WEBVTT 00:00:52.000 --> 00:01:03.000 Questions anonymously for whatever reason you can also do that in the Q&A panel as well. Once the session has ended, we do strongly encourage you to fill out the very brief survey to provide your feedback. 00:01:03.000 --> 00:01:12.000 This helps us continue to improve our virtual offerings. And the recording and slides for this presentation will be made available on our website under the on-demand webinars page. 00:01:12.000 --> 00:01:17.000 Lastly, registration is now open for the CTAC Capsi leadership summit transforming care for people with serious illness. 00:01:17.000 --> 00:01:23.000 The summit takes place October 20 third and 20 fourth at the Hamilton Hotel in Washington DC. Space is limited. 00:01:23.000 --> 00:01:33.000 So if you're interested, we do encourage you to register early. And now on to today's webinars, our presenters today are Alison Silvers, Capsie's Chief Healthcare Transformation Officer. 00:01:33.000 --> 00:01:37.000 CC Sinclair, Associate Director and Policy and Care Transformation. Rachel Hitner, Associate Director of Research and Insights, and Dr. 00:01:37.000 --> 00:01:46.000 Julia Friedman, assistant professor of the Brookdale Department of Geriatrics and palliative medicine at Mount Sinai. 00:01:46.000 --> 00:01:50.000 So thank you all for being here with us today. 00:01:50.000 --> 00:01:55.000 Thank you so much, Chelsea. Welcome everyone. Good morning. Some of you. 00:01:55.000 --> 00:02:10.000 It's pretty early in the morning. Where gonna talk today about a conundrum in the field of palliative care actually trying to identify who are the patients and who are the providers delivering palliative care using available data. 00:02:10.000 --> 00:02:14.000 Next slide. 00:02:14.000 --> 00:02:18.000 So I'm gonna kick this off with some good news. There's actually a lot of folks who are interested in identifying palliative care. 00:02:18.000 --> 00:02:41.000 There are payers who are as we speak trying to build networks of palliative care programs. There are state policy makers who are looking to advance Medicaid coverage and are often starting with UN need versus capacity analysis. 00:02:41.000 --> 00:02:53.000 The CMMI, the Centre for Medicare and Medicaid Innovation. Some strong interest in promoting and evaluating palliative care and researchers. 00:02:53.000 --> 00:03:08.000 And I'm going to guess that probably a lot of you on this webinar are the researchers are trying to investigate all sorts of questions outcomes who are the patients what are the workforce gaps where are their disparities and a whole lot more. 00:03:08.000 --> 00:03:17.000 So it's it's getting to be hot if wonky topic. Next slide. 00:03:17.000 --> 00:03:28.000 But this isn't so easy. Palliative care doesn't have the usual mechanisms for identification unlike things like hospice or even laboratories. 00:03:28.000 --> 00:03:36.000 There's no federal certification for palliative care programs. Next. State licensure. Same thing. 00:03:36.000 --> 00:03:53.000 There's no state license here for palliative care programs. And I'll add even if you wanted to survey some other license type, there's too many types of administrative homes that are sponsoring palliative care. 00:03:53.000 --> 00:04:04.000 There's hospitals, hostages, home care medical groups, etc. Next. So let's say you're like, okay, I realize there's a lot going on. 00:04:04.000 --> 00:04:09.000 I'm gonna narrow it down. I'm gonna focus on hospital based palliative care. 00:04:09.000 --> 00:04:16.000 Well, nope, you can't do that either because it's not a service line that shows up on a hospital operating certificate. 00:04:16.000 --> 00:04:30.000 Next. Okay, let's talk about the professionals. Well, unlike a lot of your colleagues, palliative care is actually a subspecialty and not a specialty. 00:04:30.000 --> 00:04:45.000 So when you go to register for Medicare or other private pay or credentialing systems. Poly of care often gets hidden and we'll talk about this more later. 00:04:45.000 --> 00:04:57.000 Next. Distinct CPT codes. Nope, not here either. Palliative care uses evaluation and management codes which as some of you might know it's the most commonly billed type of code across all specialties. 00:04:57.000 --> 00:05:08.000 So using CPT codes won't even get you close. Next. And the same thing with patient codes, the diagnostic codes. 00:05:08.000 --> 00:05:25.000 There are literally thousands. Amy Kelly, who had been at Mount Sinai had created a list of all the at the time I see D 9 codes and there were thousands and thousands. 00:05:25.000 --> 00:05:36.000 It's also, I will say, far too sensitive if you run just those diagnosis codes it can pick up 40 maybe even 50% of all Medicare beneficiaries. 00:05:36.000 --> 00:05:52.000 So it needs to be paired with some other information like function or pain, but of course those things do not show up in the codes. 00:05:52.000 --> 00:06:01.000 So all the usual suspects to get these answers aren't available to us. Next. 00:06:01.000 --> 00:06:17.000 But besides this dead ends, there are existing approaches that are being used and we'll go through how to identify programs, how to identify the specialists, how, people are identifying patients. 00:06:17.000 --> 00:06:28.000 And we'll talk through the implications of these, including research which is the the most obvious but there's also a lot of payment and policy implications. 00:06:28.000 --> 00:06:37.000 And after we go through all the good news, bad news will and and with some ideas for what can be done about it. 00:06:37.000 --> 00:06:41.000 Next. 00:06:41.000 --> 00:06:48.000 Okay, so this is going to start us off. I know this is a lot on one slide, but I'm gonna walk everyone through it. 00:06:48.000 --> 00:06:56.000 So. How's Alison mentioned it's not very easy to identify what a palliative care program is or where they all are. 00:06:56.000 --> 00:07:05.000 So there's no one single data set that contains all of the specialty p of care teams or programs that. 00:07:05.000 --> 00:07:13.000 Function across the country or even across care settings. For hospital programs, the current best option is the American Hospital Association annual survey database. 00:07:13.000 --> 00:07:22.000 It's again it's for hospitals only participation is voluntary so it's self-report. 00:07:22.000 --> 00:07:29.000 And participation usually averages about 80% but I think that's been a little bit off due to COVID. 00:07:29.000 --> 00:07:36.000 19. The survey has 2 questions related to palliative care. And there are 2 yes or no questions. 00:07:36.000 --> 00:07:47.000 So does your hospital have a palliative care, program? Through a house through the hospital itself through the health system or through a joint venture. 00:07:47.000 --> 00:07:54.000 And then do you have a palliative care unit with those 3 other types of options? So those 2 questions are order in the survey. 00:07:54.000 --> 00:08:03.000 There is no equivalent, however, for community palliative care programs. They run in, offices, long term care facilities in home. 00:08:03.000 --> 00:08:10.000 So there's no one database that has all the programs, operating in all those care settings. 00:08:10.000 --> 00:08:16.000 There are a couple of current directory options, but they also do have limitations. So get palliative care. 00:08:16.000 --> 00:08:18.000 Dot org's provider directory, which is, on Capsie's patient or public facing website. 