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340
P. Winn and L. Gelman
• For billing purposes, it is essential to use the appropriate place of service and
modier codes.
• Contact your local Medicare Administrative Contractor (MAC) for queries on
billing and coding.
• The home visit codes are now to be used for those visits performed at an assisted
living facility, a residential care facility, a group home, custodial care facility, or
a residential substance abuse facility.
• Be cognizant that an E/M code and documentation requirements may change
over time and the responsibility rests with practitioners to keep informed of any
changes. (Updated January 1, 2023).
• CMS has published a memorandum (04/07/2022) ending several waivers related
to the COVID-19 Emergency Declaration Waivers for SNFs/NFs (Ref:
QSO-22-15-NH&NLTS&LSC).
• The authors of this edition recognize Drs. Alva ‘Buzz’ Baker and Leonard
Gelman who wrote the rst and second editions on Documentation and Coding
from which content for this third edition was updated and expanded upon.
Web Resources
• Centers for Medicare and Medicaid Services Manual Update on Prolonged
Service Codes from April 2008. http://www.cms.hhs.gov/transmittals/down-
loads/R1490CP.pdf.
• AMA Website CPT Code/Relative Value Search Engine based on Current CPT
codes and Medicare payment information. https://catalog.ama- assn.org/Catalog/
cpt/cpt_search.jsp.
• Find-A-Code, a commercially available website that helps nd ICD and CPT
codes. http://www.ndacode.com.
• CMS Revisions to Consultation Services Payment Policy, information for physicians. http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf.
• Guide to Post- Acute and Long-Term Coding, Reimbursement and Documentation
can be obtained. http://www.paltc.org.
Acknowledgements Information in this section was partially extracted from a presentation on:
“Billing and Coding in PALTC and Beyond!” Presented by Charles Crecelius MD, PhD, FACP,
CMD and Robert Zorowitz MD, MBA, CMD at the PALCT 22 Annual Conference in Baltimore,
MD given by AMDA—The Society for Post-Acute and Long-Term Care Medicine in March 2022.
References
1. American Medical Association. Current procedural terminology CPT, professional edition.
Chicago: American Medical Association; 2022.
2. AMA CPT Evaluation and Management (E/M) Codes and Guideline Changes effective
January 1, 2023. https://www.ama- assn.org/system/les/2023- e- m- descriptors- guidelines.pdf.
Accessed 16 Dec 2022.
Medication Management inLong-Term
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Care
KeithA.Swanson, RaghuveerVedala, andPeterWinn
Introduction
Two-thirds of Americans over the age of 65 have multiple chronic conditions (i.e.,
multi-morbidities) that affect both quality of life and longevity. The most common
chronic diseases and the leading causes of death in older adults are heart disease,
cancer, stroke, respiratory disease, dementia, and diabetes mellitus. Census projections estimate that by 2030, 20% of the US population will be 65years of age and
older. As pharmacotherapy is an essential part of care in older adults, optimization
of their drug regimen (where benet outweighs risk) is an important public health
issue [1]. Chronic disease, limited physiologic reserves, changes in pharmacokinetics and pharmacodynamics, and impaired immune and inammatory systems all
predispose elders to serious adverse drug events (ADEs) such as falls, hip fractures,
weight loss, cognitive and functional decline.
K. A. Swanson (*)
Department of Pharmacy: Clinical and Administrative Sciences, OU College of Pharmacy,
Oklahoma City, OK, USA
R. Vedala · P. Winn
Department of Family and Preventive Medicine, University of Oklahoma Health Sciences
Center, Oklahoma City, OK, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
P. Winn et al. (eds.), Post-Acute and Long-Term Care Medicine, Current Clinical
Practice, https://doi.org/10.1007/978-3-031-28628-5_18
341
342
Since 27% of patients in a long-term care facility (LTC) routinely take nine or
more medications a day, it is not surprising that over 65% will have an ADE occur
during a 4-year period, with one in seven of these ADEs resulting in a hospital transfer [2]. Thus, the prevention and recognition of medication-related events is a principal health care quality and safety issue at LTC facilities, hospitals, and community
settings. Understanding the basics of drug pharmacokinetics and pharmacodynamics is essential to quality and safe prescribing.
K. A. Swanson et al.
Physiologic Changes intheElderly
Both the physiologic changes that occur with normal aging, and pathophysiologic
changes due to disease can affect the pharmacokinetics and disposition of many
drugs that includes their absorption, distribution, metabolism, and elimination that
must be considered when prescribing any medication.
