cutting edge regulatory strategies for your idg: regulatory requirements and idt impacts on...

Cutting Edge Regulatory Strategies for Your IDG: Regulatory Requirements and IDT impacts on Organizational

Compliance

Jennifer Kennedy, MA, BSN, RN, CHCNational Hospice and Palliative Care Organization

September 2015

© National Hospice and Palliative Care Organization, 2015. All rights reserved. 2

FY2013 Medicare Part D Payments Outside Hospice Benefit

• Medicare Part D spending:– FY2013: $347.1 million – CY2012: $334.9 million


Four case studies on frequent hospice diagnoses

• Case studies presented for following diagnoses– chronic airway obstruction– congestive heart failure– cerebral degeneration– lung cancer

• Citation of :– Typical symptoms– Evidence-based practice interventions/ recommendations

• Comments on Medicare spending outside the hospice benefit

© National Hospice and Palliative Care Organization, 2015. All rights reserved.

Concurrent Payments for Services Provided to Hospice Patients Lung Cancer, CY 2013

Total $3,405,083

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Concurrent Payments for Services Provided to Hospice Patients with COPD, CY 2013

Total $10,400,319


CMS Concern

• Analysis reveals:– Clinical based practices are not being covered under the

Medicare hospice benefit. – Potential systematic unbundling of the Medicare hospice

benefit – May be valuable analysis to inform policy stakeholders


NHPCO Comments to CMS• NHPCO is concerned that CMS is holding hospice providers

alone solely responsible for all claims filed on behalf of beneficiaries who have elected hospice, and yet hospices often do not know, and are not in control of, whether or how other providers bill, and for what services, nor can hospices control whether and when a beneficiary sees a non-hospice provider.

• We encourage CMS to establish systems in claims processing so that other providers are immediately aware of the patient’s hospice election and are guided to coordinate with the hospice and to bill appropriately.


Assessment of Conditions and Comorbidities Required by Regulation

• We (CMS) continue to state that those circumstances would be “exceptional and unusual” and that hospices continue to be required to provide virtually all the care that is needed by terminally ill patients.


Assessment of Conditions and Comorbidities Required by Regulation

• Comorbidities are recognized as important factors – Contributing to the overall status of an individual – Should be considered when determining terminal

prognosis.

• Mental health comorbidities must also be considered. – Not uncommon for terminally ill individuals to have

underlying mental health conditions– Could contribute to their prognosis and/or affect the plan

of care


NHPCO Comments to CMS

• The cause and impact of a mental health (or any other) diagnosis has to be determined on a case by case basis, and expecting global adherence to general rules is unreasonable.

• In addition, the impact of any comorbid diagnosis may vary based on the individual length of prognosis.

• A hospice physician needs to make the determination of what is related to the terminal prognosis based on each individual patient’s clinical condition.



• “Virtually all”– NHPCO strongly asserts that determinations of

“relatedness” must be made on a case by case basis, as CMS has stated previously, and it is the role and responsibility of the hospice medical director or hospice physician to determine what is related to the terminal prognosis, and what is not.

– We urge CMS to avoid blanket assertions or assumptions about which services are always related to a patient’s terminal prognosis.


% of Claims with One Diagnosis

2010 2013 20140

10

20

30

40

50

60

70

80

9077

67

49

% claims

% claims


All diagnoses on the claim form

• We are clarifying that hospices will report all diagnoses identified in the initial and comprehensive assessments on hospice claims, whether related or unrelated to the terminal prognosis of the individual. – Includes the reporting of any mental health disorders and

conditions that would affect the plan of care as hospices are to assess and provide care for identified psychosocial and emotional needs, as well as, for the physical and spiritual needs.



• If CMS expects hospices to report all diagnoses, whether related to not, we must be able to distinguish between related and unrelated by using a modifier, or another mechanism, that indicates diagnoses that the hospice has determined are unrelated.

• NHPCO believes it is important that anyone reviewing the claim be able to identify the diagnoses determined by the hospice as not being related to the terminal prognosis.


IDG Strategies for Compliance• Collect as much information about patient diagnoses

at referral intake and the comprehensive assessment.• IDG meeting discussion – Update to comprehensive assessment

• Review of diagnoses status, relatedness, and prognosis.• Is the patient still eligible for hospice?

– Update to plan of care• New interventions R/T change in diagnoses.• Have measurable goals for care changed?


IDG Strategies for Compliance

• Documentation– Is there hospice physician documentation in the clinical

record that supports why a diagnosis, medication, treatment, etc… does not medically contribute to the terminal prognosis?

– Is the documentation updated as the patient’s condition changes?