00:08:18.000 --> 00:08:31.000 It's open to any programs who want to participate, but again, NHPCO has a map and directory on their website as well. 00:08:31.000 --> 00:08:53.000 But it's for, it shows an HCO member organizations on it. Some states have directories that include powdered care programs practicing within their state, but their few and far between so you would have to check your own state to see if there's maybe a state association that has a directory. 00:08:53.000 --> 00:09:01.000 Some palliative care programs also go for program certification. So that's also potentially an additional source of program lists. 00:09:01.000 --> 00:09:16.000 Currently the joint commission both has a hospital and a community one. The accreditation commission for health care the community health care accreditation partner and DMV also have certification programs. 00:09:16.000 --> 00:09:23.000 And you can see the the current number from a couple of weeks ago for each of those on the screen. 00:09:23.000 --> 00:09:30.000 So it's, it's not a big number. Next please. 00:09:30.000 --> 00:09:36.000 So like the pout of care programs, there's also no single data set that includes all palliative care clinicians. 00:09:36.000 --> 00:09:39.000 So one of the things that you all know very well about powder care teams is that they're interdisciplinary. 00:09:39.000 --> 00:09:52.000 So there are different disciplines all on the team. And there's also the chance that some members of the team could have certification and some don't. 00:09:52.000 --> 00:09:59.000 Some disciplines have some publicly available data and reports while others a little it's a little harder to access. 00:09:59.000 --> 00:10:06.000 So for medicine, the American Board of Medical Specialties releases an annual report that includes counts of board certifications. 00:10:06.000 --> 00:10:12.000 And like Alison mentioned a couple of minutes ago, hospice and palliative medicine is a subspecialty. 00:10:12.000 --> 00:10:19.000 For the board. So it's actually listed under 6 different primary specialties. And the most recent report. 00:10:19.000 --> 00:10:27.000 Anesthesiology, Emergency Medicine, Family Medicine, internal medicine, pediatrics, and preventative medicine. 00:10:27.000 --> 00:10:35.000 So you would have to go to see the sub specialty under each of those 6 specialties and then see how many people there are. 00:10:35.000 --> 00:10:41.000 So in the 2021, 2022 report, it's approximately 7,500 physicians with this board certification. 00:10:41.000 --> 00:10:51.000 For nursing. The hospice and palliative credentialing center offers 5 different hospice and pot of care certifications within the discipline. 00:10:51.000 --> 00:11:05.000 So there's the Advanced Certified Houspice and palliative nurse, the certified, and palliative license nurse, the certified hospice and palliative nurse, the certified hospice and palliative nurse, the certified hospice and palliative nursing assistant, and the certified hospice and 00:11:05.000 --> 00:11:18.000 palliative pediatric nurse. And those are those counts on the screen. The credentialing center also has a certification verification tool and that's where I was able to get these counts. 00:11:18.000 --> 00:11:26.000 So they would really very again, I guess, the date that you access the verification tool because those numbers are always gonna be changing. 00:11:26.000 --> 00:11:35.000 The hospice and palliative credentialing center also now houses the advanced palliative hospice social worker certification as well. 00:11:35.000 --> 00:11:48.000 So that's in the same place. For chaplains, the palliative parent hospice advanced certification is offered through the board of chaplain Certification, who's an affiliate of the Association of Professional Chaplains. 00:11:48.000 --> 00:11:55.000 But it doesn't seem that there's a report readily available that has the number of chaplains with that certification. 00:11:55.000 --> 00:12:14.000 Wait till can I add I believe that the academy, the American Academy of Medicine has their list of members and not only certified but also non-certified members of the academy. 00:12:14.000 --> 00:12:19.000 That is for sale. I just wanted to add that. 00:12:19.000 --> 00:12:25.000 Thanks, Alison. Next slide. 00:12:25.000 --> 00:12:37.000 So Rachel sort of got us started talking here about how to identify palliative care programs and clinicians and there are many different ways to do it and it's a complex issue. 00:12:37.000 --> 00:12:44.000 There's also the question of identifying patients who saw palliative care teams and had encounters with palliative care providers. 00:12:44.000 --> 00:13:02.000 And that's also tricky issue. So what you see here are what used to be the ICD 9 code v 6 6.7 now the ICD 10 code Z 51.5 It's called encounter for palliative care. 00:13:02.000 --> 00:13:10.000 And it has been used, especially in the research setting to think about which patients saw palliative care team. 00:13:10.000 --> 00:13:20.000 But you do need to proceed with caution because when this code was developed, it wasn't really developed to say this patient saw a palliative care team. 00:13:20.000 --> 00:13:30.000 It was developed. To think about any patient admitted to the hospital who maybe saw palliative care provider in the community was getting palliative chemotherapy. 00:13:30.000 --> 00:13:41.000 Was admitted with, you know, part of their plan was a comfort focus plan of care. And not only that it's not just palliative care providers that can use the encounter for palliative care code. 00:13:41.000 --> 00:13:54.000 It's actually any provider they could just assess the patient as having palliative care needs or part of their admission is a palliative care admission and then they're gonna use the ICD, 10 C, 51.5. 00:13:54.000 --> 00:13:58.000 Next slide. 00:13:58.000 --> 00:14:09.000 So I wanna take a moment to just walk everyone through some of the studies have that been done to validate, well at the time was again the ICD 9 code be 66.7. 00:14:09.000 --> 00:14:15.000 To see to validate it as it means of identifying specialty palliative care consultations. 00:14:15.000 --> 00:14:24.000 So there are 3 studies up on the screen that have all worked on this. And in all 3 of these studies, the researchers calculated the sensitivity and specific specificity of the code. 00:14:24.000 --> 00:14:45.000 And identifying specialty palliative care. So this is in in the research but it's for the sensitivity it's basically the percentage chance that the code will accurately appear in the medical chart for a patient who has received a palliative care console. 00:14:45.000 --> 00:14:55.000 So it's a true positive. And specificity is the percent chance that the code will not appear in the medical chart for a patient who has not received a palliative care consult. 00:14:55.000 --> 00:15:03.000 So it's really a true negative. So you want to see what those numbers are for this code when identifying specialty palliative care. 00:15:03.000 --> 00:15:20.000 So you can see from the numbers on the screen the code sensitivity. So the chance that it would positively positively identify specialty palliative care patients very widely between the 3 studies here from 11% to 84%. 00:15:20.000 --> 00:15:25.000 And each paper's authors I just wanted to make sure I noted to also mention the limitations of their studies when they published their papers and had cautions against generalizing their findings. 