to receive now, inefficient medication, dosage wise that is documented as being Very successfully used for patients over the years and decades. Dot/gov should NOT have the authority to overide tests, alternative treatment, and judgement used by our VERY qulaified doctors. A true “guideline” or protocol is necessary but interogation reminds me of the early 1940 years.

Thank tou for giving us a voice and giving important information thank ywou again and godbless

All this is great but who can accomplish this? We cannot even go to 1 Doctors appointment and get much of anything done. Referrals take a while and then by the time they order test and try for instance approval you are 4 months out. My Wife cannot tolerate 1 car ride. She gets so sick. It is hard to watch and then the cost of missing work is such a hardship. Also, getting perscriptions on the day the patients are do to run out is ridiculous. What if the Pharmacist is out of the medication or other issues. The toll this has taken on Patients was bad and now it is even worse and then to have to sit down with a stack of Medical Records and do an accounting is virtually impossible. We still have a family to care for within all this mess and destruction of my Wife’s health and our Family is suffering like never before. I am lucky my Wife has a sense of humor and an Attitude that we cannot give up. This whole thing must stop and at least minimum have an injunction to stop the CDC from restricting Chronic Pain Patients their Medication until a real investigation can take place with real numbers and a committee representing both sides. Someone over stepped their Authority and at a cost so great it is Heartless! But, we all do appreciate your article and your time.

Listen, I know this was a huge amount of effort. I appreciate it, I really do. However, all your effort is wasted when your readers can not follow your articles, nor understand them.

I reakize about 5 years ago that I needed a Pain Management doctor and mine is wonderful a God send – with all tje new laws and policy.. I dont blame some doctors for being fo fearful..I dont believe most w serious diagnose is going to have big problems at least I hope not.. I am already on Palliative care – and I feel my health conditions are getting worse
I am more then willing to share tje horrible issue Ive been through battling 4 invisible illnesses all pain related – Ive been told ti ti leave ER by security telling me I was there drug seeking- Been told id I lose weight ill feel better
I pray E1 who Needs Opiates have no issue getting the medications theu need ti handle your illness

How does this help me to get my opioid prescriptions reinstated? I have 10 things wrong with me along with CRPS. My doctor isn’t going to treat me anymore to relieve my pain. My life has been taken from me and the only thing that allowed me to function at a high level was the opioids he use to prescribe. He’s totally afraid the DEA is going to take his license, so no offense, and I appreciate all of your hard work, but no matter what we discuss in these forums, my quality of life is gone forever.

IF UR THAT ILL
HOW CAN U WRAP YOUR MIND AROUND SUCH MEDICAL/BUREAUCRATIC DEMANDS WITHOUT THE STRESS PAIN CYCLE GOING INTO OVERDRIVE???FROM ONE WHO LIVES IN THAT WORLD!
SEEMS TO ME THIS WRITER IS OUT OF TOUCH WITH REALITY!

Thank you for all your efforts to support the Chronic Pain Patient community Dr. Lewis.