Absorption
Medications enter the systemic circulation via oral, rectal, inhalation, percutaneous, subcutaneous, intravenous, and intramuscular routes. The effect of aging on
decreased gastric and intestinal motility have not shown to have a consistent effect
on drug absorption. Gastric hypochlorhydria seen with normal aging can decrease
the absorption of some medications such as ketoconazole. The widespread use of
acid suppressive therapies [proton pump inhibitors (PPIs) and H2 antagonists]
results in hypochlorhydria with consequences on drug and vitamin B-12 absorption (decreased) being more prevalent [3, 4]. Physiologic changes of reduced gastric motility, slowed gastric emptying, and reduced peristalsis can alter drug
absorption [5].
Comorbid conditions can also alter the absorption of some medications.
Congestive heart failure causing bowel wall edema can decrease the absorption of
diuretics such as furosemide and thus reduce its clinical efcacy. The transdermal
absorption of medication can be signicantly decreased [6]. Epidermal thinning and
other skin changes common to aging can signicantly decrease the absorption of
fentanyl from patches although reduced clearance may increase analgesic effect and
risk. Other skin changes that decrease drug absorption include:
• Diminished peripheral blood ow and impaired microcirculation (especially in
patients with cardiovascular and peripheral vascular disease).
• Increased keratinization.
• Decreased hydration and surface lipid content affect both water-soluble and fatsoluble topical medications.
• Increased intramuscular connective tissue.
Medication Management inLong-Term Care
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343
Distribution
Once absorbed, drug distribution within body compartments depends upon its
lipid and water solubility and the extent to which it is bound to plasma proteins.
The volume of distribution (Vd) is the pharmacokinetic variable that relates the
drug dose administered to its concentration in body uids. Aging decreases the
body’s lean-to-fat ratio and total body water is reduced by 10–15% by age 80 [7].
Subsequently, this results in a decreased Vd for water-soluble drugs and those
drugs distributed to lean body tissues (e.g., muscle). Therefore, it is recommended to reduce loading doses by 10–20% for water-soluble medication.
Conversely, the age-related increase in body fat content increases the Vd for
lipid-soluble medication such as benzodiazepines, amiodarone, and some hormones (e.g., thyroid), thereby reducing clearance and increasing its metabolic
half-life.
Albumin and alpha-1-acid glycoprotein are the most common plasma proteins
to which many drugs are bound. Although the concentrations of these plasma
proteins do not normally decline signicantly with normal aging, nutritional
deciencies, or catabolic states may cause a clinically important decline. Drugs
that are highly protein- bound, such as carbamazepine, phenytoin, valproic acid,
and warfarin will have higher free serum concentrations in the elderly with a
decreased level of plasma carrier proteins [8]. To avoid the adverse effects associated with drug toxicity, dose adjustments may need to be based on the free
medication concentration, not on the total blood concentration (e.g., free
phenytoin).
Metabolism
Liver mass and liver blood ow decrease signicantly with aging, reducing clearance and increasing the half-life and bioavailability of drugs that undergo extensive rst-pass liver metabolism such as propranolol and labetolol [7]. On the other
hand, the bioavailability of some ACE inhibitors, (e.g., enalapril) and opioids (e.g.,
codeine) are reduced as they require hepatic activation [9]. The activity of the
cytochrome P450 oxidase system decreases with age, as well as Phase I reactions
(reduction, oxidation, hydroxylation, and demethylation). Table1 summarizes isoenzymes of the P450 cytochrome system and commonly prescribed drugs whose
metabolism is affected by them. Of note, grapefruit juice is a known inhibitor of
the cytochrome P450 3A4 pathway. Such inhibitors can decrease clearance,
increase half-life, and thus increase toxicity of some drugs [10]. Phase II reac-
tions (drug glucuronidation, sulfation, and acetylation) are minimally inuenced
by aging.