00:15:25.000 --> 00:15:38.000 So for example, Feder at all who found both the highest sensitivity and specificity for the code. 00:15:38.000 --> 00:15:47.000 I had a very small sample. It was only a hundred heart failure patients from the VA system. And in their discussion they cautioned. 00:15:47.000 --> 00:15:59.000 Against generalizing their findings because they noted that the veteran health administration's work has been to ensure both consistent powder care availability and consistent coding practices. 00:15:59.000 --> 00:16:14.000 So that would also account for their high sensitivity and specificity. So to take that into account when reading through their results that it's a small sample and that the VA has maybe a different outlook on palliative care than other hospitals. 00:16:14.000 --> 00:16:29.000 So The key takeaway here, you know, from this is that there is a risk of misclassification when using these codes to identify specialty palliative care encounters and just everyone researchers or otherwise just should keep that in mind. 00:16:29.000 --> 00:16:31.000 Next slide. 00:16:31.000 --> 00:16:37.000 So, I'm gonna actually, maybe say something a little controversial, but there's actually a good reason. 00:16:37.000 --> 00:16:51.000 Why the code? Is appropriate to be used beyond specialty palliative care encounters. 00:16:51.000 --> 00:17:04.000 Julia describes some of the situations. But remember that, I see the international classification system for diseases or something like that. 00:17:04.000 --> 00:17:08.000 I should have flip that up. It is patient based and it's patient need and patient circumstance based. 00:17:08.000 --> 00:17:28.000 So it's not about what procedure or what in professionals the patient receive care from that's what CPTs or Hickspix codes are for. 00:17:28.000 --> 00:17:31.000 A professional as the patient receive care from. That's what CPTs or Hickspix codes are for. 00:17:31.000 --> 00:17:38.000 So it is meant to capture what is going on with the patient. I'll also say I pull this quote. 00:17:38.000 --> 00:17:48.000 This is the guidance that professional coders are given. If they want to indicate comfort care or, they're directed to see code C. 00:17:48.000 --> 00:18:01.000 51.5 and I'll also add that comfort C. 51.5 and I'll also add that comfort care isn't a real thing. 00:18:01.000 --> 00:18:10.000 Isn't quite something you can professionally wrap your arms around. I'll also add a little story several years ago. 00:18:10.000 --> 00:18:21.000 A capsi and the academy and a few other organizations. Did try to explore what would be possible in terms of advocating for additional ICD 10 codes. 00:18:21.000 --> 00:18:32.000 It was interesting. We talked to ACDIS, the Association of Clinical Documentation and Integrity Specialists. 00:18:32.000 --> 00:18:37.000 I look that one up. And they, they were considering advocating for splitting the code. 00:18:37.000 --> 00:18:47.000 Interestingly, it wasn't about specialty versus non-specialty palliative care. 00:18:47.000 --> 00:18:54.000 They were interested in tagging one for end of life versus palliative needs regardless of prognosis. 00:18:54.000 --> 00:19:08.000 So again, very patient need based and as you can see even if they move forward with that, it wouldn't help us to identify who the who's receiving specialty palliative care. 00:19:08.000 --> 00:19:11.000 Next slide. 00:19:11.000 --> 00:19:21.000 I'll also add that the poor sensitivity of the code is made even worse by some hospital practices. 00:19:21.000 --> 00:19:38.000 Here I took some information that Bryan Castle presented a few years ago about how the code affords some protection in some of the mortality calculations that are out there in use and recently there's been some publicity about one for profit chain that was also interested in pursuing this protection. 00:19:38.000 --> 00:20:04.000 So I think it raises a caution. I can't say for certain that the numbers with the codes are over inflated, but it does raise a caution that even perhaps the trying to get to the patients might not be completely accurate. 00:20:04.000 --> 00:20:20.000 Next slide. 00:20:20.000 --> 00:20:21.000 Yeah. 00:20:21.000 --> 00:20:29.000 So I wanted to jump here and talk a little bit more about the use of, Z. 51.5 you know in the research context and maybe based on what you said Alison the word correctly shouldn't be on the slide right because maybe it is correctly used based on patient needs but what I mean by correctly here is 00:20:29.000 --> 00:20:40.000 even when you have Z, 51.5. Assigned to an encounter for a patient who did receive a palliative care consultation. 00:20:40.000 --> 00:20:49.000 It still gives us pretty limited information. So this is a non-vilable code. It's never gonna appear very high. 00:20:49.000 --> 00:21:01.000 On you know in the ICD 10 billing structure it's meant to do things like risk stratification or mortality reporting like you were just talking about Alison. 00:21:01.000 --> 00:21:02.000 So it's not a reimbursable service. So essentially what happens is the C. 00:21:02.000 --> 00:21:17.000 51.5 code gets attached to a patient's entire hospital admission. So what you can say is the patient either did or didn't get a palliative care consultation during that hospital admission. 00:21:17.000 --> 00:21:27.000 It's binary. And because of that, you're missing a lot of the really important information about the kind of services that the patient got. 00:21:27.000 --> 00:21:33.000 When did they get their palliative clear consultation with regard to when they were admitted to the hospital? 00:21:33.000 --> 00:21:37.000 Who saw them? How many times were they seen? What was the cadence of the visits? 00:21:37.000 --> 00:21:56.000 So you don't get, a good sense of the service delivery for a given patient. Even when the code is attached to appropriately to an admission where the patient received a palliative care consultation. 00:21:56.000 --> 00:22:00.000 Next slide. 00:22:00.000 --> 00:22:04.000 And I think that gets down sort of to this concept of you know, what I call full dose palliative care. 00:22:04.000 --> 00:22:17.000 And many other folks have written about this as well. The idea that palliative care is a really high touch specialty and Many of the patients who we see and their families and caregivers have a lot of needs. 00:22:17.000 --> 00:22:26.000 And you need really expert clinicians. And the vast majority of the time you need a pretty high intensity of services delivered. 00:22:26.000 --> 00:22:39.000 And when you have those things come together. The clinician expertise and Hi intensity of services in that full dose palliative care. 00:22:39.000 --> 00:22:49.000 That's what really. Changes patient and caregiver outcomes and moves the needle on things like improving symptoms. 00:22:49.000 --> 00:23:05.000 Improving quality of life for people with serious illness in their caregivers and improving our understanding of goals and values around medical interventions and making sure that those get transmitted and honored. 00:23:05.000 --> 00:23:14.000 So the way the way in which C. 51.5 is structured doesn't allow us to get in any of these really important concepts. 00:23:14.000 --> 00:23:19.000 Next slide. 