In a formal letter to Centers for Medicare & Medicaid Services
(CMS), the American College of Chest Physicians (CHEST) endorsed the
need to make a key change to the designation of delirium that recognizes
it as a major complication or comorbidity. CHEST is grateful to the
American Delirium Society for leading this charge.
The proposed change would more accurately represent the clinical
importance of delirium and the tremendous costs associated with it. The
suggested change will make the complexity designation consistent with
toxic (G92) and metabolic (G93.41) encephalopathy (TME) which is implied
in cases of delirium as an underlying factor.
CHEST, which represents a large portion of the community of critical
care clinicians, recognizes that this change is essential to our ability
to improve the clinical care and outcomes of patients who are
cognitively vulnerable.
The full letter can be found below.
Dear Center for Medicare & Medicaid Services,
We write to request that causally specified delirium be designated as major
complication or comorbidity (MCC), which would make its complexity
designation consistent with toxic (G92) and metabolic (G93.41)
encephalopathy (TME).
This change is essential to recognizing the clinical importance of delirium
and, crucially, the tremendous costs associated with it.1,2
Placing delirium and encephalopathy on par with TME in terms of
reimbursement is intended to facilitate systematic efforts to detect
delirium as recommended across specialties and settings,3-6
thereby enhancing awareness of delirium and its dire impact on patients,
their families, care delivery, and healthcare systems.7
The ultimate goal of this change is to improve the clinical care and
outcomes of cognitively vulnerable patients.
Executive summary
We request that all causally specified delirium diagnoses be designated as
MCC, consistent with TME. This is justified because a delirium diagnosis in
the DSM-5-TR8 and ICD-109 requires both a defined
clinical syndrome plus attribution to a direct physiological cause. In other
words, a diagnosis of causally specified delirium implies an underlying TME.
Our requests are tabulated below (Table 1), with requested
changes are in red.
Background
Endorsed by 10 medical societies (Table 2), a 2020 position
statement on preferred nomenclature of delirium and acute encephalopathy,
clarified definitions of “acute encephalopathy” and “delirium,” as well the
relationship between them.1 The statement provides the following
definitions:
Acute encephalopathy: “a rapidly developing (in less than 4
weeks) pathobiological brain process which is expressed clinically as either
subsyndromal delirium, delirium or coma.”
The diagnostic codes for acute encephalopathy include toxic, metabolic,
other, and unspecified encephalopathy.
Subsyndromal delirium: “acute cognitive changes that are
compatible with delirium, but do not fulfil all DSM-5 delirium
criteria”
Delirium: “a clinical state defined according to the
criteria of the DSM-5” (n.b., the current edition is
DSM-5-TR8)
Coma: “a state of severely depressed responsiveness defined
using diagnostic systems such as the Glasgow Coma Score (GCS) or the Full
Outline of UnResponsiveness (FOUR) score”
The clinical syndromes of subsyndromal delirium, delirium, and coma alert
the clinician to an underlying acute encephalopathy, as they are the
cognitive evidence of a pathobiological brain process disrupting global
consciousness. Conversely, acute encephalopathy would not be suspected, let
alone diagnosed, in the absence of such clinical syndromes. That is,
the presence of a delirium-spectrum syndrome entails the presence of an
underlying acute encephalopathy,10 as all editions of the DSM have included a
diagnostic criterion for delirium, variably worded, requiring that the
cognitive disturbances be attributable to the “direct physiological
consequence of another medical condition, substance intoxication or
withdrawal, or exposure to a toxin, or is due to multiple etiologies.”
Delirium in relation to acute encephalopathy
Reliability is necessary for high-quality care; however, the diagnosis of
acute encephalopathy risks being unreliable on its own because it lacks
operationalized diagnostic criteria. Further, to our knowledge, no clinical
severity thresholds have ever been validated to define acute encephalopathy
caseness. Several EEG patterns may support a diagnosis of acute
encephalopathy,11,12 but without reliable criteria this
diagnosis will be diagnosed based on nonspecific changes in mental status.
