Prolonged Services - Inpatient

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Prolonged Services - Inpatient

Postby JJones » Thu Oct 18, 2018 4:15 pm

Hello!

Thank you in advance for any help provided with this question, and I apologize for the length of this de-identified note. We are trying to determine the levels that are billable. The provider billed as a 99223, 99356 and a 99358. We (Coders) are only seeing a 99223 and a 99358 being met:

DATE OF CONSULTATION: 10/10/2018

REQUESTING PHYSICIAN: Dr.

ATTENDING PHYSICIAN: Hospitalist Team Orange

PRIMARY CARE PHYSICIAN:

DIAGNOSIS:
1. Hepatic encephalopathy (CMS/HCC)
2. ESLD

REASON FOR CONSULTATION:Goals of care decision-making.

HISTORY OF PRESENT ILLNESS: is a 58 y.o. male who has a past medical history of ESLD who was admitted on 10/7 with altered mental status. He has had multiple hospital admission - 3rd in the last month. He is on maximum medical therapy and not a candidate for any other interventions for his liver disease. He is able to sustain at home for only days at a time before becoming encephalopathic, obtunded and ending up back in the hospital.

Patient is well known to the palliative care service. At the beginning of our time I met with wife outside the room. We spoke of her frustrations with this cycle and difficulty of caring for patient at home. Wife wants to honor what patient wants but is very concerned about his QOL and his dignity. Even at his best, she identifies his mental status as being significantly less than a month ago. He is more agitated, irritable at home and is very demanding. She also communicates a lot of conflict with patient's mother and father. She feels there is a lot of blame from them as to why he keeps needing to come back to the hospital and she feels very isolated. I offered a lot of support and validation for her feelings and experience. Some conclusions with wife were that she would want patient to be in a place where we could keep him out of the hospital and keep him comfortable the next time he becomes obtunded/stops taking his medications. She does NOT want him to die at home though so home with hospice is frightening to her. As much as she feels that it is time for these decisions - patient is still able to make choices and will not engage in these conversations, is very angry all the time and she does not know what to do. She also does not want to wait until he is obtunded and then make a decision to not do all this because her son and patient's family are very persistent about continuing the care since he has not made the decision to stop.

Following our conversation we went to the room with patient, patient's mother and father. I tried to explain the purpose of our visit and goals. Patient is almost belligerent at times. He is blaming me for "cutting off his water" and continues to talk around in circles with frustration. I acknowledged that he much be very frustrated. I was able to answer some questions for his mother and father about his medical situation and it seemed that they really did not have a good understanding of where he is at with his medical condition and just how carefully his mental status is balanced on a very particular medical plan. Even after extensive education and discussing the understanding - using examples of how even when he takes medication sometimes he ends up back in the hospital - I am not sure how much they really understand the big picture prognosis of liver failure. They had questions like " how does the lactulose work" and " why can't we just increase it". We spent time really trying to get on the same page in regards to the medical situation.

During out conversation Patient made statements such as "they can't keep refusing me water, I will just walk out of here." and "i'm going to go home and I am not going to follow this stupid rule." he also acknowledged that he refused his medication today because they won't give him more fluids. I believe this was good for family to hear because they are very focused on the fact that the only reason he comes back here is because " they don't know what wife and everyone is really doing for him when he is at home."

I tried to ask patient very direct questions and align with the fact that I don't ever want him to be in the hospital if he does not want to be here. That our team wants to support him in his goals and that is the purpose of our meeting. He starts to answer that but then gets confused and starts talking about things that do not entirely make sense in that context. I offered to have conversation outside the room and offered that I really just wanted to make sure his parents had all their questions answered and I could support them. He answered that he "doesn't care what I do" but then as parents start to leave room says " you don't need to go with her."

I told patient I hear he is frustrated about being here and frustrated at the strict rules that he has to follow here. I feel that after extended time, this is all that can be accomplished today as patient is really not agreeable in taking these conversations further.