– Does the IDG documentation support the hospice physician documentation?• I.e.: Communication with patient and family, communication with

attending physician, …


Determining Relatedness


The Regulation

§ 418.3 Definitions“Terminally ill means that the individual has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course.”


Why all the Fuss?

• CMS discussion about relatedness

• Virtually all care at EOL is related

• Diagnoses on claim form

FY 2014 Hospice Wage Index Rule

• Abt data related to $ leakage in to Medicare Parts A, B, D

• Proposed definitions for terminally ill and related conditions

• Virtually all care at EOL is related

• Diagnoses on claim form

FY 2015 Hospice Wage Index Rule • $ leakage in to

Medicare Parts A, B, D• Virtually all care at EOL

is related• Co-morbidities• Diagnoses on claim

form

FY 2016 Hospice Wage Index Rule


NHPCO Relatedness Workgroup• A subcommittee of the NHPCO Regulatory

Committee. • Formed in 2013 in response to FY 2014 proposed

Hospice Wage Index Rule. • The group’s mission was to develop resources for the

NHPCO membership that will assist in determining related diagnoses, treatments, medications, supplies, and equipment for a patient.

Determining Relatedness


Hospice physician reviews all available

information

Hospice physician confers with

attending physician and IDT

Determination made

• Relatedness is not determined by the CFO based on cost to hospice provider.

• It is determined patient by patient, case by case related to the palliative plan of care.


Role of the Nurse

• Provision of clinical information to the hospice physician. – Comprehensive assessment– History and physical– Discharge summary from hospital– Clinical information from attending physician

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Role of the Other IDT Members

• Social worker, dietician, chaplain, …• Continuous provision of information to the hospice

physician. – Updated to the comprehensive assessment

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Role of the Hospice Physician

• Determining the diagnoses is within the scope of practice of medicine– Formal diagnoses for the record vs. nursing diagnoses

– Hospice physician can determine new diagnoses that are present but have not been previously designated formally– Example: Dementia is documented in the record, but does

not state the etiology of the dementia

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The Determination Process

• Is the condition being considered a diagnosis or a symptom (or both)?– Diagnoses will need a determination of whether they are

related or unrelated– Symptoms are almost automatically related

(Coding guidelines state these do not need to be listed if they are a normal part of the diagnosis)

– What if they are both diagnosis and symptom?(Example: Depression)



• Is there active pain or an active symptom?– Should be considered related

• Is there a likelihood of pain or another symptom?– Should be considered related

• Questions about:– Arthritis pain, Migraine prophylaxis, etc.


The Determination Process• Is the diagnosis caused by or causing the terminal

condition?• Some obvious examples include:– HIV AIDS– Ischemic heart disease Congestive heart failure– Cerebral atherosclerosis Vascular dementia

• How far do you drill down?– Diabetes mellitus Diabetic nephropathy ESRD– HTN Hypertensive nephropathy ESRD DMT2



• Is the diagnosis in question stable?• If not requiring management – Does not need to listed – Example: Remote prostate cancer

• If requiring management, does the treatment interact or potentially interact with the terminal illness?– Determined case by case


Other Considerations

• All determinations must be done with consideration of the patient’s prognosis– If not eligible all the above is moot

(Discharge (or do not admit) the patient)– If any DX (or TX for a DX) contributes to the terminal

prognosis it is related

• Is a TX under consideration still beneficial within the patient’s expected prognosis?– May still be related, but should be discontinued


Common Denominator

• All the above determinations require medical judgment

• The hospice physician must complete the documentation

• Must have hospice physicians who can make such decisions– Must have adequate information on the patient’s status


Relatedness Flow Chart

Determining relatedness is a

continuous process by the

hospice physician which

takes into account the

changes in the patient's

condition.


Coverage per the Regulations

418.200 Requirements for coverage. – To be covered, hospice services … must be reasonable and

necessary for the palliation or management of the terminal illness as well as related conditions.

418.202 Covered services. – (f) Medical appliances and supplies, including drugs and

biologicals. Only drugs … which are used primarily for the relief of pain and symptom control related to the individual's terminal illness are covered.

34© National Hospice and Palliative Care Organization, 2015. All rights reserved.

Buckets of “Relatedness”

RELATED and

HELPFUL

UNRELATED & HELPFUL—

PART DELIGIBLE

UNRELATED, BUT NO LONGER HELPFUL

RELATED BUT NOT HELPFUL

RELATED BUT NOT ON FORMULARY


Related vs. Unrelated• …, unless there is clear evidence that a condition is

unrelated to the terminal prognosis; all services would be considered related.

• It is also the responsibility of the hospice physician to document why a patient’s medical needs would be unrelated to the terminal prognosis.