At the same time, these same EEG findings for acute encephalopathy are
correlated with delirium severity,13 which is important because
delirium is a well validated clinical construct with reliable
operationalized criteria.14 The severity of the
delirium-spectrum illness from subsyndromal delirium to delirium to coma is
the bedside clinical analog of an EEG that indexes the severity of the
underlying acute encephalopathy. Clinical complexity increases and outcomes
worsen incrementally with the severity of mental status change: subsyndromal
delirium with moderate impact,15,16 delirium with major impact,7,17,18 and coma with severe impact.19
A robust literature details the impact of delirium on care complexity and
costs,20,21 readmissions,22 rates of functional
decline,23,24 institutionalization,25 cognitive
decline,26-28 dementia,29 and mortality,30,31
yet curiously there is no parallel in the “toxic/metabolic encephalopathy”
literature (Table 3). Delirium continues to attract
increasing32 and increasingly serious international attention33,34 for its tremendous public health impact. Further, the
relationship between delirium and Alzheimer’s disease and related dementias
is prioritized in research.35
The models of delirium and acute encephalopathy each have a rich tradition,2 yet a variety of historical, institutional, and even
clinician-level factors have conspired against their integration.10
This is despite the fact that they represent interdependent aspects of a
shared set of acute neurocognitive syndromes. Among the most pressing
reasons for their division, though, is economic.55 Currently,
at each level of specification, each acute encephalopathy code
(G-series) is designated as a higher complexity of illness than the
corresponding delirium (F-series) code even though causally specified
delirium codes provide even greater specificity (Table 4).
* ICD-10-CM requires that one “Code first the underlying
physiological condition” for F05, whereas the relevant substance is denoted
by the ones digit in the diagnostic code for intoxication denoted x
in the table and withdrawal deliria. The tenths digit denoted by y
in the table refers to the substance use pattern. ICD-10-CM
requires that one “Code first, if applicable, drug induced (T36-T50) or use
(T51-T65) to identify toxic agent” for G92 but does not have similar coding
requirements for G93.41.56
The coding landscape in the U.S. bears this out: in 2011 encephalopathy
diagnoses outnumbered delirium nearly 4:1 but in 2018 the ratio was more
than 13:1,57 which one suspects is due in large part due to the
higher reimbursement.55 [Note, in a supplementary
document, we provide an updated analysis based on the National Inpatient
Sample for 2019—the last full year before the COVID pandemic—that considers
the impact of our proposal.] The effects of the current system, by
prioritizing reimbursement of G-series codes over F-series codes, may
inadvertently reward institutions that are savvier with such billing
incentives, either institutions whose practitioners have been taught to code
the corresponding G-series code preferentially or those with separate coding
departments. The issue of upcoding delirium to TME was among the key
allegations in a whistleblower lawsuit brought by Integra Med Analytics LLC
against Providence Health and Services.58 Although the case was
ultimately dismissed,59 it clearly highlights this disparity. In
the initial filing, the Integra complaint noted that “[e]ncephalopathy is a
term for brain disease or damage to the brain where the brain is regarded as
‘altered in its structure or function.’ The telltale symptom is an altered
mental state, but altered mental state alone is insufficient for diagnosing
encephalopathy” (as quoted in the minutes from the case60).
However, one considers it telling that no clinical definition for
encephalopathy appears to be offered by the plaintiff in this case.
On the origins of the disparity
Why, when the MS-DRG was being developed, might acute encephalopathy—and, in
particular, TME—have performed like an MCC whereas delirium performed like a
CC?55 Whereas these diagnoses had been on par in terms of
reimbursement prior to the MS-DRG system, they were clearly not being used
interchangeably in hospitals. How might coding practices at the time have
introduced an artifact of severity?
The first observation applies to both delirium and TME diagnoses. That is,
only a fraction of patients with TME/delirium ever receive either diagnosis.
A review of coding in 2018 revealed that the combined prevalence of both was
roughly 3%,57 yet prospective studies find substantially higher
values. For instance, it is rare to find studies that report a lower than
10% prevalence of delirium after major surgery, and more than half of
patients in critical care develop delirium.61 Delirium rates
across acute medical settings vary by population and, typically, age,
pre-existing cognitive impairment, and overall morbidity.62
Therefore, in view of this likely type II error in national coding, the
question becomes, “What clinical factors would lead to an artifact of
differential complexity?”
Consider TME. First, neurologists have historically favored the term TME
whereas most other specialties have favored delirium2 (notably,
coding in internal medicine has increasingly favored TME for reasons that
are addressed in this proposal1). Returning to the mid-2000’s
when the MS-DRG system was developed, we should consider the role of
neurology in clinical care. For a neurologist to be involved in a patient’s
care either as the primary or consulting service, the mental status change
is typically to such a degree that it warrants independent clinical
attention for neurological evaluation, often being accompanied by focal
neurological findings. Diagnostic consideration would naturally include
encephalitis, seizure disorders, space-occupying lesions, cerebrovascular
accidents, and the like. Such an evaluation often involves head imaging, EEG
evaluation, or even lumbar puncture. As such, TME diagnoses at the time were
all but certainly enriched with more severe clinical scenarios.
