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Refined GOLD

Refined GOLD

faqThe Global Strategy for the Diagnosis, Management, and Prevention of COPD (GOLD) has released its 2017 report. The executive summary highlights the “most significant” changes:

  • The assessment of COPD has been refined to separate the spirometric assessment from                       symptom evaluation. ABCD groups are now proposed to be derived exclusively from patient                 symptoms and their history of exacerbations
  • For each of the groups A to D, escalation strategies for pharmacological treatments are                         proposed
  • The concept of de-escalation of therapy is introduced in the treatment assessment scheme
  • Nonpharmacologic therapies are comprehensively presented
  • The importance of comorbid conditions in managing COPD is reviewed

The remainder of the report explains and expands upon these five shifts in strategy for the management of COPD. When implementing the refined GOLD strategy, here are 3 tactics to consider:

Drive the management of COPD patients with standardized assessment protocols

Immediately out of the chute the refined GOLD assessment recommends “escalation strategies” and “de-escalation of therapy” be implemented based on the patient assessment grouping ABCD and ongoing treatment regimen.  According to Stoller, the effective use of protocols…“adjust the duration of therapy to assure that patients continue to receive therapy as long as needed but that therapy is curtailed or eliminated when a change in the patient’s clinical status (ie, improvement) permits”1  Stoller also noted that studies have shown that protocols demonstrate “a higher rate of concordance with a gold standard respiratory care plan”2.

Perform an individualized patient discharge assessment and post discharge follow-up

Under the subheading Prevention and Maintenance Therapy the report emphasizes: “Each pharmacologic treatment regimen should be individualized and guided by the severity of symptoms, risk of exacerbations, side-effects, comorbidities, drug availability and cost, and the patient’s response, preference and ability to use various drug delivery devices.” Daily integration of the newly “refined” ABCD assessment criteria with an algorithmic assessment protocol designed to tailor the patient’s care plan to their unique needs and situation is paramount to an effective discharge plan of care and guiding follow up post discharge.

Work with home health care and other clinical agencies to prevent acute exacerbation

The GOLD report stresses: “the goal for treatment of exacerbations is to minimize the negative impact of the current exacerbation and to prevent subsequent events.” Prevention of AECOPD is key both for decreasing readmission, with all its concomitant risks, as well as staying the patient’s disease progression. Evidentially, this can best be effected by the management of the patient at home: “Routine follow-up of patients with COPD is essential. Symptoms, exacerbations, and objective measures of airflow limitation should be monitored to determine when to modify management and to identify any complications and/or comorbidities that may develop. To adjust therapy appropriately as the disease progresses, each follow-up visit should include a discussion of the current therapeutic regimen.

Symptoms that indicate worsening or development of another comorbid condition should be evaluated and treated.” Collaboration by respiratory therapy beyond the confines of the hospital, with the visiting nurse, PT, OT, social worker and others is imperative for the wellbeing of the COPD patient.

To the one lucky enough to catch hold of a Leprechaun the familiar Irish legend promises the chance that the wily green imp will lead him to the pot-o-gold buried somewhere at the rainbow’s end.  In similar fashion the clever integration of the refined GOLD strategies into a far reaching clinical paradigm holds for our COPD patients, the promise of improved quality of life and fewer return trips to hospital.  Hmm, there may be treasure at the end of this rainbow after all?

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Hot Off The Press!

Hot Off the Press!

The AARC has updated its “Coding Guidelines for Certain Respiratory Care Services” to reflect recent changes through January 2017! Based on the Medicare program’s coding and coverage policies, the AARC offers the document to assist members with “coding guidance for those respiratory care services we are asked about most frequently.” The PDF document is available to anyone via the AARC website and offers a summary of the NCCI Edits, general Medicare information, and various code regulations pertinent to respiratory care services.

Here are a few highlights:

Outpatient Only: Citing the updated introduction to the National Correct Coding Initiative, AARC’s coding guidelines document explains, right out of the gate, that: “The Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment of Part B claims.”

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Medicare Part B refers to outpatient claims.  This needs to be foundational to every discussion about how these rules are applied to respiratory care services. Underscoring this fundamental understanding, the AARC document asserts that “PTP edits prevent inappropriate payment of services that should not be reported together. NCCI PTP edits are utilized by Medicare claims processing contractors to adjudicate provider claims for physician services, outpatient hospital services, and outpatient therapy services. They are not applied to facility claims for inpatient services.

Back-to-Back: How you are reporting serial nebulizer treatments delivered in the emergency department may need to be re-evaluated according to the new regs: “If inhalation drugs are administered in a continuous treatment or a series of ‘back-to-back’ treatments exceeding one hour, CPT codes 94644 and 94645 should be reported instead of CPT code 94640.”

Episode of Care: I posted about this issue before the beginning of the new year. The NCCI update defines episode of care as follows: “An episode of care begins when a patient arrives at a facility for treatment and terminates when the patient leaves the facility.”  Some may read this and falsely interpret it to mean that only one nebulizer treatment may be “billed” or worse, “administered,” during an entire inpatient stay. However, a complete review of the rule places “episode of care” clearly in an outpatient context: “If a patient receives inhalation treatment during an episode of care and returns to the facility for a second episode of care that also includes inhalation treatment on the same date of service, the inhalation treatment during the second episode of care may be reported with modifier 76 appended to CPT code 94640” (emphasis mine). The AARC guidelines rightly supply the phrase “of outpatient” into this portion of the rule. Only an outpatient returns to a facility for additional episodes of care. When inpatients do this we call it a readmission, which CMS is discouraging via punitive financial measures.

The “Coding Guidelines for Certain Respiratory Care Services” doesn’t pretend to be a comprehensive compendium of coding know-how. Indeed, the AARC disclaims: “Although this guidance is an informed opinion of respiratory therapists and advisors who are not coding specialists but have experience and knowledge of codes and coverage policies, it is always best to verify the patient’s eligibility and payer coding requirements before providing a service as benefits are subject to specific plan policies which can vary among both public and private payers.” It is a good reference, however, and certainly a great go-to document when engaging coding issues in your facility. So get your copy now!

Click to learn more.

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