78 Federal Register 152 (7 August 2013), p.48236-7


Documenting “Un-relatedness”

• It is the hospice physician’s responsibility to document what is unrelated

• Where should that occur?– In the certification narrative? Not the best place– In a progress note? May be hard to locate– In the med profile? Include non-med treatments?– Stand-alone document?

• EMR vs. Paper documentation concerns


Documenting “Unrelatedness” cont…

• What does the hospice physician document?• CMS has providing varying guidance on this– Recent CMS Open Door Forum call:

should be a brief narrative that is reasonable in explaining why the condition is unrelated


Examples of Unrelatedness

• Two examples are repeatedly offered for unrelatedness– Neither has been validated by CMS

1. “Glaucoma is pathophysiologically unrelated to the patient’s lung cancer, and does not contribute to the terminal prognosis.”

2. “Hypothyroidism is physiologically unrelated to the patient’s COPD, and since it is well managed, it does not contribute to a worsened prognosis.”


Reasonable and Necessary

• The Medicare Hospice Benefit requires the hospice to cover all reasonable and necessary palliative care related to the terminal prognosis and related conditions….

• Section 1862(a)(1)(C) of the Social Security Act (the Act) forbids payment for any items or services which are not reasonable and necessary for the palliation and management of the terminal illness. Services which are not needed . . . would not be reasonable and necessary.

78 Federal Register 152 (7 August 2013), p.48236, 48274.


Discontinuation

• When is the right time to discuss discontinuation?

• What drives the determination of discontinuation?

• Who determines discontinuation?

• Does the patient have a choice?


IDG Strategies for Compliance• Process for determination of relatedness.– Do you have one?– Do IDG members know their role?– Is your physician skilled in determining relatedness?

• Does he or she require training?

– Are your staff trained to have the “discontinuation talk” with patient’s and family’s?

– Does your documentation reflect your practice?– Is your clinical documentation defensible?


LIVE DISCHARGES


Live Discharge and Readmissions

Hospice Discharge

Hospital Admission

Expensive test/procedure$126 M

Hospital Discharge

Hospice Readmission

Source: CMS CY 2012; FY2015 Hospice Wage Index Final Rule

2010 Data

13,770 patients of 182,172 live discharges – 7.5%



• Live discharge practice in your organization.– What is your incidence of live discharge?

• Last 12 months (includes revocation)

– Why do you discharge live?– Are you collecting as much information as you should be?

• Revocation• Reelection

– Are patients/ families really understanding that hospice approval is required for all care related to the terminal prognosis?


If medication is deemed related…• Hospice covers the cost – Care (services, treatment, etc. …) – Medications– DME & supplies

• Documentation should appear in the clinical record that it is related– Physician narrative– Plan of care– Medication profile

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46


Related and NOT in Plan of Care

• Not effective– not “supported by the evidence” or “truly necessary”

• May be harmful for reasons not usually thought of by patients and families– “not free from harm”

• Duplicate medications• Not on hospice formulary or preferred med list– And pt/family decline an equivalent medication that would

be covered


If medication is deemed unrelated…

• CMS expects that another health care professional would come to the same conclusion after reviewing the same data– Subject to MAC and auditor review– Subject to Part D plan sponsor review

• Audits directed to start again with 2014 Part D claims

• Documentation should appear in the clinical record that it is NOT related– Consistent, accessible location

• “We expect drugs covered under Part D for hospice beneficiaries will be extremely rare.”

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• Do you have a process in place for assessing all medications and determining relatedness?– Does it work?

• Are your staff trained to have the “discontinuation talk” with patient’s and family’s?

• Does your documentation reflect your practice?• Is your clinical documentation defensible?

Questions

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NHPCO members enjoy unlimited access to Regulatory AssistanceFeel free to email questions to [email protected]


mailto:[email protected]


Regulatory and Compliance Team at NHPCO

Jennifer Kennedy, MA, BSN, RN, CHCDirector, Regulatory and Compliance

Judi Lund Person, MPHVice President, Regulatory and Compliance

Email us at: [email protected]

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mailto:[email protected]


NHPCO Resources

http://www.nhpco.org/regulatory-compliance-hospices/determining-terminal-prognosis







References

CMS Hospice Centerhttp://www.cms.hhs.gov/center/hospice.asp

Conditions of Participation HospiceMedicare Benefit Policy Manual; Chapter 9 - Coverage of

Hospice Services

NHPCO Regulatory Pagehttp://www.nhpco.org/resources/regulatory

53© National Hospice and Palliative Care Organization, 2015. All rights reserved.

http://www.cms.hhs.gov/center/hospice.asp

http://www.nhpco.org/resources/regulatory

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