00:23:19.000 --> 00:23:29.000 So again, we wanted to go back to the research implications because some of these things are quite subtle and if you you know if you don't think about it overtly it can kind of confuse things a little bit. 00:23:29.000 --> 00:23:47.000 So we wanted to give you an example from our actual our work at Capsi. So we conducted a literature review 2 years ago during a larger environmental scan about the taking care of black patients with serious illness. 00:23:47.000 --> 00:23:57.000 And one of the research questions included in that was Are there palliative care disparities between black and white patients with serious illness? 00:23:57.000 --> 00:24:13.000 So we did our literature review and our conclusion was that we had mixed findings related to that research question. There were many articles that said black patients receive less palliative care than my patients. 00:24:13.000 --> 00:24:25.000 There were some that said black patients receive just as much palliative care as white patients. And there were even a couple that said black patients receive more palliative care than white patients. 00:24:25.000 --> 00:24:35.000 So we weren't really sure what to do with those findings because it was so variable. So, you know, we looked a little bit deeper and we realized that there were some methodological implications of all of these things we've been talking about about identifying. 00:24:35.000 --> 00:24:47.000 Palliative care. So for example, how are researchers defining palliative care in and of itself? 00:24:47.000 --> 00:24:52.000 Are they referring to specialty palliative care consultations? Are they talking about non-specialty services, what some people call primary palliative care. 00:24:52.000 --> 00:25:08.000 Also what outcomes are they looking at? Are they talking about access? Are they talking about utilization, which are 2 different outcome variables and would be measured differently too. 00:25:08.000 --> 00:25:20.000 And again, what methodology were they using to identify quote unquote palliative care? So were they going into the charts and looking for consultation notes and the EHR? 00:25:20.000 --> 00:25:27.000 Were they possibly using some of the codes that we've been talking about, which we know have certain limitations in this area. 00:25:27.000 --> 00:25:37.000 So we really need additional clarity on how we are identifying palliative care as a service. To understand the potential impacts on research efforts. 00:25:37.000 --> 00:25:42.000 Next slide. 00:25:42.000 --> 00:25:49.000 So then moving from the research space into the policy space, what are the implications of? The challenges that we're seeing in identifying. 00:25:49.000 --> 00:26:00.000 Palliative care service delivery in patients is I actually sit on the Nebraska palliative care and quality of life advisory council. 00:26:00.000 --> 00:26:10.000 So I'm the vice chair person there. This is one of the state legislatively established councils that we see in a lot of states across the country. 00:26:10.000 --> 00:26:21.000 And they, you know, passed by the legislature, signed into law by the governor. And we've been working since 2,017 to try and grow awareness of palliative care. 00:26:21.000 --> 00:26:32.000 And we had an opportunity, we reached out, we invited the governor, then Governor Pete Rickett, to join a council meeting to see the work that we had been doing to better understand the landscape and see if we could get him on board to be able to move forward. 00:26:32.000 --> 00:26:48.000 Some potential recommendations. And we were able to sell him on palliative care very quickly. You know, I think we have a lot to point to what is the value of palliative care. 00:26:48.000 --> 00:26:59.000 How does it improve patient outcomes? How does it help the state meet its goals? And so he was impressed by the information that we had on palliative care at large. 00:26:59.000 --> 00:27:05.000 But he had some questions for us as he was starting to think through what might he be able to do in his role. 00:27:05.000 --> 00:27:15.000 What might he be able to recommend? And he got to the heart of the issue pretty quickly which is all right so how much palliative care do we have in our state? 00:27:15.000 --> 00:27:23.000 How many providers do we have? How many people are currently receiving services? And he didn't want to know national level numbers. 00:27:23.000 --> 00:27:43.000 He really wanted to know what the problem was specific. To Nebraska. And so I think that's something that has your talking to policy makers, they're gonna wanna know how much palliative care is available, the number of train clinicians, the number of patients receiving it, the landscape as it currently 00:27:43.000 --> 00:27:51.000 is because that helps them wrap their head around the scope of our field. And then where it makes sense to take action. 00:27:51.000 --> 00:28:02.000 And I just, I hate to say, we didn't have that information at the time. So we were able to talk in generalities around how many patients we anticipated needed it. 00:28:02.000 --> 00:28:14.000 We had a wonderful representative from a children's hospital in Omaha who was able to at least provide some solid numbers on his program. 00:28:14.000 --> 00:28:26.000 But we didn't have a good answer and that actually that encounter was 3 year 4 years ago and it still haunts me to this day because We don't know what have what could have happened. 00:28:26.000 --> 00:28:36.000 We had the chief executive of it or the chief executive of our state. In a meeting and it's just really hard to let those windows of opportunity pass. 00:28:36.000 --> 00:28:40.000 Next slide, please. 00:28:40.000 --> 00:28:48.000 So at the federal and state levels, the palliative care field is advocating for policies to help grow and strengthen our workforce. 00:28:48.000 --> 00:29:07.000 Expand payment models to increase access. And ensure quality and this information about how to identify where palliative care is being delivered, how many people are delivering it, how many people are at different levels of policy making, you're gonna see more granular questions being asked for different reasons. 00:29:07.000 --> 00:29:15.000 For example, In Illinois, we actually saw a bill introduced this, most recent session to establish a loan repayment program that was specific to POSIS and palliative care. 00:29:15.000 --> 00:29:31.000 It didn't get through, but they made some really good progress and that's incredibly exciting. But to help legislature, legislators understand the scope of the issue, what is the need and the shortfall? 00:29:31.000 --> 00:29:42.000 If they estimate that there are 1.2 million people in Illinois living with serious illness. And only a couple of 100 palliative care certified doctors and advanced practice providers. 00:29:42.000 --> 00:29:50.000 That's, But how many, how many doctors might they need to train in order to make a significant impact? 00:29:50.000 --> 00:29:57.000 On this problem because they're not gonna have 30 million dollars to train to do loan forgiveness for palliative care clinicians. 00:29:57.000 --> 00:30:07.000 So they need to understand what is the shortfall and then what a what are good estimates of numbers that they can invest in to make a difference towards the problem. 00:30:07.000 --> 00:30:17.000 In Hawaii, very exciting. We saw that there, they just filed a benefit with CMS to establish community based palliative care. 00:30:17.000 --> 00:30:27.000 But as they were in their planning process, part of the considerations are, okay, this benefit is going to open up services to X number of thousands of beneficiaries. 