Following time in the room I stepped out and talked to wife more regarding what the future may look like. I am hopeful that his parents hearing him say " I wont follow the diet or fluid restrictions" and seeing him refuse medication here will start an open dialogue and process where we can demonstrate Randy's goals/wishes based on these statements and actions.I expressed to wife I do NOT think patient will be in a place where he is going to honestly agree to a comfort care situation mostly because he will not engage and I fear her hope to hear him make that decision is something we might not see. This is difficult for her because she does not want to be the 'one' that has to decide that especially given the complex family dynamics. I offered support and validation that we will continue to help going forward but that this is a process. Again I offered encouragement that while Randy may not say he is ready to go home on hospice... That he is verbalizing some of his goals and definition of QOL and we need to hear that and use that to help support decisions moving forward.



Information is obtained from EPIC, Patient and Spouse, patient's mother and father.

PAST MEDICAL HISTORY, PAST SURGICAL HISTORY, and FAMILY HISTORY reviewed and unchanged from prior.

SOCIAL HISTORY: (credit to , PC MSW and , PC MSW, see notes in EPIC from 08/2018): Patient. was born and raised in. He graduated from high school. He is married and has three children. Patient owns a business. Pateint is an Elder Tribal member.

He gets access to Tribal benefits including concerts, other events and meals at restaurant which he enjoys doing. He also loves to attend football games.

Living situation: home with his wife and son

The patient has a DNR order in EPIC at this time.


MEDICATIONS ON ADMISSION:


Current Outpatient Prescriptions on File Prior to Encounter
Medication Sig Dispense Refill
• acarbose (PRECOSE) 25 MG Oral Tab Take 2 Tabs (50 mg total) by mouth with meals for 30 days 90 Tab 0
• allopurinol (ZYLOPRIM) 100 MG Oral Tab Take 200 mg by mouth daily
• glucose 4 g Oral Chew Tab Chew 4 g as needed
• insulin aspart (NOVOLOG) Subcutaneous Injection Inject 6 Units below the skin before meals (07-11-17) -
Custom Sliding Meal dose of aspart
6 Units with each meal 3 mL 0
• insulin glargine (LANTUS) 100 UNIT/ML Subcutaneous Solution Pen-injector Inject 55 Units below the skin twice daily 5 Pre-filled pen syringe 0
• lactulose (DUPHALAC) 10 GM/15ML Oral Solution Take 30 mL (20 g total) by mouth four times daily 600 mL 2
• neomycin 500 MG Oral Tab Take 1,000 mg by mouth twice daily (9am/5pm)
• promethazine (PHENERGAN) 12.5 MG Oral Tab Take 1 Tab (12.5 mg total) by mouth every 6 hours as needed 40 Tab 0
• rifaximin (XIFAXAN) 550 MG Oral Tab Take 1 Tab (550 mg total) by mouth twice daily for 30 days 42 Tab 0
• skin protectant cream (EUCERIN) Apply externally Cream Apply to the skin as needed
• sulfamethoxazole-trimethoprim (SEPTRA DS, BACTRIM DS) 800-160 MG Oral Tab tablet Take 1 Tab by mouth twice daily for 30 days (Patient taking differently: Take 1 Tab by mouth daily ) 28 Tab 0


ALLERGIES: Chlorhexidine and Tape

REVIEW OF SYSTEMS: Unable to answer - does not maintain focus

PALLIATIVE PERFORMANCE SCALE (PPS): Per wife report: 50
100% (Full ambulation, normal activity and work, NED, full self-care, normal intake, full LOC)
90% (Full ambulation, normal activity and work, some evidence of disease, full self-care, normal intake, full LOC)
80%(Full ambulation, normal activity with effort, some evidence of disease, full self-care, normal or reduced intake, full LOC)
70% (Reduced ambulation, unable to do normal job/work, significant disease, full self-care, normal or reduced intake, full LOC)
60% (Reduced ambulation,unable to do hobby/ housework, significant disease, occasional assistance for self-care, normal or reduced intake intake, full LOC or confusion)
50% (Mainly sit or lie, unable to do any work, extensive disease, mainly assistance, normal or reduced intake, full LOC or confusion)
40% (Mainly in bed, unable to do most activity, extensive disease, mainly assistance, normal or reduced intake, full LOC or drowsy, and/or confusion)
30% (Totally bed bound, unable to do any activity, extensive disease, total care, normal or reduced, drowsy or coma and/or confusion)
20% (Totally bed bound, unable to do any activity, extensive disease, total care, minimal to sips, full and/or drowsy or coma and/or confusion)
10%(Totally bed bound, unable to do any activity, extensive disease, total care, mouth care only, drowsy or coma and/or confusion)