Next, consider delirium. The vast majority of delirium is never diagnosed,
which means that it would be more informative to ask, “When is delirium
diagnosed?” rather than “When is it undiagnosed?”63-66 In
general, a diagnosis of delirium tends to be made when there is
hyperactivity and, in particular, behavioral disturbances. The far more
common hypoactive presentations go either undiagnosed
or preferentially diagnosed as TME
. Additionally, the tradition of the neurologists Victor and Adams was to
reserve the diagnosis of delirium for hyperactive states and encephalopathy
for hypoactive ones.2 However, of the motoric subtypes of
delirium, hypoactive delirium is consistently associated with worse clinical
outcomes, including greater risk of mortality.67-71 That is, the
data used to create the MS-DRG likely would have included a small group of
largely hyperactive delirium as the complication or comorbidity in question,
leaving the majority of patients with the more severe hypoactive delirium in
the non-delirium reference group, thereby creating a false impression that
delirium is of lower complexity.
Delirium and the nine guiding principles for reconsideration of its
MS-DRG complexity designation
Delirium is a textbook example that maps onto the nine guiding principles to
evaluate when considering a potential change to CMS coding and
reimbursement.72 However, an epistemic principle, even more
foundational than the nine, is added as a preceding item as number zero
below because the ability to detect a condition reliably is necessary for
consistent detection and clinical intervention.
0. Delirium can be diagnosed reliably whereas TME cannot be diagnosed
reliably without a defined threshold.
-
An independent TME diagnosis currently lacks demonstrated
reliability whereas delirium has reliable, operationalized
diagnostic criteria.8
-
Delirium instruments are available to detect delirium reliably
across settings. In particular, the suite of Confusion Assessment
Method delirium assessment instruments has been validated
extensively both categorically and as severity instruments,73-78 leading the CAM to be the most widely used
set of instruments to detect delirium worldwide. Further, the
Ultra-Brief CAM79 can equip a large range of
healthcare clinicians to detect delirium reliably in less than a minute
and a half, with most patients screening negative in less than a minute
on an initial 2-item screener.80
-
Recognizing the link between delirium and acute encephalopathy
encourages diagnostic reliability by standardizing clinical
definitions and allowing for systematic detection efforts.81
1. “Involves a chronic illness with susceptibility to exacerbations or
abrupt decline.”
-
Acute and chronic forms of cognitive impairment share a
bidirectional relationship such that preexisting cognitive
impairment increases the risk of delirium and delirium increases the
risk of subsequent cognitive decline and dementia.82
The relationship between delirium and Alzheimer’s disease and
related dementias remains of critical importance to older adults,
especially within the Age-Friendly Health Systems and Geriatric
Surgery Verification Program initiatives.
-
Delirium superimposed on dementia may be a particularly virulent
condition and appears to involve the acceleration of decline and
increased risk of mortality.83
-
Further, these proposed changes, by requiring clinical specificity,
bear similarity to the recent changes in dementia diagnostic codes
that provide greater specification of neuropsychiatric disturbances
beyond simply “with/without behavioral disturbances.”84
2. “Serves as a marker for advanced disease states across multiple
different comorbid conditions.”
-
Delirium is common across hospital settings and comorbidities, in
particular occurring in roughly a third of hospitalized older
adults.81
-
Prioritizing delirium detection facilitates the recognition of
mental status changes heralding clinical deterioration for prompt
recognition and redress of contributing clinical factors.
-
Regarding its broad applicability to clinical care, mental status
changes may be regarded as a vital sign.85,86
3. “Reflects systemic impact.”
-
Delirium is an essential element of the Age-Friendly Health System,
with deep interconnections with each of the 4M’s,87 and Geriatric Verification Program88
initiatives.
-
Delirium in post-acute care settings is associated with more than
twice the risk of 30-day mortality, 40% increased risk of 30-day
hospital readmission, and 40% lower rate of discharge home within 30
days.89
-
Table 3
(see above) details many aspects of delirium’s systemic impact.
4. “Post-operative/post-procedure condition/complication impacting
recovery.”