00:30:27.000 --> 00:30:41.000 Do we actually have the specialty palliative care capacity to meet the demand? Because that's, you know, you don't wanna build a benefit and then realize that there aren't enough providers to be able to meet the need. 00:30:41.000 --> 00:31:04.000 And then at the federal level, this problem is also relevant nationally. And in 2021, the Center for Medicare and Medicaid Innovation or CMMI began implementing its Medicare Advantage value based insurance design or And among other things, the big carves, hospice into Medicare 00:31:04.000 --> 00:31:16.000 Advantage and allows plans to offer hospice benefits concurrent with a curative treatment. And it requires participants to offer palliative care services. 00:31:16.000 --> 00:31:26.000 So given that the share of Medicare beneficiaries enrolled in Medicare Advantage actually finally reached 50% in 2023. 00:31:26.000 --> 00:31:34.000 Being able or the requirement to deliver palliative care could be an actual game changer. But in the first model evaluation report. 00:31:34.000 --> 00:31:42.000 Participating organizations reported that only 2,596 MA beneficiaries had received palliative care. 00:31:42.000 --> 00:31:51.000 Which when you think through, 50% of MA beneficiaries and only 2,500, you see palliative care that's just infinitesimally small. 00:31:51.000 --> 00:31:58.000 And that was lower than expected. And part of the reason that participating organizations gave is because They just were having difficulty tracking and reporting palliative care use. 00:31:58.000 --> 00:32:08.000 They couldn't figure out from the available data what was going on. And so this may have led to an under estimate of palliative care utilization. 00:32:08.000 --> 00:32:17.000 And just the lower the end is, the more difficult it is to get a clear picture of impact. Awesome. 00:32:17.000 --> 00:32:33.000 And Stacy, if I could just interject, there was also a team of evaluators at CMMI who are trying to sip through all the claims to answer that question. 00:32:33.000 --> 00:32:39.000 And yeah, they came to the conclusions that were articulated here in this presentation. 00:32:39.000 --> 00:32:42.000 Next slide, please. So one final area of as we're teasing out what are the implications of not having the information. 00:32:42.000 --> 00:33:03.000 Opioid prescribing policies is a really big one. As I folks on this Call me no many states across the United across the US have passed laws and regulations regarding opioid prescribing to address the crisis. 00:33:03.000 --> 00:33:10.000 And to their credit and I think a lot of this is thoughtful policy makers. A lot of this is advocacy from the field. 00:33:10.000 --> 00:33:23.000 But these policies, a lot of the laws do try to balance the need. Of preventing opioid misuse while also ensuring that people with legitimate medical needs have access to these medications. 00:33:23.000 --> 00:33:33.000 And so some states. Do have provisions in opioid prescribing laws that exempt palliative care from restrictions or prescribing limits. 00:33:33.000 --> 00:33:42.000 The challenge here is that Many of these states do not also have a complementary definition of or standards for palliative care. 00:33:42.000 --> 00:33:52.000 And if they do, then a lot of those exist under hospice. And so for states without definition or standards, it's really hard to know what palliative care means. 00:33:52.000 --> 00:33:58.000 And then beyond that, how do you know who's delivering palliative care with integrity? 00:33:58.000 --> 00:34:06.000 There's just no state wide way to track that. So this is something that I think, makes us nervous. 00:34:06.000 --> 00:34:16.000 You know, we haven't had or heard of any significant abuses that have been reported or have risen to the attention of mainstream media. 00:34:16.000 --> 00:34:29.000 But my fear is it just takes one. You know, it takes one state where there's, you know, unclear language around what is palliative care and yet that's used as an exemption and that opens space for bad actors to come in. 00:34:29.000 --> 00:34:33.000 And so, you know, we're 00:34:33.000 --> 00:34:50.000 Yeah, I think just wanted to flag that as a concern. So some of the big takeaways from this policy related section are that our inability to systematically identify who is delivering palliative care or who is receiving palliative care services. 00:34:50.000 --> 00:35:06.000 Hampers are efforts to advocate for supportive policies. Inform the development of programs. You know, if we don't, if a state wants to create a program and we are not coming to the table with good information on how to find palliative care or deliver it. 00:35:06.000 --> 00:35:13.000 States will find their own answers. They're very good at it. They do have some data available, but those answers may not look like what we want them to look like. 00:35:13.000 --> 00:35:22.000 Another, Another limitation is that it does about or it limits our ability to evaluate the quality and impact of programs. 00:35:22.000 --> 00:35:30.000 And then finally in force policies that directly impact patient health and safety. Next slide, please. 00:35:30.000 --> 00:35:34.000 But wait, there's more. In addition to impacting the integrity of research and limiting our policy options. 00:35:34.000 --> 00:36:04.000 It actually has big implications on payment. Remember I said that the the E and M codes are the most comprise most palliative care encounters and yet they also comprise most encounters with just about every other provider out there. 00:36:04.000 --> 00:36:19.000 Well, in a lot of cases it can lead to denials. So if the palliative care clinicians sees the patient, the same patient on the same day as another clinician and they both use, I don't know. 00:36:19.000 --> 00:36:32.000 You know, the mid-level EM code and they both use the principal diagnosis of, I don't know, let's say COPD or one of the COPD ones because after all it's the same patient they've got to have the same principle diagnosis. 00:36:32.000 --> 00:36:43.000 And they're both credentialed in the same primary specialty and I'll just find that a little bit more. 00:36:43.000 --> 00:36:54.000 In a minute, but let's say somebody's seeing, you know, their Primary care doctor for COPD or, you know, even a internal medicine. 00:36:54.000 --> 00:37:01.000 Person for COPD and then they see the internal medicine palliative care. Person. 00:37:01.000 --> 00:37:08.000 One of you is gonna get to denied and the one who is not is the one who submits the claim second. 00:37:08.000 --> 00:37:29.000 So, it doesn't matter if, somebody was actually I don't know you know managing the dysmia and somebody else was, making recommendations for surgery or whatever you might think. 00:37:29.000 --> 00:37:36.000 The systems can't tell the difference. Next slide. And this is why the systems can tell the difference. 00:37:36.000 --> 00:37:48.000 So the credentialing systems and I'm gonna what I show here and I apologize it's tiny. 00:37:48.000 --> 00:38:00.000 Is the Medicare registration system and in the Medicare registration system, you go into peacose in order to create an API number. 00:38:00.000 --> 00:38:16.000 You can only designate one primary specialty. There's not an option for co-primary or anything like that you just get to pick one and logically people pick their primary specialty because remember, this is a subspecialty. 