PHYSICAL EXAMINATION
VS: Blood pressure 149/77, pulse 90, temperature 97.7 °F (36.5 °C), resp. rate 18, height 5' 10" (1.778 m), weight 255 lb 11.7 oz (116 kg), SpO2 96 %.

GENERAL: This reveals a chronically-ill appearing male lying in a hospital bed. Very distended abdomen with ascites. Speech clear but confused at times - gest off topic. Irritated. Family at bedside.

LABORATORY STUDIES: 

Recent Labs
10/09/18
0112 10/08/18
0000
WBC 3.4* < > 3.9*
HCT 24.1* < > 25.9*
PLT 33* < > 37*
INR -- -- 1.4*
< > = values in this interval not displayed.


Recent Labs
10/09/18
0112
GLU 177*
CRE 1.01
BUN 37*
GFR >60


Recent Labs
10/09/18
0112 10/08/18
0616
ALKP 214* < > --
SGOT 61* < > --
SGPT 44* < > --
TBIL 0.7 < > --
NH3 -- -- 298*
< > = values in this interval not displayed.


 
ASSESSMENT:
Medical situation: male with ESLD and multiple hospitalizations for hepatic encephalopathy. His medical management is optimized and he has no other interventions available for his liver disease. He is only able to maintain being out of the hospital for days to a week at a time before he requires rehospitalization.

Prognosis:Short term prognosis is poor due to his very short time between hospitalizations and his hepatic encephalopathy. Even when compliant he has episodes of encephalopathy.

Symptoms: Patient appear to be well controlled.

Family dynamics: Family dynamics are complicated. Wife is struggling and burnt out. She is very concerned about QOL and his dignity. Patient has been more frustrated and angry with her all the time and she is not sure how much longer she can do this. Patient's mother and father are very difficult for wife wife and complicate the situation.

Primary decision-maker: Self with support of wife

Patient goals: to drink what he wants, to eat what he wants. To get out of the hospital. To get better and stay better.

Requirements for discharge: Anticipate discharge home when medically stable.
 
RECOMMENDATIONS:
1. GOC: Patient's medical situation is starting to change with more frequent hospital visits, less clarity with medical intervention. Wife does not want to be the 'one' to decide when it is time to stop coming back to hospital and not doing things like rectal and NG lactulose but she does feel that it is time. She would like family to be supportive of that and would like Randy to make that decision but I worry he may be unable to engage in a conversation such as that given his demeanor today. Wife fear's she will be in a situation to make that decision at some point in the hospital but that patient's parents and family will not support her and she is struggling with that.

Patient is saying he is not going to follow the fluid restriction. He is saying he is going to eat whatever he wants. He is saying he does not want to be here. Using these goals to help support family to hear Patient's wishes will be helpful if able to do so.

2. ACP/ Code status: DNR entered into EPIC. He has declined completing POLST in past.

3. Symptom Management/ Supportive Care: Per primary team

4. Discharge Planning: Continue to support patient and family. Pending hospital course.

Discussed with PC team
Discussed with bedside RN

Initial visit was 100 minutes with over 50% spent in counseling and/or coordination of care.
Total face to face time 65/100 minutes
Start time: 15:15
Stop time: 16:20


In addition, 55 minutes spent in separate meetings with family, not face to face with patient to discuss patient's care and discuss recommendations.

SIGNED BY
JJones
 
Posts: 38
Joined: Sun Dec 21, 2014 2:32 am

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