Today's topic on palliative care for sickle cell disease may raise eyebrows with some of you. You might think, wait, now we're doing sickle cell? On top of liquid cancer and transplant, kidney disease, liver disease, and survivorship? Where does it end? Do we have staff for all of this?

Well I implore you, dear listeners, to keep an open mind and listen to this podcast. Our guests do a fabulous job of stating the case for palliative care in sickle cell disease, to the point that we ask: why haven't we been doing this all along?

Our guests today are Craig Blinderman, Stephanie Kiser, Eberechi Nwogu-Onyemkpa, three palliative care docs who have been advancing the practice in palliative care for sickle cell for a long time. Our discussion ranges from what is sickle cell; to outcomes; to social determinants and discrimination; to PCAs, ketorolac, and bupenorphine; and to the importance of the interdisciplinary team.

I would also encourage you to check out Eberechi's NEJM Perspective on Involving Palliative Care to Improve Outcomes in Sickle Cell, which includes a table of the challenges and action items needed to move the field forward. I'd also encourage you to sample this AAHPM Flight on the same topic (we learned that a flight is similar to a flight of drinks - a quick sampling).

As Eberechi notes at the start, we should be grateful for the community of people who are advancing palliative care in sickle cell. Thank you for being a friend (song hint!).

-Alex Smith

Last month, the "Billing Boys"—Chris Jones and Phil Rodgers—joined the GeriPal podcast to demystify medical billing and coding in palliative care. This month, we're back with part two, shifting the focus to geriatrics. While billing and coding may not be the most exciting topic, they're essential for ensuring fair reimbursement for the complex care we provide and for supporting the work of our interprofessional teams, many of whom can't bill directly for their services. When we underbill or leave money on the table, we not only shortchange ourselves but also devalue the critical role of geriatrics in the healthcare system.

This time, we're joined by experts Peter Hollmann, Ken Koncilja, and Audrey Chun to dive into key questions: Why does billing matter, and who does it benefit? What's the difference between CPT, E&M, and ICD-10 codes (if you need a refresher, check out our chat with the Billing Boys here)? We explore how to think about billing for complexity versus time, and unpack new and impactful codes like the Cognitive Assessment and Care Plan Services code (99483), advance care planning (ACP) billing codes, and G2211, which acknowledges the added work of managing patients with chronic conditions. We also highlight the new APCM G-codes for 2025, a set of HCPCS codes that could provide substantial financial support for interdisciplinary teams in geriatrics.

Finally, we discuss the advocacy behind these codes. The American Geriatrics Society (AGS) plays a vital role on the AMA's RUC committee, helping to improve reimbursement for the complex care of older adults. Tune in to this week's GeriPal podcast for expert advice, practical strategies, and insights that will help you optimize your billing practices and sustain the future of geriatrics!

Here are some of the resources we also talked about:

• The physician fee schedule look up tool Wwere you can find out CMS expected charge based off where you practice

• AGS's annual coding update

• Geriatrics at Your Fingertips, which has a one-pager on billing

• Medicare Claims Processing Manual

👉 NOTE:
Eric and Alex are giving UCSF Geriatrics Grand Rounds on Wednesday November 5, 4-5pm Pacific Time. The topic is, "What we've learned from nearly 400 GeriPal podcasts." Join us! This will be highly interactive. If you'd like to join via Zoom, you can use this link: https://ucsf.zoom.us/webinar/register/WN_qLJSlL0wSlq3SwASXw_S4w. Or join in person, grand rounds are open to all! We will be speaking at the main UCSF Campus, 500 Parnassus Ave, in the Health Sciences West Building, 3rd floor, room 303. You can ask for directions when you arrive at UCSF, or email Alex to arrange for someone to meet you at the front (https://profiles.ucsf.edu/alexander.smith).

I'm going to begin with a wonderful quote from a recent editorial in Bioethics by our guests Parker Crutchfield & Jason Wasserman. This quote illustrates the tension between the widely held view in bioethics that slow codes are unethical, and the complexity of real world hospital practice: "Decisive moral positions are easy to come by when sitting in the cheap seats of academic journals, but a troubling ambivalence is naturally characteristic of live dilemmas."

Gina Piscitello, our third guest, recently surveyed doctors, nurses and others at 2 academic medical centers about slow codes. In a paper published in JPSM, she found that two thirds had cared for a patient where a slow code was performed. Over half believed that a slow code is ethical if they believed the code is futile.

Slow codes are happening. The accepted academic bioethics stance that slow codes are unethical is not making it through to practicing clinicians. Our 3 guests were panelists at a session of the American Society of Bioethics and the Humanities annual meeting last year, and their panel discussion was apparently the talk of the meeting.

Today we talk about what constitutes a slow code, short code, show code, and "Hollywood code." We talk about walk don't run, shallow compressions, and…injecting the epi into the mattress! We explore the arguments for and against slow codes: harm to families, harm to patients, moral distress for doctors and nurses; deceit, trust, and communication; do outcomes (e.g. family feels code was attempted) matter more than values (e.g. never lie or withhold information from family)? We talk about the classic bioethics "trolley problem" and how it might apply to slow codes (for a longer discussion see this paper by Parker Crutchfield). We talk about the role of the law, fear of litigation, and legislative overreach (for more see this paper by Jason Wasserman). We disagree if slow codes are ever ethical. I argue that Eric's way out of this is a slow code in disguise.

One thing we can all agree about: the ethics of slow codes need a rethink.

Stop! In the name of love. Before you break my heart. Think it over…

-Alex Smith