When does pain treatment become palliative care?

In this article, Dr. Kline makes a brilliant suggestion: patients with intractable (incurable, life-long) pain should be receiving “palliative care“.

When does pain treatment become palliative care treatment? – Mar 22, 2018 – A Medical Office Approach — Clinical and Reimbursement Guidelines
Thomas F. Kline, M.D.,Ph.D. and Carolyn D. Concia, Palliative Care N.P.

The purpose of this paper is to encourage primary care providers to offer palliative care in their practices for patients suffering from intractable pain — of any origin.  

What a brilliant idea! This is the truth we live and the care we need. Naming it palliative care is appropriate and is not only a way to circumvent opioid dose restrictions.

Palliative care’s evolution, CDC exemptions and reimbursement will be explained.

Finally, guidance on how physicians and practitioners can easily start offering palliative care without restrictions on pain medication dosage.

“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

Pain care becomes palliative care when three criteria are met:

1. The underlying disease has no cure
2. There is a likelihood the disease will shorten lifespan
3. Symptomatic treatment has a high probability of improving the quality of life

These can be met if we have a diagnosis besides chronic pain, like fibromyalgia or Ehlers-Danlos Syndrome, though medical experts now consider chronic pain a disease in and of itself (central sensitization).

And a doctor will have to determine that our diagnosis will shorten our lifespan. Of course, there’s plenty of research that suggests earlier mortality just from having the symptom of lifelong pain, but I think this would be a point of contention.

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

Palliative care is not new. “Palliative care” 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.

Palliative care has evolved in scope since that time.

So far, I haven’t found definitive rules about how to qualify for such care, though there is no longer a requirement to be dying soon.

“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

DOSAGE RESTRICTIONS WAIVED BY CDC AND MOST STATES

Palliative care exemption for CDC restrictions regarding the prescribing of opioid pain medicine gives providers the freedom to do what is proper to manage pain.

Directly from the CDC “Guideline” page one, 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.”

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.

Palliative care determinations can be made by licensed providers only. By the same token, people without licenses cannot try to ignore or delete Palliative Care Status (PCS) once in place. Once the PCS is determined, tCDC and state restrictions for opioid prescribing are bypassed.

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 loose other benefits as occurs in Medicare programs.

The definitions of palliative care that I found in various places on the websites of the National Institute of Health (NIH) always seem to include a phrase about “with life-threatening illnesses“, but I also see “independent of prognosis“.

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 standard offices focusing on symptom management, not the disease.

Palliative care like any other type of care is billed fee for service using symptom codes instead of or in addiction 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.

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 cumbersome the AMA “2 of 3” CPT guideline rules for standard office billing codes.

Exemption is Exemption.

If a pain patient is suicidal, proper pain treatment will usually treat the problem and becomes a suicide prevention tool.

In this context, sufficient opioids to treat intractable pain will definitely prevent some suicides. Is that not a worthy medical goal?

If additional psychological counseling for the suicidal ideations, or other problems is needed, this can be added to the office visit using the 90837 series codes.

WHAT CAN I DO TO START HELPING MY PATIENTS?

2. Offering office palliative care is the first and most important step in returning care to first line practitioners and returning compassionate medical care to the office.
   The Palliative care certification allows freedom for primary care practitioners to treat with full doses of pain medications, bringing back old-fashioned compassion to our first job — relieving pain.
3. Provide a “Palliative Care Certificate” which can be generated by the licensed practitioner including a certifying statement the patient has the triad for palliative care: no cure, condition existing more than 6 months, and the need of symptom treatment. 
4. Add the words, “palliative care” to your prescriptions so the pharmacist understands the patient’s severity and chronicity of the illness and has Palliative Care Status. Provide the patient and pharmacist with a copy of the certificate. 
5. Encourage your patients to be part of the solution. Get them involved in their own care in 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. Tell the patient what is going on, they love to help. 
6. Learn coding for improved reimbursements for non-face to face time needed for complex, time consuming patients

Original article: When does pain treatment become palliative care treatment? 

Authors:
Thomas F. Kline, M.D., Ph.D. Chronic Disease Specialist , Raleigh, North Carolina , 27613, 919–561–0144, Twitter @thomasklinemd
Carolyn D. Concia, N.P. Palliative Care Practitioner Portland, Oregon

Dr. Kline also posted images and instructions to get certified as a palliative pain patient: Palliative Care Certificate

I think this could be a solution to getting the correct pain care, but I anticipate problems in qualifying.

Perhaps some reader here knows where I can find more information on how to qualify for this category of medical care.