WHEN DOES PAIN TREATMENT BECOME PALLIATIVE CARE TREATMENT? An Office Approach — Clinical and Reimbursement Guidelines

June 20, 2018

Thomas F. Kline, M.D.,Ph.D. and Carolyn D. Concia, Palliative Care N.P.

Together we have had primary care practice experience of 70 years. A key feature of both our individual practices has been to alleviate fears, discomforts, and pains along with direct treatment of disease. The recent interference in the practice of medicine by the CDC, an agency without regulatory authority to do so and with self-confessed scientific validity issues, started a wildfire of fear and panic among physicians and practitioners. The CDC produced a Guideline that suggested forced tapering of successful, life-giving, and safe medicine for patients with painful disease. If the practitioners did not comply, they would lose their licenses to practice medicine, or so they thought.

When we read the CDC Guideline and found on line one: “This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care.” Palliative care has always been the standard of practice for patients suffering from painful diseases having no cure. This CDC Guideline, line one, protected our long-term pain or palliative care patients and also protects us as practitioners. We can use FDA approved titration dosing methodology to whatever it takes, no “cutoffs”.

There is the perception, magnified by single case reports, of addiction occurring in just about anyone. If this were the case with all the opioids being prescribed there should be far more cases of addiction than there are. The government reports 2 million cases of opioid use disorder (SUD), a newly created category of people who “used their prescription opiate in a way other than prescribed” hoping everyone would believe this is the same as opiate addiction, which it is not. The fear and concern it caused — worked.

Even if the SUD figure were not inflated by a factor of 200% two million OUDs claimed by household survy divided by the US population of 320 million gives a rate of 6 addictions per 1000 people, fairly rare. There has been a fixed occurrence rate of addiction over time going back to the 1920s, ruling out environmental factors such as availability of opiate pain medicine. No one can become addicted if they have a history of opiate use without addiction. 994 people of 1000 population will never become addicted.

We wanted to share this paper with you, our fellow medical practitioners, to encourage all primary care providers to offer palliative care in their practices for patients suffering from intractable pain of any origin. The evolution of palliative care, CDC exemptions, and reimbursement will be explained. Finally, guidance will be given on how physicians and practitioners can easily start offering palliative care without restrictions on pain medication dosage ethically practice on patients with less fear of retribution, and to be reimbursed for the extra time in caring for people with long term illness.

“If we know that pain and suffering can be alleviated, and we do nothing about it, then we ourselves become the tormentors.” — Primo Levi

Palliative care allows more comprehensive and humane treatment as it is exempted from opioid dosage restrictions set by CDC and many states over the past two years. Primary care doctors and practitioners can avoid restrictions if their patients qualify for palliative care. (1)

Pain care becomes palliative care when three criteria are met:

● The underlying disease has no cure.

● There is a likelihood that the disease may shorten lifespan.

● Symptomatic treatment has a high probability of improving the quality of life.

EVOLUTION/DEFINITIONS OF PALLIATIVE CARE: WHAT IT IS AND WHAT IT IS NOT

Palliative care is not new. The concept was created by Balfour Mount, a Canadian-trained physician serving as visiting professor at the first hospice, St. Christopher’s Hospice in London. In 1973, he established a palliative care program at Royal Victoria Hospital in Montreal, the first palliative care program to be integrated in an academic teaching hospital. (2) Palliative care has evolved in scope since that time.

1990 — World Health Organization (WHO): “…The active total care of patients whose disease is not responsive to curative treatment.”

1993 — The Oxford Textbook of Palliative Medicine: “The study and management of patients with active, progressive, far-advanced disease for whom the focus of care is the quality of life.”

2007 — WHO (revision): “An approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.” (4)

2013 — National Consensus Project: “Palliative care means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice.”

“The goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies” - the Oxford Book of Palliative Medicine. (3)

DOSAGE RESTRICTIONS WAIVED BY CDC AND MOST STATES

The palliative care exemption in the CDC restrictions regarding the prescribing of opioid pain medicine gives providers the freedom to do what is proper to manage pain. As mentioned the CDC Guideline page one, line one: exempts palliative care from the rest of the “Guideline”. Nothing in the “Guideline” that follows applies to the palliative care patient you have in your office.