344
K. A. Swanson et al.
Table 1 Potential metabolic effects of P450 cytochrome isoenzymes enzymes
Common
P450
enzyme
CYP
3A4
Common
substrate
medications
Simvastatin
Atorvastatin
Amiodarone
Azithromycin
Erythromycin
Warfarin
Quetiapine
Solefenain
Losartan
Amlodipine
Prednisone
Omeprazole
Sertraline
Sitagliptin
Oxycontin
inhibitor/
inducera
medications
Amiodarone
(moderate)
Erythromycin
(moderate)
Ciprooxacin
(moderate)
Amlodipine
(weak)
Rifampin
®
Atripla
Problematic drug–drug
interactions Clinical problem
Fat soluble
statin+Amiodarone
Fat soluble statin+Cipro
Azithromycin+Amiodarone
Amiodarone+Ciprooxacin
Increased statin
level, which can
cause a myopathy
Leads to QT
prolongation, and
arrhythmia
Warfarin+Amiodarone High INR can lead
to bleeding
Statin+Atripla Decreases statin
levels
Warfarin+Rifampin Decreases INR
and efcacy
Rifampin+Atripla
®
Decreased
HAART efcacy
Vardenal
Mirtazapine
Indinavir
Saquinavir
ritonavir
Cyclosporine
Tacrolimus
CYP
2D6
Fluoxetine
Paroxetine
Aripiprazole
Metoprolol,
timolol,
carvedilol
Fluoxetine
(strong)
Sertraline
(weak)
Amiodarone
(weak)
Metoprolol+Fluoxetine Bradycardia, AV
block
Sertraline
Oxycontin
Mirtazapine
CYP
2C9
CYP
2C19
Losartan
Glipizide
Phenytoin
Warfarin
Clopidogrel
Fluoxetine
Omeprazole
Sertraline
Fluoxetine
(weak)
Amiodarone
(weak)
Fluoxetine
(moderate)
Omeprazole
(moderate)
Warfarin+Fluoxetine High INR can lead
to bleeding
Glipizide+Amniodarone Hypoglycemia
Omeprazole+Warfarin High INR can lead
to bleeding
Warfarin
(Adapted from [10])
a
enzyme inhibitors or inducers may respectively reduce or enhance the molecular metabolic pathway and thus increase or decrease substrate concentrations
INR international normalized ratio, HAART highly active antiretroviral therapy
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345
Renal Elimination andClearance
Decreased renal elimination of drugs is the most signicant pharmacokinetic change
seen in older adults. In one study of 10,000 long-term care residents, 40% had signicant renal insufciency [11]. Renal mass decreases an average of 20% from the
fourth to the eighth decade of life with a concomitant reduction in renal blood ow,
glomerular ltration rate, and tubular secretion. Thus drugs that are dependent upon
renal clearance require a dosage reduction [12].
With decreased muscle mass, reduced physical activity, decreased protein intake,
and altered tubular secretion of creatinine, serum creatinine by itself is not an accurate measure of renal function. Calculators based on equations such as the Cockcroft–
Gault Equation that take into account a patient’s serum creatinine, sex, age, and
estimated lean body weight, provide a more accurate approximation of creatinine
clearance [13]. Another formula that estimates glomerular ltration rate, the
Modication of Diet in Renal Disease (MDRD) equation, has also become a standard for determine renal function used by some clinical laboratories, although it
hasn’t totally replaced the Cockcroft–Gault Equation [14].
Pharmacodynamics
Pharmacodynamics is the interaction between a drug and its effector organ(s) (i.e.,
receptor) that results in either a therapeutic or adverse effect or both. In addition, the
elderly can exhibit increased sensitivity to the therapeutic as well as the toxic effects
of many medications due to comorbid illness such as Alzheimer’s, Parkinson’s,
strokes, congestive heart failure, and frailty that reduce the ability of the body to
maintain homeostasis. Age-related pharmacodynamic changes that commonly
occur in the elderly [3, 9] include:
Increased response
• Increased sensitivity to the CNS effects of benzodiazepines and alcohol.
• Greater analgesic response to opioids.
• Increased sensitivity to anticoagulants (warfarin, heparin).
• Increased risk of delirium from anticholinergic medication.
• Increased risk of bladder outlet obstruction from anticholinergics.
• Increased risk of extrapyramidal side effects and tardive dyskinesia from
antipsychotics.
Decreased response
• Reduced sensitivity to beta-adrenergic agonists and antagonists.
346
K. A. Swanson et al.
Medication Selection intheElderly
In LTCFs, the primary responsibility for prescribing, dosing, ordering, procuring,
administering, monitoring, and when appropriate, altering or discontinuing medication therapy involves the triad of prescriber, nursing personnel, and pharmacy provider/consultant. Each has a specic role and responsibility to ensure that patients
receive the most appropriate medical therapy (maximize benet and minimize the
risk). Collaborative practice and respectful communication between these health
care providers is thus essential.
