Prolonged Care 99356

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Posts: 48
Joined: Sat Dec 20, 2014 9:32 pm

Tue Jul 10, 2018 1:40 pm


In the past we have been dinged with errors from outside auditors for allowing conversations with physicians and phone calls with patient family towards prolonged care code (99356). The reason stated only face-to-face can count towards prolonged care. Unit floor time would be for the base code only. Or in other words an additional 30 minutes face-to-face must be spent above and beyond any unit floor time. What is NAMA's take on this? Allow unit floor time 99356 or not? Here is the note in question if you need it:


REQUESTING PHYSICIAN: Dr. Blank requested consult on 7/5/18.



REASON FOR CONSULTATION: "Please discuss goals of care with patient when in normal state of mind."

INTERVAL HISTORY: Patient is a 86 y.o. Caucasian male well-known to the Palliative Care service from previous admission. He was admitted to Salem Hospital on 7/00/2018 with a diagnosis of CHF, difficult fluid status to manage.

He is now referred for goals of care decision-making. Information is obtained from EPIC, Daughter Blank.

I saw pt in April 2017. Since then, he has been admitted 8/2017 and 4/2018 with CHF.

"Summary Statement for Admission: Patient is a 86 y.o. male with combined CHF, severe AR, HTN, hx of CVA, CAD, permanent Afib, seizure d/o admitted on 7/5/2018 with complaint of dyspnea. S/p atropine x1 for bradycardia."

My understanding is that Mr. Patient has severe dilation of the thoracic ascending aorta, not the abdominal aorta. He has heart failure related to diastolic dysfunction and severe aortic regurgitation.

Mr. Patient returned this time with weight gain, anasarca, respiratory failure. Medical team has successfully diuresed off several pounds of fluid, but pt remains confused. Pt is unable to recall why he is here. He is unable to discuss his medical conditions or goals of care.

I interviewed his daughter Blank, and by conference call, also interviewed his daughter Blank, who lives in Texas.

This pt and his now-deceased wife, had married as teenagers, ages 14 and 17 respectively. They had four children. The youngest of these is estranged from the family. A son lives in southern California, but his involvement with Dad's life is minimal. The remaining two daughters are involved with decision making. Of these, Blank lives in Texas and participates in discussions. Blank lives in Salem and care for her Dad.

Mom had been disabled for years. Dad was her caregiver for 6-7 years. He was worn out and finally he had a stroke in October 2012. About this time, Daughter moved in to help care for Mom, who then died in April 2013. Daughter thought Dad would not live long, maybe a year or less, but he has survived now 5 years.

Dad enjoyed reading, watching TV, working in garden. He liked reading about nature, and raising wild birds in birdhouses. We his mobility declined, he could only sit out on the patio to watch nature.

Since I met him 4/2017, he has had decline in quality of life. He doesn't tolerate car rides, has become incontinent, walks only with walker. He needs help with personal care. He has urinary retention, which requires Flomax or a catheter. Flomax was stopped due to concern about side effects. Currently there is a trial of removing the catheter. He sees Dr. Blank for urology care.

Pt has had over the last 15 months, repeated admissions for CHF and declining functional state. This has reached a point that family say "He wants to go." "Just kill me now."

After his latest admission here, he was discharged to SNF, released to home, but after taking out catheter, was brought to ED for inability to void.

He lives in east Salem in his own mobile home. Daughter lives in the home with him. She works full time, from home home as a software administrator, 8-9 hours per day. She works on computer and phone. She has been doing cooking, cleaning, shopping and IADL's for him. Care needs have been increasing, particularly with increasing incontinence over the last month. He has been unable to manage the foley drainage to bag, frequently getting that unhooked from the bag when getting dressed or undressed. The has been distressing as it resulted in urine draining everywhere, and also he has gotten yeast or other kind of infection on penis, which distresses Daughter who prefers not being involved with cleaning and treating that area. Pt has inability to follow instructions on dressing and self care.

He does have home health and a bath aid. Pt "wants to care for himself but doesn't understand, and can't learn new stuff."

He had been walking with a walker, but became so weak that he couldn't walk, due to fluid retention. Mental function, reasoning and overall cognition have greatly decreased. He cannot execute any complex thought sequences, but must be kept to single-step thought processes.
Please see Palliative Care consult of 4/2/17 by me for PAST MEDICAL HISTORY, FAMILY HISTORY, HABITS, SPIRITUAL CHECKLIST, and baseline SOCIAL HISTORY all have which have been reviewed.

BODY OF NOTE - EXAM, ETC. (not including here)

RECOMMENDATIONS: I was asked not to speak to patient about end of life because, although family state pt has been saying "he wants to go" and "just kill me now," it is said that someone discussed end of life care with him on Friday 7/6; After that pt kept talking about end of life without understanding and unable to have a coherent conversation about it. I found today, that pt was unable to engage in coherent conversation about his medical situation and plan of care.

Family say pt doesn't want to keep returning to hospital. Regarding hospital treatments, "he doesn't want to be saved." This is because of degradation in his quality of life; He can no longer do the things that he formerly enjoyed.

I do think that because of high symptom burden from CHF, symptoms at rest, and dementia resulting in severe loss of functional capacity, pt's predicted survival is less than 6 months if not returned to hospital. His goal is not to prolong life but rather, to allow natural death, and he prefers to be at home.

Daughter feels severely challenged by father's increasing care needs. She is fatigued and feels she can no longer cope with increasing care needs. She does want support of hospice. We have discussed what that would provide. We discussed routine hospice support at home or in ICF. She feels that home hospice care would be more in keeping with her Dad's wishes than being in ICF. Either way, she sees added financial burdens to providing end of life care.

I have spoken with Dr. Blank and with Blank, care manager. We will arrange hospice meeting tomorrow for Vicki. I have explained to Blank, that Daughter may need additional hired caregivers to help her cope with end of life care at home.

PC team will follow as needed.

Palliative care time spent was 115 minutes, greater than 50% spent in counseling and/or coordination of care in shared decision-making and in education and support.

Time in: 1135, time out: 1330 115 minutes

Face to face time: 1200 to 1310, 70 minutes.

Dr. Blank

Thank you for your time and help!
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Thu Jul 12, 2018 9:17 am

Per CMS prolonged time has to be time spent face-to-face with the patient, you cannot use prolonged time for unit floor time.

This is what CMS states:

Image ... mm5972.pdf

I hope that helps!

Your question has been answered by Stephanie Allard, CPC, CEMA, RHIT
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