Most states provide palliative care exemptions as well. Palliative care is for all prognosis levels, diagnoses, and ages groups. The only qualifications are unavailability of a cure and persistent symptoms. It can be CHF with shortness of breath, COPD with intractable coughing, or a person with lupus, arachnoiditis, or advanced arthritis where cure is impossible and treatment focuses on symptoms of pain interfering with the enjoyment of life. It is no different than certifying one of your patients’ needs cardiac care or comprehensive diabetic care. Only licenced personnel can establish or unestablish diagnoses: “palliative care status” (PCS), a new term as well, is a

By the same token, people without licenses cannot try to ignore or remove Palliative Care Status (PCS) once in place. Pharmacists, insurance executives, or other doctors not involved with the primary care cannot interfer with the PCS diagnoisis or try to ignore it. It is law in most states and for the Veternes adminstration. Once the PCS is determined, CDC, VA, and state restrictions for opioid prescribing are bypassed. If palliative care is not mentioned in the law, regulation, or guidelines, then the PCS does not apply.

This allows physicians and practitioners to prescribe what they want. As usual if medically necessary and humane to relieve suffering - without interference. Placing any restrictions on palliative care would be tantamount to ignoring CDC and state guideline legal and intended exemptions and imposing unwarranted constraints on providers engaged in palliative medical care. Most of all ignoring this provision for care affects the 10 million patients in the US taking long term opiates, many of whom are already being tapered off or worse discontinued — all in violation of the PCS provisions.

Although the DEA is concerned about the prescribing of “too much” pain medicine, the Palliative Care Status and the DEA definition of prescribing for a “legitimate medical purpose” should help decrease concerns of high and prolonged doses equating with a federal crime. Prescription of any high, low or very high mg doses is still legal for any FDA approved opiate for anyone , and clearly proper for those under PCS exemptions

FDA does warn to “watch for addiction and excessive sedation,” both of which are rare and are no different that all side effects of all medication we use. We do not normally refuse to prescribe medications with serious side effects. There is no rational reason to do so for opiates. It is always the patients choice after being informed. This is true for PCS patients as well. PCS pateints can rest assured, after a intensive search we found virtually no evidence of addiction in stable patients irrespective of dose, or lenght of time treated. Overdoses in non-addicted medical patients are rare as well, almost unheard of, according to physicians interviewed with combined 100 years of pain management clinical experience. Still these are side effects, about like Humira. We do not refuse to prescribe Humira, even though its profile may be worse than opiates. PCS patients need to decide about Humira, and about opiates.

Palliative care is not a prescribed program like hospice and does not require the patient to be near end of life, nor to sign up and lose other benefits as occurs in Medicare programs. Palliative Care Status is commonly misunderstood as being available to only those who are at end of life, which is incorrect.

BILLING AND REIMBURSEMENT

Palliative care visits can occur in any setting — hospital, home, or office — not billed as palliative care but as a standard office visit focusing on symptom management, not the disease which is allowable. Palliative care, like any other type of care, is billed fee for service using symptom codes instead of or in addition to disease codes. Symptom codes are fully reimbursed just like disease codes. For example, G89.29 is the ICD-10 code for chronic pain and is fully reimbursable by itself. Painful disease management under a palliative care plan is complex, may involve other team members and is very time consuming. To reimburse for the extra time spent, CMS had provided three mechanisms to increase revenues and compensation for time.

One such mechanism is billing by time. If more than 50% of the visit is concerned with “counseling and/or coordination of care,” time itself controls the visit parameters, obviating the cumbersome AMA “2 of 3” CPT guideline rules. It allows the primary care professional the extra time needed with complex palliative care patients without having to worry how many body parts are examined. The time spent must be in the presence of the patient or a family member for “counseling and coordination of care.” For example, a level 5 established patient is set at 40 minutes. If 25 of the 40 minutes is spent with coordination of care by calling the pharmacist during the visit and coordinating care with the patient, time will then override the clinical coding rules. (5)

If you are supervising a palliative care certified person at home under Medicare home health services, you can bill separately for non face to face time through the Home Care Plan Oversight code series G0180 (which pays about $100). This cognitive time will cover phone calls to pharmacists, home health nurses, colleagues, reviewing labs/x-rays/consults, etc. and is important in receiving reimbursement when caring for complex Home Health Agency home bound palliative care patients.