Preventing Adverse Drug Events
Several years ago, a consensus panel of experts established a list of medications commonly called the “Beers’ List” that should be prescribed with caution in older adults.
The current American Geriatrics Society Beers’ Criteria for Potentially
Inappropriate Medication [15] has evolved into evidence-based recommendations
listing medications that have increased risk-to-benet ratio that are best avoided or
cautiously prescribed in the elderly due to the high likelihood of potential adverse
effects. This tool has been subsequently adapted and applied by State surveyors of
LTCFs. The AGS Beers Criteria include a list of medications with signicant anticholinergic effects such as antihistamines (e.g., diphenhydramine) and antiemetics (e.g.,
promethazine), and other medications with a propensity to worsen mental status, (i.e.,
delirium/encephalopathy), and cause falls, urinary retention, orthostatic hypotension,
dehydration, and movement disturbances such as extrapyramidal symptoms (EPS)
and tardive dyskinesia. Benzodiazepines increase the risk of altered mental status,
sedation, and falls. Limiting the use of medications on the AGS Beers’ Criteria is not
necessarily contraindicated when a patient is receiving hospice care [15].
Another screening tool to promote optimization of medication use is the STOPP
criteria (Screening Tool of Older Person’s Prescriptions). This may be more userfriendly than the AGS Beers Criteria. A systematic review found this tool to be a
more sensitive measure of potentially inappropriate prescribing patterns in
community- dwelling and acute and long-term care facilities in Europe, Asia, and
North America. The STOPP criteria were developed as many clinicians considered
that certain drugs designated as inappropriate by the AGS Beers’ Criteria were debatable, and rather could be safely prescribed in certain specic clinical situations [16].
Tools such as the AGS Beers Criteria and STOPP criteria do not substitute for
thorough clinical assessment and good judgment, as clinicians must rst and foremost consider whether medications are possibly the cause of signs and symptoms
presenting in older adults. By optimizing and minimizing medication use, unnecessary and potentially harmful adverse side effects and prescribing cascades (use of a
medication to treat the side effects of another) can be lessened or avoided [17, 18].
The STOPP criteria are summarized in Table2 with examples of potential adverse
drug outcomes [16].
Medication Management inLong-Term Care
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STOPP criteria for potentially inappropriate prescribing
Table 2
Medication by
physiological system Prescribing pitfall Potential adverse outcome
Cardiovascular system
Digoxin >125μg per day with impaired renal
function
Digoxin toxicity from
decreased renal clearance
Thiazide diuretics With history of gout Gout attack, nephropathy
β-Blockers With COPD COPD exacerbation
Diltiazem or verapamil Class III or IV heart failure CHF exacerbation
Calcium channel
blockers
Dipyridamole As monotherapy for cardiovascular
Chronic constipation Worsening constipation,
impaction
Orthostatic hypotension
secondary prevention
Warfarin Use in rst episode of uncomplicated
Increased risk of bleeding
pulmonary embolus for >12months
Warfarin, clopidogrel,
or aspirin
Aspirin With history of PUD without histamine
Use with concurrent bleeding disorder Development of hidden or
covert bleeding
Gastrointestinal bleeding
H2 antagonist or PPI
≥150mg/day
With no history of coronary, cerebral, or
peripheral vascular symptoms or
Occlusive event
Central nervous system
TCAs With dementia CNS adverse effects
With cardiac conductive abnormalities Cardiac arrhythmia
With constipation Impaction, worsening
constipation
With prostatism or history of urinary
Urinary retention
retention
Long-term, longacting benzodiazepines
Long-term
neuroleptics
Any use Falls, confusion, lethargy,
overdose
In those with parkinsonism or dementia CNS and extrapyramidal
adverse effects, cardiovascular
events
Phenothiazines Use in patients with epilepsy Increased risk of seizure
SSRI antidepressants Use in patients with history of
hyponatremia
First-generation
Prolonged use Falls, CNS adverse effects
Increased risk of altered
mental status
antihistamines
Gastrointestinal system
Diphenoxylate,
loperamide or codeine
phosphate
For treatment of diarrhea of unknown
cause
For severe infective gastroenteritis, i.e.,
Delay in treatment of
bacterial/other causes of
diarrhea
Bacteremia, sepsis, death
bloody diarrhea, high fever, or severe
systemic toxicity
(continued)
347
348
Table 2
(continued)
Medication by
physiological system Prescribing pitfall Potential adverse outcome
Proton pump inhibitors For peptic ulcer disease at full
Respiratory system