00:38:16.000 --> 00:38:33.000 However, very few people actually go on. You're allowed to pick. Multiple additional specialties. But there's no There's no real reason to there's no real benefit to people might not even know that they could add an additional specialty. 00:38:33.000 --> 00:39:03.000 And in provider, excuse me, private credentialing systems, it's even worse. And in provider, excuse me, private credentialing systems, it's even worse. 00:39:06.000 --> 00:39:22.000 The there was only one choice. So this is the reason why a hospice and palliative care clinicians get hidden in the systems. 00:39:22.000 --> 00:39:26.000 Next slide please. 00:39:26.000 --> 00:39:38.000 And This has implications even beyond the same plane, same day, denials. It causes all sorts of other payment implications. 00:39:38.000 --> 00:39:50.000 Your organizational support, a lot of organizations look to RVs to calculate compensation or to figure out resource allocation. 00:39:50.000 --> 00:40:03.000 But the, without even within an organization without knowing who's really on. Palliative care. 00:40:03.000 --> 00:40:08.000 Some of that RVU credit is going to other service lines. And that's a problem. 00:40:08.000 --> 00:40:26.000 Patient burden too. There are private payers, you know, you can think good news Medicare Advantage has the ability to wave cost sharing on pretty much anything that they deem as appropriate. 00:40:26.000 --> 00:40:32.000 And they do need palliative care as appropriate to wave cost sharing. But again, they can't. 00:40:32.000 --> 00:40:40.000 Have make their systems make that happen. As I mentioned before, there is interest among payers to incentivize palliative care, even inpatient. 00:40:40.000 --> 00:40:46.000 There's a couple of large national payers who are incentivizing palliative care encounters in the hospital. 00:40:46.000 --> 00:40:59.000 And there are others who are trying to build community networks, but the fact that palliative care providers are hidden in the data gets in the way. 00:40:59.000 --> 00:41:15.000 I do wanna mention Stacy did an analysis for this presentation. If, you could go back one slide, Chelsea, if, you could go back one slide, Chelsea. I apologize. 00:41:15.000 --> 00:41:27.000 I, so When you look as Rachel said, you can count the number of clinicians that hold specialty certification and if you look at least of the Medicare-eligible providers. 00:41:27.000 --> 00:41:34.000 There's nearly 10,000. Huspice and palliative medicine, specialty certified providers. 00:41:34.000 --> 00:41:43.000 And of course there's thousands more that are working full time in the field that don't have their, specialty certification. 00:41:43.000 --> 00:41:51.000 But when you run that code, which is code 17 in any fields, primary, which might not be appropriate or any of the other fields. 00:41:51.000 --> 00:42:01.000 There's only 1,800. So that's less than 20% of just the certified. Clinicians, let alone, all the others. 00:42:01.000 --> 00:42:15.000 So there's a lot of, I'll call it a coding opportunity in the credentialing systems. 00:42:15.000 --> 00:42:20.000 Okay, now could you go forward to please? Sorry. 00:42:20.000 --> 00:42:33.000 So it's been about 42 min of doom and gloom. Like, you know, I think it's a pretty thorny problem and it's a complicated one and it's a complicated one and it has real implications for how the field can advance. 00:42:33.000 --> 00:42:43.000 How do we advocate one and it has real implications for how the field can advance? How do we advocate for resources? How do we ensure program integrity? 00:42:43.000 --> 00:42:45.000 And I will say it's tricky stuff and I'm afraid that we don't have a magic bullet answer for you. 00:42:45.000 --> 00:43:06.000 But I think our aim in the next couple of slides is to present. Little things that you all can do in your respective lanes to Take advantage the most advantage of that we can of the data opportunities and then as we get better information that gets us better prepared to be able to do more and paint a clearer picture. 00:43:06.000 --> 00:43:09.000 Next slide, please. 00:43:09.000 --> 00:43:28.000 So, you know, the first opportunity and again speaking from the policy and advocacy side. We've seen as Rachel said a couple of statewide databases and that is something that we could continue to advocate for at the state level because they do have more granular information. 00:43:28.000 --> 00:43:33.000 What is Alison mentioned? I mean, it's the NPI and Pecos codes. 00:43:33.000 --> 00:43:48.000 That are used to identify half percent palliative care or medicine among individual group providers. I was noticing that or I was trying to scam through some Medicaid provider enrollment applications and they do ask for NPI and even in several states would ask for secondary or tertiary or additional NPI numbers. 00:43:48.000 --> 00:44:11.000 So even if you're putting in your primary you can put in your but as Alison mentioned, I mean, it's Currently when it comes to NPI and publicly available databases There are very, very few people who are indicating hospice and palliative care in. 00:44:11.000 --> 00:44:24.000 In their own what they're selecting for themselves. I think taking the numbers that Alison mentioned was something like an average of 26 providers per state that could be identified using P. 00:44:24.000 --> 00:44:34.000 So what we can't go to a state policy maker and say, hey, you should build a database to house on the state health department website to identify palliative care when right now we only have 26 people to build it around. 00:44:34.000 --> 00:44:53.000 So I think part of that is just saying, you know, look at how your registering yourself how you're representing yourself through some of the existing systems and and that might help then grow or provide more information that then we can take the states. 00:44:53.000 --> 00:45:02.000 Alison mentioned, 2 that's HPM and HPNA do offer membership lists for purchase as a way for states to identify violated care providers. 00:45:02.000 --> 00:45:10.000 So that can then also help round out the information that we can get to states. Program credentialing requirements to receive payment. 00:45:10.000 --> 00:45:24.000 So this is also an opportunity that we're seeing growing in states that if there is a policy in place that Medicaid managed care organizations must provide access to palliative care and have clear criteria around what college care is. 00:45:24.000 --> 00:45:34.000 Then Medicaid can pull those files of network providers. So for instance, I think that might be doing what they've done in California as they've implemented SP. 00:45:34.000 --> 00:45:41.000 10 of 4. In voice application for a state plan amendment, which again would establish palliative care services. 00:45:41.000 --> 00:45:53.000 For Medicaid beneficiaries in non-hospital settings. It has a section that says that the Medicaid agency will establish additional credentials and or criteria for healthcare providers. 00:45:53.000 --> 00:46:03.000 To provide community based palliative care services. And so we don't know exactly what these will look like, but it's certainly something to monitor moving forward. 