If your patient is not covered by home health, the same type of non-face-to-face time can be billed using the newer Chronic Care Management (CCM) code series 99490. These charges begin sy about $50 for 15 minutes and are unlimited for further documented time spent with, for example, pharmacies, prior authorizations, phone calls from members of the palliative care teams, etc. Some of the glitches have been worked out this past year. Substantial recoupment of time with complex palliative care disease can be billed. Details are at: CMS FAQs for CCM (6)

Patients with dementia and cognitive impairments frequently exhibit maladaptive behaviors when pain is overlooked. Some physicians have the patients undergo brief trials of low dose pain medication to empirically diagnose the pain as the cause of changes in behavior. If pain is diagnosed and there is no cure for the underlying cause, billing would be the same fee for palliative care as other patients. The patient would be eligible for the new code G0505, a $200 cognitive assessment. Older palliative care patients, with or without dementia, would be free of imposed restrictions on their pain care and need not be forced off their medication as is occurring in many states, such as Washington

If a pain patient is suicidal, proper pain treatment will usually help solve the problem. This treatment becomes a suicide prevention tool. If additional psychological counseling for suicidal ideation or other problems is needed, this can be added to the office visit using the 90837 series codes.

Commercial insurances generally follow the Medicare standard. The Palliative Care Plan needs to be developed and documented like any other care plan. It can be supplemented with other services, or not, at the discretion of the licensed primary care professional certifying the patient. Other services requiring Chronic Care Management (CCM) billable time can include therapists, nurses, home care agencies, and even palliative radiation for painful tumors (not allowable under hospice rules).

It is because of these complex palliative care pain and other symptomatic patients, young or old, that CMS is finally providing reimbursements for non-face-to-face or cognitive work time done by all the primary care practitioners willing to accept and treat challenging patients especially importand for PCS patients.

WHAT CAN I DO TO START HELPING MY PATIENTS?

1. Offering office primary care, palliative care is the first and most important step in returning compassionate medical care to the office.

2. Provide a “Palliative Care Certificate,” which can be generated by the licensed practitioner, including a statement certifying that the patient has the triad for palliative care: no cure, condition existing more than 6 months, and the need of symptom treatment. (Please see attachment for an example certificate.) Pateints without documentation are treated universally as drug seeking addicts.

3. Add the words “palliative care” to your prescriptions so the pharmacist understands that the patient has a severe, chronic illness and Palliative Care Status. Provide the patient and pharmacist with a copy of the certificate.

4. Encourage your patients to be part of the solution. Get them involved in their own care through fact-finding, keeping a diary, setting goals, and communicating routinely. They can help with documenting the time spent on the phone with you, etc. These discussions are billable under time coding and CCM.

5. Learn coding for improved reimbursements for non-face-to-face time with complex, time-consuming patients. Many patients are looking for competent, caring practitioners willing to handle the challenges of all aspects of complex illnesses especially after being cast aside as “too troublesome” or “too DEA risky.”

The enclosed palliative care certification allows freedom for primary care practitioners to treat with full doses of pain medications, bringing compassion back to our essential goal of relieving pain and providing wonderful rewards at stopping pain from functionally disabling our patients. At the same time, the certification will allow us to be properly reimbursed for the extra time needed to do our job as real doctors and practitioners. We deserve the freedom to provide quality care based on science and experience unfettered by those without licenses trying to control the practice of medicine.

Citation Sources:

1. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016, March 15, 18, 2016.

2. Mount BM. The Royal Victoria Hospital Palliative Care Service: a Canadian experience. In: Saunders C, Kastenbaum R (eds). Hospice Care on the International Scene. New York, NY: Springer; 1997: 73–85.

3. Doyle D, Hanks GWC, McDonald N. Introduction. In: Doyle D, Hanks GWC, MacDonald D (eds). Oxford Textbook of Palliative Medicine. Oxford: Oxford University Press; 1993:.

4. World Health Organization. Cancer Pain Relief and Palliative Care. Technical Report Series 804. Geneva: World Health Organization; 1990.

5. CMS Manual System Pub. 100–04 Medicare Claims Processing Transmittal 178 MAY 14, 2004 CHANGE REQUEST 2321

6. https://www.cms.gov/Medicare/Medicare.../Payment_for_CCM_Services_FAQ.pdf

Thomas F. Kline, M.D., Ph.D. Chronic Disease Specialist 
Raleigh, North Carolina
6409 Pernod Way
Raleigh NC 27613
919–561–0144

thomasklinemd.com for media page

Newspaper article for reference of my positions on opioids 
www.newsobserver.com/opinion/op-ed/article145348794.html

Carolyn D. Concia, N.P. , Palliative Care Practitioner
Portland, Oregon

Conflict of Interest Statement: Both authors are independent practitioners who receive no consideration, directly or indirectly from any entity.