Nebulized ipratropium Use in glaucoma Worsens symptoms
Theophylline As monotherapy for COPD Poorly controlled COPD,
Systemic
corticosteroids
Musculoskeletal system
NSAIDs With history of PUD or gastrointestinal
Long-term
corticosteroid
Long-term NSAID or
colchicine
Urogenital system
Bladder antimuscarinic
drugs
Antimuscarinic drugs With chronic prostatism Urinary retention
Endocrine system
β-Blockers In those with DM Unrecognized hypoglycemia
Drugs that adversely affect persons who are at risk to fall
Benzodiazepines Fall with or without injury
Neuroleptic drugs
Vasodilator drugs With postural hypotension
Long-acting
benzodiazepine
Long-term opiates In those with recurrent falls
Analgesic drugs
therapeutic dosage for >8weeks
Instead of inhaled corticosteroids for
maintenance therapy in moderate–
severe COPD
bleeding, unless with concurrent
histamine H2 receptor antagonist, PPI,
or misoprostol (Cytotec)
With moderate to severe HTN Poorly controlled HTN
With heart failure Exacerbation of HF
With warfarin (Coumadin) Bleeding
With chronic renal failure Worsening renal function
For relief of mild–moderate joint pain
in osteoarthritis
As monotherapy for rheumatoid or
osteoarthritis
For chronic treatment of gout where
there is no contraindication to
allopurinol
With dementia CNS adverse effects
Aspiration pneumonia, B12
deciency, magnesium
deciency
theophylline toxicity
Any corticosteroid side effect,
especially hyperglycemia,
osteoporosis, cataracts,
confusion
Gastrointestinal bleeding
Bleeding, exacerbation of
renal function, heart failure,
hypertension
Corticosteroid adverse effects
(see above)
NSAID or colchicine adverse
effects
K. A. Swanson et al.
Medication Management inLong-Term Care
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Table 2
(continued)
Medication by
physiological system Prescribing pitfall Potential adverse outcome
Long-term potent
opioids
Long-term opioids In those with dementia unless used for
Regular scheduled
opioids
Adapted from reference [16]
Use as rst-line therapy for mildmoderate pain, e.g., morphine or
fentanyl patch
palliative care
For more than 2weeks in those with
chronic constipation without
concurrent use of laxatives
CNS adverse effects, falls
with or without injury,
hypotension
Impaction, worsening
constipation, bowel
perforation, and ischemia
349
The AGS Beers Criteria and the STOPP and START screening tools (the latter to
be discussed later) aim to both reduce polypharmacy and the incidence of adverse
drug events. However, these tools are more applicable to the general adult older
population and not specically frail individuals with a limited life expectancy. A
recent addition to these tools is the STOPPFrail list, which was developed to help
guide deprescribing for persons in the last year of life [19]. For example, frail
elderly patients with limited life expectancy most likely will not survive long
enough to reap the benets of medication suggested by the START criteria.
Furthermore, the STOPP criteria do not exclude medications that should be stopped
due to their limited benet in those with a limited life expectancy (e.g., statins). The
STOPFrail list consists of 27 criteria relating to medication that may be considered
unnecessary or inappropriate in frail elderly and thus encourage practitioners to
deprescribe. In general, this list of medication appropriate for discontinuation is
recommended under the following conditions:
• End-stage irreversible disease.
• Poor 1-year survival prognosis.
• Severe functional or severe cognitive impairment (or both).
• Symptom control is the priority (palliation) rather than prevention of disease
progression.
• Medications that are persistently refused, forgotten, or have intolerable side
effects despite adequate patient education and optimized dosing safeguards.
In a randomized controlled trial using STOPPFrail, individuals did not suffer
undue harm or negative outcomes when potentially unnecessary medications were
discontinued versus those who continued usual drug therapy [19, 20].
Though studies that assess suboptimal prescribing often focus on overuse and
misuse of medication, it is equally important to ensure against the underuse of medication or the omission of a clinically indicated drug for treatment or prevention of
disease, if compatible with a patient’s goals of care and goals of life. Such occurrences (that is underuse or omission) are reported in up to 50% of community dwelling elders. Examples of drug omissions in LTCFs include the lack of GI protection
with proton pump inhibitors (PPIs) for patients taking a NSAID or prednisone, no
ACE inhibitor therapy in diabetics, no vitamin D supplementation for those at risk
for osteoporosis, and lack of venous thromboembolism (VTE) prophylaxis.
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