00:46:03.000 --> 00:46:13.000 And then one option that feels like it's perennially on the table but hasn't been pursued yet, is this idea of creating a standalone license for palliative care? 00:46:13.000 --> 00:46:24.000 Community based holiday care programs currently operate under a smorgasbord of license, be a combination of hospice, home health, medical group, etc. 00:46:24.000 --> 00:46:30.000 It depends on the state regulations and nothing should be construed as legal advice for how you should go about doing that. 00:46:30.000 --> 00:46:41.000 And certainly there would be benefits to having a standalone license, would be recognizing palliative care as distinct from other care delivery models. 00:46:41.000 --> 00:46:51.000 Then that would allow an opportunity to create rules and regulations that facilitate interdisciplinary access across care settings and patient populations. 00:46:51.000 --> 00:47:00.000 Provides a more logical mechanism for accountability and then for the purposes of this discussion it would be much easier to identify who was delivering palliative care. 00:47:00.000 --> 00:47:08.000 What, there are also a lot of drawbacks. It would put palliative care front and center and invite some level of scrutiny where it may not have existed before. 00:47:08.000 --> 00:47:21.000 Which I would argue is a net positive for patients and families. And even maybe the programs themselves, but programs would need to ask themselves honestly if they're ready for that level of attention. 00:47:21.000 --> 00:47:30.000 Creating this standalone license would take resources that states and programs don't generally have right now it's a resource draft environment. 00:47:30.000 --> 00:47:36.000 And then a big thing for me is the feasibility. I think, well, it's not always wise to speak in generalities. 00:47:36.000 --> 00:47:56.000 Our country is not currently in a pro regulation wave. And at the state level, many policy makers are looking to remove regulations and programs, and in part to be able to reduce patient and provider burden and preserve resources for states that are looking at crunch budgets and then it just hasn't been done before and a lot of 00:47:56.000 --> 00:48:03.000 policymakers. And then it just hasn't been done before. And a lot of policymakers do want to see where there's precedent. 00:48:03.000 --> 00:48:17.000 So on the advocacy side, I think the primary answer is to for palliative care field to get our own data house in order so that we can eventually come to the table with our state and federal policy makers to help co-create solutions. 00:48:17.000 --> 00:48:21.000 Next slide, please. 00:48:21.000 --> 00:48:34.000 And speaking of getting our house in order, you could probably tell where I was going for a recommendation, but, the PCA system is horribly complicated. 00:48:34.000 --> 00:48:51.000 But if you perhaps can evaluate yourself of administrative assistance. You can go back into your NPI file and add as many specialty codes as you. 00:48:51.000 --> 00:49:01.000 Would like. So if you can figure it out, idea I realize it's not easy. I do definitely think adding, code 17 onto your file would help policy makers would help. 00:49:01.000 --> 00:49:15.000 Researchers, it's doing it for the good of the field. I think it's worthwhile also to clarify with your finance folks. 00:49:15.000 --> 00:49:29.000 Your administration, how does your revenue get reported? And if it is, if you do find out it's being credited elsewhere, I think you could come up with some creative elsewhere. 00:49:29.000 --> 00:49:46.000 I think you could come up with some creative solutions to figure out how to get that clarified solutions to figure out how to get that clarified. 00:49:46.000 --> 00:49:59.000 Come up with a network for palliative care providers so it's worthwhile if you are working with health plans to discuss these limitations with the network managers and they might be able to come up with creative solutions. 00:49:59.000 --> 00:50:15.000 That they have, secondary systems in certain cases. When you do overlap with other clinical services, so on the local level you know who you're. 00:50:15.000 --> 00:50:23.000 Colleagues are who you more commonly work with. So have a quick conversation. Hey, what's your primary specialty? 00:50:23.000 --> 00:50:35.000 You know, with and if there is overlap, in the older days of palliative care, using symptom as the a principal diagnosis for palliative care claims is another workaround to get to that. 00:50:35.000 --> 00:50:54.000 And lastly Rachel mentioned the get palliative care directory. We're gonna be doing soon a big call out to ask people to register themselves. 00:50:54.000 --> 00:51:01.000 So I'll ask you to keep your eyes peeled. Next slide. 00:51:01.000 --> 00:51:10.000 I think from the perspective of researchers, the situation is also pretty tricky. And there are some things, we can do. 00:51:10.000 --> 00:51:21.000 So. You know, I think it's appealing to think about potentially a new ICD 10 code for palliative care. 00:51:21.000 --> 00:51:30.000 But the feasibility of implementing that code is clearly a major issue. You know, we see even with encounter for palliative care. 00:51:30.000 --> 00:51:42.000 It's implemented very differently depending on setting. So if you were to have a new ICD 10 code specifically for specialty palliative care, you'd need to think about significant incentives to implement that code. 00:51:42.000 --> 00:51:48.000 In a uniform way. It's not only that, how are you gonna define the code? 00:51:48.000 --> 00:51:56.000 What are we gonna include in specialty palliative care and who's gonna regulate that? I mean, it's really, really tricky. 00:51:56.000 --> 00:52:06.000 Because of all of those things related to definition implementation challenges and regulatory challenges. I don't think that that's. 00:52:06.000 --> 00:52:11.000 A viable path forward any time in the near future. 00:52:11.000 --> 00:52:12.000 Yeah. 00:52:12.000 --> 00:52:18.000 And I'll just add that I see the tens. Supposed to be used for. For procedures. 00:52:18.000 --> 00:52:26.000 Exactly, yeah, right. So it's not again, it's not a procedural code like a hip replacement or you broke your arm. 00:52:26.000 --> 00:52:35.000 So it may not even be an appropriate match. Even though sort of it's an appealing and seemingly quick fix to this problem. 00:52:35.000 --> 00:52:52.000 So the electronical medical record data is probably the best path forward and I think fortunately there is significant federal movement now on making electronic medical records and health records interoperable with each other. 00:52:52.000 --> 00:53:05.000 So I think the government has finally realized definitely not related to palliative care researchers or care, but in general that if we cannot aggregate patient data across settings and systems. 00:53:05.000 --> 00:53:14.000 We are doing a major disservice to our patients because continuity of care is really broken up. It's also really costly for the health system because if your provider doesn't know what happened in another setting. 00:53:14.000 --> 00:53:19.000 Then they're not able to take care of you properly and might actually just order the same thing. 00:53:19.000 --> 00:53:32.000 So because of that, the federal interoperability movement is in full swing. And I think that palliative care providers and researchers, are potentially gonna benefit from that. 00:53:32.000 --> 00:53:38.000 And it's from these aggregate medical records, both that are taking place regionally and. 00:53:38.000 --> 00:53:46.000 On the national level that we're hopefully going to be able to get a much better sense of who is and isn't getting tired of care. 00:53:46.000 --> 00:53:51.000 I do think the time horizon on that, you know, probably most optimistically is like 5 years, but it's probably a decade. 