Q&A: Review palliative care charts and query for 'comfort care' when appropriate

February 16, 2012

Q: I had a followup question about the Jan. 5, 2012 CDI Strategies article (“Important change impacts all CDI programs that review mortality charts”). What I took from the posting was that CDI should query for the term(s) comfort care or comfort measures when the provider has documented indicators that this diagnosis is appropriate. Is this correct? And am I also interpreting correctly that comfort measures will continue to be a diagnosis that exclude the patient from quality data?

Also, because palliative care and comfort care have previously been synonymous, and because there is not a separate code for comfort care, how can we code comfort care differently from palliative care? How can we ensure comfort care patients are excluded?

A: What I would advise (if you have the staffing to do so) is, whenever palliative care is coded/documented, review the chart to determine if the patient is receiving any treatment and/or if they are a do not intubate (DNI)/do not resuscitate (DNR). If the patient is a DNI/DNR I would recommend querying for “comfort care only” documentation as this is an abstracted term not based on the assignment of V66.7.

Use of the term “comfort care only” doesn’t have a direct impact for CDI staff because it doesn’t affect DRG assignment or SOI/ROM assignment, but it can affect core measure compliance rates that would impact inpatient and outpatient annual payment rate increases (IQR/OQR) and value based purchasing (VBP) return rates. Providers need to be aware that there is a difference between palliative care and comfort care only; however, documentation of either will result in the same code assignment of V66.7. The presence of code V667 will exclude the case from some mortality rate calculations; however, if only palliative care is documented the patient can be included in the population for core measures.

For example, a patient on hospice/palliative care for dementia has an acute myocardial infarction (AMI). The patient is only receiving palliative care in relation to the dementia and its associated condition so they can receive curative care/treatment related to the AMI (Medicare would cover the hospital expenses associated with the AMI admission even though the patient is on hospice for dementia). Therefore, the patient must meet core measure requirements (i.e., ASA, ACEI/ARB, beta blocker, etc.) for AMI. A patient can be receiving palliative care and not be a DNR.

Another way to think of it is all hospice patients are palliative care, but all palliative care patients are nothospice patients. The term palliative is being applied very liberally in the acute healthcare setting. Research has found that palliative care actually has a positive effect on mortality by decreasing the mortality ratecompared to those who are not receiving palliative care.

Conversely, comfort care means that regardless of the palliative care diagnosis the patient wants no curative care/treatment for any condition that may arise. These patients should be a DNI/ DNR. It should be very infrequent for a comfort care only patient to be in the acute hospital setting unless they had a catastrophic event that caused the admission and the family made the decision to provide only comfort care during the admission. Patients who are comfort care prior to hospitalization would rarely meet InterQual criteria for an inpatient admission because they would not meet intensity of service criteria. They would be observation patients in the hospital setting and subject to outpatient core measures.

Additionally, hospice patients don’t require acute inpatient care in the hospital setting. The hospice inpatient benefit for pain management or stabilization, etc. of their hospice condition is not the same as an acute care inpatient hospital admission as it is not reimbursed by Medicare/Medicaid as a typical inpatient admission and does not have to occur in an acute care hospital setting (it can be provided in a skilled nursing facility [SNF]). Inpatient hospice care (a level of care within the hospice benefit) which is frequently misunderstood by acute care hospitals, is paid at a flat daily rate. Also dying is not justification for inpatient hospice care. Therefore, these patients typically will not be acute care inpatients and would only be subject to outpatient core measures if applicable.

The Medicare Benefit Policy Manual, Chapter 9, Section 40.1.5, states the following (emphasis added):

"Medicare covers two levels of inpatient care: respite care for relief of the patient’s caregivers, and general inpatient care which is for pain control and symptom management. General inpatient care may be required for procedures necessary for pain control or acute or chronic symptom management that cannot feasibly be provided in other settings. Skilled nursing care may be needed by a patient whose home support has broken down if this breakdown makes it no longer feasible to furnish needed care in the home setting. General inpatient care under the hospice benefit is not equivalent to a hospital level of care under the Medicare hospital benefit. For example, a brief period of general inpatient care may be needed in some cases when a patient elects the hospice benefit at the end of a covered hospital stay. If a patient in this circumstance continues to need pain control or symptom management, which cannot be feasibly provided in other settings while the patient prepares to receive hospice home care, general inpatient care is appropriate."

Editor’s Note: This information was provided courtesy of Cheryl Ericson, MS, RN, manager of Clinical Documentation Integrity and core measures abstraction for the Medical University of South Carolina and a member of the ACDIS Advisory Board.

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