Going Beyond Diagnosis®: Hospice Cardiopulmonary Conditions Local Coverage Determination (LCD)
The goal of the Hospice Cardiopulmonary Conditions LCD is to encourage the collection of more descriptive information to support predictions and decisions made by hospice organizations serving individuals with cardiopulmonary conditions.
The objectives for the LCD and its companion case scenario included:
• Incorporation of the concepts of the International Classification of Functioning Disability and Health (ICF) into the LCD.
• Providing a documentation framework to support the predictions and decisions required of hospice organizations.
• Demonstrating, via case scenario, a descriptive methodology that promotes communication and coordination across the continuum of care.
Palmetto Government Benefit Administrators (GBA's) approach to policy and education recognizes the importance of continuous quality improvement. As both Palmetto GBA and providers strive to make the best decisions possible, we are often faced with incomplete information despite voluminous documentation. Palmetto GBA’s recent policies and educational efforts have highlighted the fact that in order for information to be of value to health care organizations it must allow the end-user to make high quality predictions or decisions. In addition, the resulting outcomes, whether positive or negative, should be used to continuously improve our processes. Palmetto GBA has published several articles describing its approach. Please refer to the Palmetto GBA Web site articles titled:
Going Beyond Diagnosis®: Communicating Debility in Hospice & Palliative Care
Going Beyond Diagnosis®: Continuous Quality Improvement
Measurement is a critical piece of continuous quality improvement and requires the collection of relevant data. These data are then used to create information to continuously improve organizational processes, including facilitating semi-structured decisions such as admissions, level of care, re-certifications, and discharge. Whether you’re evaluating structure, process, outcomes, or patient/caregiver satisfaction, a standard language is essential when describing the health status and care needs of your patient population. That’s where the specificity inherent in the International Classification of Functioning, Disability and Health (ICF) taxonomy can help.
Health care organizations often evaluate the quality of their services by performing utilization review audits. These audits typically focus on high volume/high risk tasks that are critical to the organizational strategic plan. The evaluation often involves the selection of critical process and/or outcome measures. The selection of the most relevant process or outcome measures may be limited by incomplete clinical documentation. Palmetto GBA’s Going Beyond Diagnosis® educational initiative is focused on helping health care organizations identify, document, and communicate the unique health care needs of their patients in a systematic fashion - making it more likely that relevant pieces of data will be available to support their quality initiatives and Medicare reimbursement.
As stated in the Hospice Cardiopulmonary LCD “the identification of specific structural and/or functional impairments, together with any relevant activity limitations, should serve as the basis for palliative interventions and care-planning”. This supports the collection of more descriptive information by clarifying that the health status of individuals with cardiopulmonary conditions is not defined by ICD-10-CM codes, but rather is the result of complex interactions among the components, domains, and categories contained in the ICF. It also reinforces the experience of many hospice providers, namely that secondary and comorbid conditions are important considerations in addressing the service needs of individuals with non-cancer conditions, often impacting both prognosis and care plan.
Recognizing and documenting the impact of the aortic valve stenosis, in the Cardiopulmonary Going Beyond Diagnosis® case scenario, is key to making the best possible predictions and decisions. According to Carabello (N Engl J Med. 2002;346:677-682), the median survival for symptomatic individuals foregoing aortic valve replacement surgery depends on their presentation. The median survival, without surgery, is 5 years for the 35% of patients with aortic stenosis presenting with angina, 3 years for the 15% that present with syncope, and 2 years for the 50% presenting with dyspnea. In the absence of a comprehensive method for characterizing health status, clinicians serving this population of patients may recommend services that do not meet their patients’ care needs.
Palmetto GBA’s Medical Review Department has developed a Medical Review form, titled Going Beyond Diagnosis®: Using ICF Guidelines Worksheet, based on the concepts of the ICF. The form contains fields for the identification of relevant ICF components/categories, a description of how they manifest clinically, clinical interventions implemented to address the identified categories, and relevant outcomes. The first column of the Going Beyond Diagnosis®: Using ICF Guidelines Worksheet has been completed using the ICF codes associated with the most relevant ICF categories identified in the cardiopulmonary case scenario.
While Medicare claims do not use ICF codes for processing, and use of the ICF is not required of Medicare providers, Palmetto GBA has incorporated the ICF into its medical review process. Palmetto GBA medical reviewers use the Going Beyond Diagnosis®: Using ICF Guidelines Worksheet to adjudicate claims for complex clinical scenarios. This systematic process helps Palmetto GBA ensure that relevant pieces of information in the health record are identified and considered during the medical review process. Please share this article, and the Going Beyond Diagnosis®: Using ICF Guidelines Worksheet, with those members of your organization engaged in continuous quality improvement, it may help them improve your organization’s approach to evaluating and documenting the care provided to individuals with cardiopulmonary conditions.
