Once considered a “teenage” or “young adult” problem, opioid usage and dependence has slowly crept into the elderly population as increasing chronic pain conditions continue to rise. The Department of Health and Human Services declared an opioid crisis in late 2017, stating that at least 91 Americans die each day of an opioid overdose and the numbers are increasing. The Centers for Medicare and Medicaid (CMS) took notice, and in August 2018 released a Medicare Learning Network (MLN) discussing the importance of not only documenting current patients’ opioid usage, but also the likelihood of all other patients starting on opioids.
Opioid Use Reporting
Medicare has declared that opioid discussion is an integral part of the Initial Preventive Physical Examination (IPPE/Welcome to Medicare Exam/G0402) as well as the Annual Wellness Visit (AWV/G0438/G0439) and if not documented correctly, there is a threat of denial. In the past, the Medicare Cost Report has viewed the IPPE and the AWV as an opportunity for discussions on a variety of topics such as depression, cognitive impairment and functional ability. As of August 28, 2018, according to the MLN Matters SE18004, CMS states that “a review of opioid use should be a standard part of the reporting elements”.
Under the “Review of Medical and Family History” element, CMS states “Medicare would like to emphasize that the review of opioid use is a routing component of this element, including OUD (opioid use disorders). If a patient is using opioids, assess the benefit from other, non-opioid pain therapies instead, even if the patient does not have OUD but is possibly at risk.” Prior to this directive, CMS simply stated “medication review” was a requirement.
While certain specialties, such as orthopedics or pain management, have a higher population of opioid usage, family practice/internal med providers are commonly providing the IPPE/AWV services. Failure to document opioid review can result in claims denial as this is currently under investigation by CMS. Documentation should show that the provider assessed the benefit of non-opioid therapies as an alternative treatment method.
Seven Key Strategies
What does this mean for your practice? Documentation is key. The American Health Information Management Association has developed seven key strategies for proper clinical documentation that should be present in every entry in a patient's health record, regardless of diagnosis. Documentation that does not meet each aspect of these characteristics can lead to inadequate patient care.
The seven strategies are:
Organizations need to ensure that the proper information is being captured on a consistent basis. This is an issue of both quality of care and financial reimbursement. With the transition to new opioid guidelines, organizations are encouraged to routinely perform internal and external reviews to identify opportunities for documentation improvements and needs for additional education for providers and health information staff.