Let me start with an article recently published in the journal of the American Cancer Society. The topic was a study surveying patients with advanced cancer about their goals of care and the actual care they were receiving.
I bet you can all guess the findings: a significant proportion of patients who requested comfort-focused care were receiving life-extending care. And interestingly, when the patients who received comfort care were compared to similar patients receiving life-extending care, there was no statistically significant difference in two-year mortality.
Remember that one of the key requirements of Medicare discharge planning Conditions of Participation is to determine a patient’s goals of care and treatment preferences. In fact, in the 2019 update to the Conditions of Participation, the Centers for Medicare & Medicaid Services (CMS) used the terms “goals of care” and “treatment preferences” 53 times. And that means you should not only be asking about our patients’ treatment preferences and goals of care (and documenting that discussion) but also ensuring that those preferences are known by all members of the treatment team – and are honored.
Moving on to more mundane things, we are getting closer to the start of two new CMS demonstration projects involving prior authorization that I have discussed in the past: the Wasteful and Inappropriate Service Reduction (WISeR) program, which will use contractors running artificial intelligence (AI) to review requests, and the Ambulatory Surgery Center (ASC) prior authorization program. Both programs will be running in a limited number of states, so some of you will be spared the pain.
Since my last update, CMS has released a guide for providers for the WISeR program that finally provides the applicable CPT® codes for each category. And if you recall, I noted that one of the listed categories was “diagnosis and treatment of impotence” – and that was about as ambiguous a category as there could be. But it turns out that one does not need prior authorization to diagnose a patient with impotence – only if the patient is going to have a penile implant placed.
Now, why penile implants? It certainly does not seem like a surgery that is subject to overuse, but apparently usage is increasing. In fact, I saw one surgeon quoted on the Internet as saying “I present it to patients as a 30-minute outpatient procedure that restores your ability to have an on-demand erection that is as hard as you want it to be and lasts for as long as you want it.”
The other thing I found out from the provider guide, that I must admit I overlooked before, is that WISeR will also require ASCs and physician offices to get prior authorization for the designated procedures. And for surgery centers in Ohio, Texas, and Arizona, they will be part of both WISeR and the ASC prior authorization demonstration project, so they will be really challenged by the additional workload.
And while physicians are not yet performing spine surgery in their offices, there are certainly doctors who do vein procedures and treat skin ulcers with skin substitutes in the office who will now have to obtain prior authorization from this yet-unknown contractor.
Now, of course, the big unknown with these programs is the effect of the federal government shutdown. While I suspect that every provider would love to see them delayed, and several members of Congress have expressed opposition to the programs, the release of the provider guide during the shutdown does suggest that CMS is still on track to proceed.
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In the Medicare fee-for-service world, “prepayment review” (also sometimes called “prepayment medical review” or “pre-claim review,” depending on the context) means that a claim is
Back in June, I was on the Monitor Mondays broadcast discussing the initial momentum within the Trump Administration for a single, national provider directory. Now,
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