-
“Postoperative delirium” is the uniformly recommended term to
describe acute neurocognitive disturbances after surgery.90
-
Apart from the nearly universal experience of postoperative pain,
delirium is arguably the most common complication after major
surgery and has an outsized impact on postoperative recovery.91 As described in the clinically focused review
in NEJM by Dr. Marcantonio,91
delirium is associated with: a 2- to 5-fold increased risk of
postoperative complications, including risk of death, an additional
2–5 days length of stay, a 3-fold increased risk of institutional
placement at discharge, poor functional recovery, and new dementia
diagnosis.
-
The healthcare costs and sequelae attributable to delirium consider
not only incremental costs during the index episode of care but also
care utilization over the following year.21
5. “Typically requires higher level of care (that is, intensive
monitoring, greater number of caregivers, additional testing, intensive care
unit care, extended length of stay).”
-
We refer, again, to Table 3 above.
6. “Impedes patient cooperation or management of care or both.”
-
Patient experience must be considered when discussing the
distinctions between delirium and TME. TME draws attention to
underlying pathobiology, but it does not specify the clinical
manifestation of that disturbance and the diverse ways that its
neuropsychiatric disturbances routinely impede care delivery and
recovery.10 A diagnosis of delirium, on the other hand,
centralizes the patient’s experience, drawing attention to the
importance of the patient’s mental status and care engagement.50,92,93
-
A diagnosis of delirium requires a clinician to characterize a
patient’s mental status.
This information is essential so that clinicians understand a
patient’s ability to engage meaningfully in care decisions, have
discussions about their care with clinicians and loved ones, and
participate productively in various aspects of care.
-
Additionally, identifying delirium as “delirium” encourages
evaluation and monitoring for neuropsychiatric disturbances that
increase the risk of danger, including impulsivity, risk of falls,
inadvertent self-extubation or line removals, and other elements of
compromised care.94
7. “Recent (last 10 years) change in best practice, or in practice
guidelines and review of the extent to which these changes have led to
concomitant changes in expected resource use.”
-
To our knowledge, there is no defined treatment pathway for the TME
diagnoses; however, several guidelines published in the past 10
years exist for delirium, both in the United States (e.g., by the
American Geriatrics Society,6 the Society for Critical Care Medicine,4 Cochrane
Database of Systematic Reviews,95 and
American Psychiatric Association [update currently in process]) and
internationally (e.g., the National Institute for Health and Clinical
Excellence,96 the Scottish Intercollegiate
Guidelines Network,97 Australian Delirium
Care Standard,98 European Society of
Anaesthesiology,99 Association of Scientific
Medical Societies of Germany,100 and
Japanese Psycho-Oncology Society and Japanese Association of Supportive
Care in Cancer101).
8. “Denotes organ system instability or failure.”
-
Although the term “acute brain failure” is discouraged by the recent
multi-society statement on nomenclature (for its redundancy rather
than for its inaccurate connotations),1 this term was the subtitle of Lipowski’s first
of two delirium monographs.102 Nomenclature
aside, there is no question that delirium represents a global
disturbance in cognition as a form of “failure of neurocognition”103
and global dysfunction.
-
Delirium is associated with markers of brain damage including on
postmortem neuropathology,104 elevated neurofilament light chain (marker of
axonal damage),105,106 elevated serum tau,107 and
several inflammatory markers known to index neural injury.108
9. “Represents end of life/near death or has reached an advanced stage
associated with systemic physiologic decompensation and debility.”
-
Delirium is a state of systemic physiological decompensation
associated with advanced illness. Delirium at the end of life
(“terminal delirium”) is a common expression of advanced disease
that can cause patients and their families distress, and dangerous
behavioral disturbances.109
Rectifying reimbursement actively facilitates prevention efforts
Finally, we consider that these changes would facilitate delirium
prevention
efforts as well. Delirium is costly, and its complexity designation should
be commensurate with its economic impact. However, delirium prevention
efforts work, preventing roughly 40% of delirium.110,111 The
costs associated with delirium not only justify its designation as MCC but
also encourage widespread delirium prevention efforts. Care bundles such as
the AGS CoCare® HELP 112,113 and the Society of Critical Care
Medicine’s ICU Liberation A-to-F bundle114,115 have been shown
to be both effective at preventing delirium and cost effective. How
might a change in delirium’s complexity designation incentivize adoption of
such delirium care bundles?
