Palmetto GBA has revised its Hospice ALS Local Coverage Determination LCD. No formal comments were submitted in response to the draft LCD. The goal of the LCD revision was to encourage the collection of more descriptive information to support predictions and decisions made by hospice organizations serving individuals with ALS. The objectives of the revision 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 GBA has previously published articles describing its Going Beyond Diagnosis® educational initiative. The articles are available on the Palmetto GBA Web site
www.PalmettoGBA.com by simply entering the title of the article in the search engine and selecting the arrow to the right of the search engine box. A list of available Going Beyond Diagnosis® titles is provided at the end of this article. Palmetto GBA's Going Beyond Diagnosis® educational initiative recognizes that as the Medicare beneficiary population grows in this century, so too will the prevalence of chronic illness and disability. The challenge for Medicare providers, across the entire continuum of care, will be to develop processes and information systems that are responsive to the Centers for Medicare & Medicaid Services' (CMS's) guiding principle, namely, the provision of 'the right care for every person, every time'.
The CMS rules and regulations addressing hospice services require the documentation of sufficient 'clinical information and other documentation' to support the certification of individuals as having a terminal illness with a life expectancy of 6 or fewer months. The hospice providers' tasks of prediction and decision-making also require the best available information. This information, if collected in a systematic manner, could not only meet the administrative requirements of the Hospice Medicare Benefit, but could also contribute substantially to the continuous quality improvement efforts currently under way in the hospice provider community.
The revised Hospice ALS LCD supports the collection of more descriptive information by clarifying that the health status of individuals with ALS is not defined by ICD-9-CM codes, but rather is the result of complex interactions among the components, domains, and categories contained in the ICF. The revised LCD also supports use of the revised Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-r). The 12 ALSFRS-r items contribute to both the descriptive and predictive information available to providers. According to a study by Kaufmann et al (
Neurology 2005;64:38-43), 'among the ALSFRS-r subscores, the respiratory score was the strongest predictor of survival time, as expected because death in ALS is ultimately due to respiratory failure'. Additionally the Kaufmann study found that 'when other clinically meaningful covariates were included in the model', the Forced Vital Capacity (FVC), % predicted was not a statistically significant predictor of death or tracheostomy in the population studied.
While the ALSFRS-r is helpful with the task of prediction (i.e., prognosis), hospice and palliative care professionals are also challenged by other semi-structured decisions, requiring descriptive rather than predictive information (e.g., recertification, discharge, and deciding whether services are related to the palliation or management of the terminal condition). This is where the comprehensiveness of the ICF taxonomy is of value. The ICF allows organizations to describe the health status of individuals using the most relevant domains and categories, thus promoting the development of a unique beneficiary-centered care plan and decision-support.
The Going Beyond Diagnosis® ALS case scenario, attached to the Palmetto GBA publication
Going Beyond Diagnosis® : The ICF and Decision-Support in Hospice & Palliative Care was developed using an interdisciplinary process and included the input of both rehabilitation and palliative care professionals. The importance of this approach was especially evident in the selection of relevant ICF domains and categories, which could serve as the foundation of the rehabilitative, beneficiary-centered care plan, and ultimately the palliative plan of care. The domains and categories contained in the ICF include all the factors identified in the ALSFRS-r, but in addition provide the necessary framework for capturing other important information needed to truly describe an individual's health status.
An important aspect of Palmetto GBA's approach is the identification of not only the primary condition, in this case ALS, but also relevant secondary and comorbid conditions. The LCD makes clear that both secondary and comorbid conditions may impact the plan of care, and thus be 'related to the terminal condition'. Some observers have mistakenly surmised that if a condition can be categorized using a different ICD-9-CM code, then it is 'unrelated' to the terminal condition. The key to answering the question 'are services related to the palliation or management of the terminal condition', is to first identify relevant secondary and comorbid conditions, using the ICD-9-CM taxonomy and then characterize them further using resources like the ICF. Such a process would provide an excellent framework for documenting the relevant palliative care interventions and their outcomes.
The following Going Beyond Diagnosis® articles are available on Palmetto GBA's Web site:
Going Beyond Diagnosis®: The ICF and Decision-Support in Hospice & Palliative Care
Going Beyond Diagnosis®: ICD-9-CM 799.3 Debility, Unspecified
(Revised July 2007)
Going Beyond Diagnosis®: Valuable Information (Revised February 2008)
Going Beyond Diagnosis®: Continuous Quality Improvement