- Is dyspnea at rest present despite treatment with maximum or near maximum tolerated doses of Digoxin (if they have not been on dig, document why very specifically, e.g.: “In patients with severe heart failure on inotrope therapy, benefits of Digoxin have not been shown and in patients with chronic/variable renal function the risk of dig toxicity is increased”), a loop diuretic AND an ACE inhibitor or another vasodilator used simultaneously (unless allergic or intolerant)?
- Are doses within the following ranges?
- Dobutamine: 2.5-10 mcg/kg/min
- Milrinone: 0.375-0.750 mcg/kg/min
- Dopamine: ≤ 5mcg/kg/min
- Are cardiac studies by either invasive hemodynamic technique or using thoracic electrical bioimpedance (impedance cardiography) performed within 6 months prior to the initiation of home inotropic therapy showing:
- Cardiac index (CI) is ≤ 2.2 liters/min/meter squared and/or pulmonary capillary wedge pressure (PCWP) is ≥ 20 mm HG before inotrope infusion on maximum medical management AND
- At least a 20% increase in CI and/or at least a 20% decrease in PCWP during inotrope infusion at the dose initially prescribed for home infusion
- Has there been an improvement in patient well being (less dyspnea, improved kiuresis, improved renal function and/or reduction in weight) with the absence of dyspnea at rest at the time of discharge and the capability of outpatient evaluation by the prescribing physician at least monthly?
- In the case of continuous infusion, is there documented deterioration in clinical status when the drug(s) is/are tapered or discontinued under observation in the hospital?
- Is any life threatening arrhythmia controlled prior to hospital discharge and no need for routine electrocardiograph monitoring at home?
- Is the patient being maintained on the lowest practical dose and efforts to decrease the dose of the drug(s) or the frequency/duration of infusion are documented during the first 3 months of therapy?
- Are the patient’s cardiac symptoms, vital signs, weight, lab values, and response to therapy routinely assessed and documented in the patient’s medical records?
Medicare A pays for home milrinone/dobutamine, not Medicare D
If the patient needs to switch medications after hemodynamics are measured (ex: hemodynamics were measured on and off milrinone, and patient now requires dobutamine), new hemodynamics are not needed. However, the team should document the reasoning for the change in medications in the chart.
If a patient is not on Medicare when his inotrope is initiated, they will not need hemodynamics. However, if they transition to Medicare in the future they will need this documentation, so it is best to have documented if at all possible.
If the patient wishes to go home with hospice while they are on inotropes, check with their local hospice agency. (as of 5/07, HospiceCare Inc is not comfortable with this plan). There is a different billing rate under "straight" Medicare then there is under the Medicare Hospice benefit; ask infusion company for quote.