00:53:51.000 --> 00:54:21.000 So in the meantime, it's a question of getting together with colleagues at other institutions and putting together large de-identified data sets to look at those granular questions that I was talking about before. 00:54:23.000 --> 00:54:28.000 Minoritized patients are getting palliative care at the same rate as white patients. You don't know what that means. 00:54:28.000 --> 00:54:36.000 You don't know the quality of services, the frequency or intensity of services or whether they're meeting the needs of patients. 00:54:36.000 --> 00:54:43.000 I think the EMR is likely the best path forward since the billing system and the way it feeds up into claims. 00:54:43.000 --> 00:54:53.000 There are many dead ends in that area. Next slide. 00:54:53.000 --> 00:55:03.000 So I see there's a question in the chat about. If we see any particular issues for pediatric palliative care versus adult. 00:55:03.000 --> 00:55:10.000 And just from the slides and the things I've mentioned today, I would say a lot of the issues are probably the same. 00:55:10.000 --> 00:55:19.000 For the validation studies one of the ones I shared was on pediatric patients and it actually have the lowest sensitivity. 00:55:19.000 --> 00:55:28.000 I don't know, you know, if you can draw. Any conclusions from that, but they did do a study on pediatric ISU patients in a children's hospital and it also had some issues with validating the B. 00:55:28.000 --> 00:55:33.000 66 code in terms of the clinicians, I'd say there's also some of the similar things. 00:55:33.000 --> 00:55:44.000 Hospice palliative medicine is one of the sub specialties under pediatrics. 00:55:44.000 --> 00:55:55.000 So that is again, it's as a subspecialty there. So your counts and how it what you're putting as your primary versus your sub specialties in Pecos or anything like that. 00:55:55.000 --> 00:56:17.000 It's gonna be, you know, much, maybe even more than some of the other things if you're gonna put auspice and palliative medicine and then also for nursing there is a pediatric specific nursing credential through the hospice and positive care credentialing system, but if there's a low number, there's nothing that says you have to have 00:56:17.000 --> 00:56:23.000 the pediatric curs is the quote unquote regular one to be a pediatric nurse. 00:56:23.000 --> 00:56:32.000 You know, that's a personal choice probably, which one you want to do. So again, there are, I'm sure many nurses working in pediatrics who have the regular nursing credential rather than the pediatric nursing credentials. 00:56:32.000 --> 00:56:43.000 So I think a lot of those problems are still going to be there. Okay, like I'd like the question set across the lifespan. 00:56:43.000 --> 00:56:44.000 I will. 00:56:44.000 --> 00:57:00.000 And it's always. I was just gonna add one little detail on Rachel's answer, which is to say that I'm looking at the numbers for NPI for that pediatric hospice and palliative medicine code and out of 1.0 4 million records the count is 58. 00:57:00.000 --> 00:57:08.000 Providers who have the specialty or the subspecialty palliative care. As their first and or second coach. 00:57:08.000 --> 00:57:15.000 So, 58 out of 1.4 million or 1.0 4 million. So lots of opportunity. 00:57:15.000 --> 00:57:24.000 And I'll also just add, it might be easier for pediatrics, because pediatric patients with serious illness are clustered in commercial or Medicaid. 00:57:24.000 --> 00:57:49.000 So and because Medicaid is increasingly, private payers. Conversations with private payers about how to get credentialed in their system or recognized in their system in that case that would be an especially good place to, use that recommendation if you're caring for children. 00:57:49.000 --> 00:58:09.000 If you can get, I don't know. Like let's say, Etna is the largest payer of, the patients that you see, a good conversation with that now is probably a good move. 00:58:09.000 --> 00:58:16.000 Let's see another question here. Alan, does Capsie have specific literature or recommended credentialing enhancements, IE. 00:58:16.000 --> 00:58:20.000 For picose, MPI, etc, that we can share with our institutions billing administrator. 00:58:20.000 --> 00:58:26.000 So I do have to, I once spent a few months registering an entire team of providers into the Medicare system. 00:58:26.000 --> 00:58:50.000 And you know, CMS or Medicare's instructions are really clear. I guess we could circulate the Medicare instructions, but there's nothing unique about it that, would need to, put out there. 00:58:50.000 --> 00:59:00.000 It's just. Understanding that you should check additional codes and I guess our claim would be make sure to. 00:59:00.000 --> 00:59:10.000 Code the number 17. 00:59:10.000 --> 00:59:16.000 We have about a minute left. If there are additional questions, I can send them over to our presenters here. 00:59:16.000 --> 00:59:27.000 And have them reach out to you directly as well. But I do want to make sure to reiterate that we will be posting this webinar recording insides on the website. 00:59:27.000 --> 00:59:35.000 I see one more question from How do you pull woman here? I've been using Andrea palliative care specialist Z. 00:59:35.000 --> 00:59:49.000 51.5 encounter for palliative care as my primary DX followed by ACP when applicable almost always for new console inpatient visits and then the systems symptoms followed by the reason for symptoms. 00:59:49.000 --> 00:59:58.000 I you dismantle cancer pain. Is this accurate or should I shift to the symptoms first and how do we best capture the data to track in our power met dashboard we can build with our IT. 00:59:58.000 --> 01:00:07.000 So I will say that my understanding is that you shouldn't be using the Z code first. 01:00:07.000 --> 01:00:29.000 I think your billers. Are probably a bit frustrated by that because it's not the Z codes are not typically a principal diagnosis so I would suggest in that case if you are already used to. 01:00:29.000 --> 01:00:42.000 Coding the symptoms and then following by the reasons that sounds like the best. Opportunity for you. 01:00:42.000 --> 01:00:48.000 Yeah, just to reiterate what Alison said, either your coders on the back end are switching that for you or you're losing. 01:00:48.000 --> 01:00:56.000 Revenue that you could be getting. So Definitely put the symptoms first from a billing perspective. 01:00:56.000 --> 01:01:01.000 Alright, thank you so much. I will, download the chat here and make sure we can reach out to folks. 01:01:01.000 --> 01:01:09.000 But thank you all so much. Thank you to our presenters and for you, all here participating with us. 01:01:09.000 --> 01:01:13.000 Please, if you can throughout the survey, provide your feedback. That'd be great. Please, if you can fill out the survey, provide your feedback. That'd be great. 01:01:13.000 --> 01:01:18.000 And, again, the recording and sides will be available on the site. So just a big thank you to all the work that you all do and hope you have a great rest of your week. 01:01:18.000 --> 01:01:20.000 Take care everyone. 01:01:20.000 --> 01:01:26.000 Thank you.