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

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.

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.
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.
Sit down with your care partner and review your records. Match your records by date to billings and claims notices (evidence of benefits – EOBs).
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
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?
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?
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
Past medical, family and social history (PFS)
1. Past Medical History
2. Family History
3. Social History
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
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
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
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
Rule in/out risks versus benefits for substance abuse, misuse -REMS criteria
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
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
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)
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.

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Photo courtesy of: National Pain Report

Originally Published On: National Pain Report

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