Update on Shared Decision-Making for Defibrillators

Uncertainty remains regarding specifics of documentation.

A couple of weeks ago I talked about the new national coverage determination (NCD) for defibrillators. At the time, the effective date was not known. Well, it is now clear: it was effective immediately. That NCD also added the requirement for a formal shared decision-making encounter using an evidence-based tool.

At the time, I questioned how we are to document such an encounter, since some of the tools are online. And the answer from the Centers for Medicare & Medicaid Services (CMS) was that they don’t know, since the claims processing instructions have not yet been written. So for now, we are left in limbo. If you use a paper tool, get a copy. If you do it electronically, note the tool used in the medical record.

Many of you may have seen an article published Friday by USA Today and Kaiser Health News titled “As Surgery Centers Boom, Patients Are Paying with Their Lives.” In this article, data was presented on the number of patients who have died in ambulatory surgery centers, because either the equipment or personnel needed to care for a complication were not available or they were sent home prematurely.

This article is especially important now, since CMS soon will be considering allowing a wide range of services in surgery centers, including joint replacements, electrophysiology procedures such as ablations and defibrillator implants, and cardiac procedures, including cardiac catheters and stents. And if you remember my article published last year, Humana has already stated that the Medicare inpatient-only list does not apply to them, and that their Medicare Advantage beneficiaries can have inpatient-only surgery at surgery centers (that includes all joint replacements, hip fracture repair, carotid artery stents, ablations, cervical spine fusions, and many more). I am hoping that this new article gets CMS’s attention, and that they reconsider their plans and stop Humana from endangering the lives of our seniors.

Last week CMS did hold its Open Door Forum, and as expected, many questions were asked about total knee replacement. And also as expected, there were few answers. I especially want to acknowledge a Monitor Mondays listener from TriHealth in Cincinnati, Linda Hogel, who called in and really brilliantly explained the difficulties we are all facing. I continue to support my position that even if your patients go home in one midnight, they can be admitted as inpatients as long as documentation supports that they are at higher risk. Each must be assessed on a case-by-case basis. I also think that CMS is going to work with the Quality Improvement Organizations (QIOs) to be sure they understand that one-day stays are allowed if documentation supports it. But my opinion is far from universally accepted. So the best I can say is that each facility must do what they think is right.

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