Anyone who works with Medicare on a regular basis understands how often the Centers for Medicare & Medicaid Services (CMS) seemingly changes its rules. Keeping up with new and ever-evolving policies can be challenging, but there are a few simple ways to stay current. Look for updates quarterly on the CMS website and follow the Prevounce blog for important and timely coverage of Medicare topics, especially those that matter the most to you, your practice, and your patients.
One relatively recent and definitely noteworthy change that directly affects primary care providers and all other providers performing the initial preventive physical examination (IPPE), also known as the "Welcome to Medicare" preventive visit, and annual wellness visits (AWV) on Medicare beneficiaries is the new push for assessing patients for opiate use. By including an opioid risk assessment as a standard component of the IPPE and AWV, CMS is trying to play a role in helping combat, spread awareness of, and provide education on the ongoing opioid crisis.
New Precision Focus on Opioid Use
It's no secret that the misuse of opioid medications has reached crisis levels here in the United States, with more than 130 people reportedly dying from an opioid overdose every day. Fueled, in part, by greed and ignorance from some major players in the pharmaceutical industry, our healthcare system inadvertently created a culture that viewed chronic pain as a problem easily treated with opioid medications. However, we now know this approach was misguided. Although there is a place in medicine for opioid pain treatment, it has become clear that opioid medications rarely have the low-risk, tangible effect on long-term pain management that many pharmaceutical companies espoused. Furthermore, they often create a secondary problem of addiction and abuse.
Spotlight on Opioid Risk Assessments
Medicare beneficiaries are among the most vulnerable populations for risk of opioid misuse or addiction. Through the natural process of aging and ailing health, coupled with the prevalence of chronic conditions, these patients increasingly fall victim to chronic pain. In an effort to reduce the number of current Medicare beneficiaries addicted to opioids and prevent new Medicare beneficiaries becoming opioid epidemic victims, Medicare is working to adopt new approaches for addressing chronic pain.
In late 2018, Medicare placed a strong emphasis on performing opioid risk assessments, specifically requiring the use of such screenings during the IPPE and subsequent AWVs. The major, validated opioid risk assessments are as follows:
- ORT: Opioid Risk Tool
- SOAPP and SOAPP-R: Screener and Opioid Assessment for Patients with Pain / Screener and Opioid Assessment for Patients with Pain-Revised
- COMM: Current Opioid Misuse Measure
- PMQ: Patient Medication Questionnaire
ORT is the most used, largely because it was released into the public domain and is more widely applicable than the others. As an article in Practice Pain Management notes, "While debate remains regarding the accuracy of various risk assessment instruments in detecting current misuse and abuse of prescription opioids, these instruments can provide important information as one component of a comprehensive risk assessment, monitoring, and mitigation process."
The positive step of Medicare emphasizing the use of opioid risk assessments will increase awareness around how often Medicare beneficiaries are prescribed pain medications and open doors to candid conversations about more appropriate means of improving the management of chronic pain.
Increasing Opioid Liability Risks
Practices are finding themselves under greater pressure to ensure they make appropriate decisions concerning opioid prescriptions because of increased liability risk. A recent report from medical liability insurance company Coverys analyzed data from five years of closed claims covering 165 patient events involving prescribed opioids. The analysis found that 39% of indemnity payments were associated with medication screening and prescribing. Dispensing and administering accounted for 29%, while monitoring and managing patients on long-term opioid therapy accounted for 31% of the dollars.
Depending upon the circumstances, practices and physicians can face significant potential penalties concerning how they approach patient opioid management. We've seen physicians lose their license, be put on probation, and receive public reprimands. Some doctors have settled allegations of over-prescribing while others contend with lawsuits, now including those from large pharmacy chains. One Ohio physician is even facing murder charges after being accused of ordering excessive opioid doses.
In its report, Coverys advises organizations hoping to better manage their liability risk to perform an opioid risk assessment on themselves to help identify potential malpractice exposures. As the report states, the assessment should "… include review of internal processes related to opioid screening and prescribing, dispensing and administration, monitoring and management, and discontinuance and prevention of drug diversion."
Movement Towards Alternative Pain Treatments
Medicare currently covers several alternative chronic pain management therapies. These include integrating behavioral health services into the patient's treatment plan, physical therapy and/or occupational therapy, manual manipulation of the spine (when medically necessary to correct a subluxation), alcohol use screenings and counseling, and individual or group therapy sessions.
Alternative therapy coverage options for treating chronic low back pain become a little more diverse, with Medicare covering treatments such as chiropractic care, injections, use of braces, and neurostimulators.
In January 2020, Medicare beneficiaries who embrace alternative therapies for pain management received some welcome news: CMS announced it had finalized a decision to cover acupuncture for Medicare patients with chronic low back pain. In a press release, CMS Principal Deputy Administrator of Operations and Policy Kimberly Brandt stated, "We are dedicated to increasing access to alternatives to prescription opioids and believe that covering acupuncture for chronic low back pain is in the best interest of Medicare patients. … Over-reliance on opioids for people with chronic pain is one of the factors that led to the crisis, so it is vital that we offer a range of treatment options for our beneficiaries."
Beneficiaries enrolled in Medicare Advantage plans should check their individual plan options concerning alternative therapies because many of these plans cover a diverse array of treatment options that may also include massage therapy.
Understand IPPE and AWV Billing Requirements
Regardless of how you treat your patients' chronic pain issues, make sure you understand and carefully follow Medicare's documentation requirements or you will put your reimbursement for performing IPPEs and AWVs at risk. Consistently complete the opioid risk assessment during each of these visits. As providers, we must play our own role in combating the opioid crisis by educating patients on appropriate pain management approaches. Doing so during the IPPE and AWVs will help your practice build revenue while positively impacting your most vulnerable patients.