Despite the effectiveness of delirium prevention bundles, encouraging
delirium prevention efforts alone, without changing the complexity
designation of delirium, would not be enough. This is because most delirium
is not preventable; this includes both delirium prevalent on admission
(inherently not preventable116) and the 60% of incident delirium
that is not currently preventable with modern delirium bundles.111
Designating delirium as MCC would signal to hospitals the costs associated
with delirium, thereby leading to a greater awareness of its scope and
healthcare impact. It would also be apparent that additional reimbursement
for delirium as MCC is modest relative to the cost savings realized by
delirium prevention.113 This is because the incremental increase
in reimbursement for delirium as MCC is relevant
only for the portion of patients without a separate qualifying MCC
. Insurance companies would also have reason to incentivize hospitals to
implement delirium preventive care. Further still, parallel efforts by the
Age-Friendly Health Systems initiative117 along with the
increasingly integrated AGS CoCare® HELP,118 the Society of
Critical Care Medicine’s ICU Liberation A-F Bundle,119 and the
American College of Surgery’s Geriatric Surgery Verification Program,120
and the integrative work of the American Delirium Society121
provide a collective counterbalance in leading and advocating for delirium
prevention.
In fact, one imagines a potentially stronger argument for how addressing the
current reimbursement disparity between delirium and acute encephalopathy
could advance not only best practices but also facilitate delirium
prevention and improve patient care. We are currently witnessing an epidemic
of burnout among clinicians in acute medical settings,122 fueled
in part by the behavioral complexity of hospitalized patients with cognitive
disorders. Currently, however, the burden of delirium bundles and other
non-pharmacological interventions to prevent delirium is being placed on
nurses, practitioners, and other clinicians providing direct patient care.
Based on the change in reimbursement outlined in our request, improved
revenue for delirium is expected to more than offset the costs of investing
in dedicated staff to ensure the consistent, successful implementation of
delirium bundles, thereby offloading already-overstretched clinicians.
Again, the cost equation of these bundles strongly suggests that, given
sufficient ‘energy of activation’ to see them implemented, they would be
financially self-sustaining.113
Clinical impact statement
Our proposal represents the logical conclusion of understanding the
integrated nature of delirium and acute encephalopathy. We expect that this
proposal, which aligns reimbursement with a robust scientific literature and
clinical practice guidelines, will facilitate improved patient care and
outcomes by way of encouraging enhanced delirium detection and actionable
delirium clinical pathways.
Many clinicians and healthcare systems are simply unaware of the scope and
impact of delirium. Those who know the scope and have attempted to implement
delirium detection efforts and delirium pathways know how hard it is to get
buy-in for these efforts, or to develop sustainable quality improvement
projects that do not depend on a single person or a small group of dedicated
champions to keep it alive. Our proposal, if accepted, would provide
healthcare institutions with appropriate and justified incentives to provide
appropriate support to patients with the greatest cognitive and functional
vulnerability—specifically, those at risk for complications and poor
outcomes. In view of such a change, one envisions education efforts to
clinical staff about what delirium is, what it looks like, and why it
matters, as well as practical tools including optimized electronic health
records for delirium functionality and the availability of
non-pharmacological interventions.
Summary
We are requesting that causally specified delirium codes be designated as
MCC. This proposal is aligned with the principles of value-based care and
the aim of the MS-DRG system to accurately account for the variance in
healthcare costs.
Respectfully submitted,
Mark Oldham, MD
President-Elect, American Delirium Society
The following organizations are in support of this proposal
(in alphabetical order) :
-
Academy of Consultation-Liaison Psychiatry
-
American Association for Geriatric Psychiatry
-
American Delirium Society
-
American Geriatrics Society
-
American Thoracic Society
-
Association of Medicine and Psychiatry
-
Society of Critical Care Medicine
-
Society of Hospital Medicine (preliminarily)
Additionally, the American Academy of Neurology and American Psychiatric
Association
Additional Supplements
-
“An Analysis of Annual Nationwide Coding of CC Specified Delirium and
MCC Encephalopathy.” This analysis estimates the number of hospital
encounters this proposal would affect annually.
-
Slooter AJC, Otte WM, Devlin JW, et al. Updated nomenclature of delirium
and acute encephalopathy: statement of ten Societies. Intensive care
medicine 2020;46(5):1020-1022.
-
Oldham MA, Holloway RG. Delirium disorder: Integrating delirium and
acute encephalopathy. Neurology 2020;95(4):173-178.
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