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Aboutthepresenter

Hospice & Home Health Consultant AHCC Advising Board Member

BETH NOYCE RN, BSJMC, HCS-H, HCS-D, COS-C

More info: noyceconsulting.com Contact: [email protected]

WhatistheHIS?

•  Atooltocaptureprocessmeasuresatadmitanddischargetoinform:–  Cer;fica;onandSurveyProviderEnhanced

Reports(CASPER)–  HospiceCompareonline•  Consumerwebsite•  Laterin2017

•  NewitemscapturebeginsApril1,2017

•  A“pay-for-repor;ng”requirement:–  Non-complianceloses2%ofAPU

•  Requiredbylawforall:–  Medicare-cer;fiedhospices

–  Hospice-pa;entadmissions

WhatistheHIS?

•  DoesNOT:–  Replacethorough,ongoing

pa;entassessmentandstandardclinicalprac;ce&judgment

WhatistheHIS?

HIS;mingandsequence

2-ItemMeasureforHospiceCompare

HISCONVENTIONSRulesforcomple;ngtheHospiceItemSetcorrectly

HISConven8ons•  Fully&accuratelycompleteAdmission&DischargeHISforalladmits.

•  Anyhospicestaffmembermaycompleteanypor;onoftheHIS.–  Allcontribu;ngtotheHISrecordmustsigninSec;onZ

accordingtoChapter2instruc;ons.–  WatchforfuturechangesastheHISevolvesintoaclinical

assessmenttool.

HISConven8ons•  Completeeachitemusingonlydatainthepa;entrecordby

HIScomple;ondate.–  Followitem-specificinstruc;ons&conven;ons.

–  Anyprocessnotdocumentedintheclinicalrecordisconsiderednotdone.

HISConven8ons

•  SubmitaHIS-AdmissionandHIS-Dischargeevenifthepa;entrevokesorisdischargedbeforerelatedcareprocessesarecomplete.–  Answer“No”toques;onsaboutincompleteprocesses,thenfollow

skippagerns.

HISConven8ons•  Clinicalrecorddataextrac;onprocessat

agencymay…–  Allowofficepersonneltoiden;fyandextract

theHISinforma;onneededfromclinicalassessmentitems.

–  Addverba;mHISitemstotheclinicalrecord/pa;entassessmentsfor1:1extrac;on.•  Themostcommonmethodforelectronicmedical

recordHIS-dataaggrega;onforsubmission.

HISConven8ons•  SubmitallcompleteHISrecordselectronicallyvia

QIESASAPsystem.–  Incorrectsequence.•  Admissionbeforedischarge.

•  CorrectanyHISerrorsdiscovereda2ersubmission.–  SeeHISGuidanceManualChapter3.

•  Consultexternalsourcesonlyasnecessaryfornon-processinforma;on,asdirectedinChapter2.

HISRecordMaintenance

•  RetainHISdocuments.–  Includeanycorrectedversions.–  Signaturepage.•  Don’ttransmit,butretainforanyfuture

valida;on.

–  EnsureHISprivacyandintegrity.

HQRPUPDATESHospiceQualityRepor;ngProgrammeetsHospiceCompare

FY2017HQRPUpdates

•  HISandCAHPS®willinformHospiceComparebeginninglaterin2017.– HospiceCAHPS®survey=Pa;ent-surveystarra;ngs– HISdata=Pa;ent-care-qualitystarra;ngs:•  Currentlycapturesprocessmeasures.

•  Tobecomepartofamorecomprehensive,standardized,pa;ent-assessmenttool.

•  Future(poten;al)pa;entoutcomes.

FY2017HQRPUpdates

•  HospiceInforma;onSet(HIS):– SubmissionratestoHISQIESASAPand30-day-from-eventsubmissiondeadlinetoavoid2%marketbasketupdatereduc;ontwofiscalyearslater.•  CY2016:atleast70%forFY2018•  CY2017:atleast80%forFY2019•  CY2018:atleast90%forFY2020

FY2017HQRPUpdates•  Agenciesmayrequestextension/exemp;onforrepor;ngHISdatawithoutpaymentreduc;onpenalty:– Within30daysofextraordinarycircumstancesbeyondtheprovider’scontrol.

– ByemailonlytoHospiceQRPReconsidera;[email protected].

FY2017HQRPUpdates•  Extensionsforandexemp;onsfromsubmisngHISdataallowedonly:–  Inextraordinarycircumstances:•  Naturalorman-madedisasterspreven;ng;melysubmissionofqualitydata– Widespreadoraffec;ngmul;plestructures

–  Isolatedandaffec;ngasinglesiteonly

– Extension/exemp;onrequestsmust:•  Beforaspecified;meperiod•  ComplywithallcriterialistedatCMS’HQRPExtensionsandExemp;onsRequestwebpage.

FY2017HQRPUpdates•  HISdatawillbeaccessibletohospicesviaCASPERpriortopublicrepor;ngfor:1.  HospiceandPallia;veCareCompositeProcess

Measure–ComprehensiveAssessmentatAdmission

2.  HospiceVisitsWhenDeathisImminent

•  CAHPS®:–  Includesstandardsurveyadministra;onprotocolsthatallowforfaircomparisonsacrosshospices

–  Currentsurveytocon;nue

FY2017HQRPUpdates•  Hospiceswith<50survey-eligibledecedents/caregiversmayapplyannuallyforexemp;onfromCAHPS®HospiceSurveydatacollec;on&repor;ngrequirementstoavoidpaymentpenal;es.

•  HospicesthatreceiveCNNa2er1/1/17areexemptfromFY2019APUHospiceCAHPS®requirement.

•  ConsiderthatCAHPS®informa8oncaninformQAPIinvaluableways.

ADMINISTRATIVEINFORMATIONFromHISManualSec;onA

29

Sec8onA:Administra8veInforma8on

•  Nochangeindatacollec;onformostadministra;veinforma;onitems.–  Entercorrectnumbertocoderesponse.–  Numbersanddatesbeginatle2,leavingnoblankboxesunlessotherwisespecified.

•  A0245:– DatetheRNbegantheini;alassessment.•  Ifnotini;atedbeforepa;entDC=adash(-)ineachbox.

•  IfA0250=09,HIS-Discharge:–  Enterdatepa;entwasdischargedfromhospice.–  Ifpa;entdied,deathdateisdischargedate.–  Iflivedischarge,indicate,asapplicable:

•  Thedatepa;entrevokedhospicebenefit.•  Thedatehospicedischargedthepa;ent.


•  Enterthepa;ent’snameasitappearsontheMedicarecardorothergovernmentdocument.–  Checkspellingtoavoidcrea;nganewrecordforapa;ent.

•  NewinHISversion2.00.–  ZIPcode+4ofpa;ent’sresidencewhilereceivinghospiceservices.

–  Enteratleast5numbers,beginningatle2.

–  Leavefinal4boxesblankifnumbersareunknown.


•  A0600A.SocialSecurityNumber:–  Leaveblankifpa;enthasnoSSN.

•  A0600B.MedicareorRRBNumber:–  EnterexactlyasonIDcard.–  AlsocalledHIC#.–  NameonIDcard&HISrecordmustmatch.

•  A0700MedicaidNumber:–  EnterMedicaidnumber,ifapplicable,evenifpa;enthasotherpayer.–  Enter“+”infirstboxifMedicaidispending.–  Enter“N”infirstboxifpa;enthasnoMedicaid.–  ConfirmlegalnamematchesthatonMedicaidcard.–  Leaveblankifunknown,orpa;entrefusestoprovide.


•  A0800Gender•  A0900BirthDate

•  A1000Race/Ethnicity:– Markallthatapply.

•  Entertwo-digitcodethatbestdescribesthepa;ent’senvironmentimmediatelybeforeadmissiontohospiceservices.

•  CompleteonlyifA0250=09,Discharge.


RECORDADMINISTRATIONFromHISManualSec;onZ

35

Sec8onZ:RecordAdministra8on

•  Sec;onZrecordssignaturesofstaffmemberswhocompletetheHIS,andwhoverifyitsaccuracy.

•  ProvidersmustcompleteandretainSec;onZforfuturereference:– Accordingtohospice’spoliciesandprocedures– Forfuturereference

•  NotsubmigedaspartofHIS

•  ItemZ0400:–  Trackinglogforinforma;onintheHIS

–  Signaturesagestthatthesigner:•  Wasauthorizedtocollect/documentHISinforma;on

•  Completedspecifieditems/sec;onsofHIS

•  Providedinforma;onthataccuratelyreflectsclinicalrecorddocumenta;on


•  ItemZ0500:– DocumentsthatZ0400indicatesthateveryHISsec;oniscomplete•  Notthateachsec;onoftheHISisaccurate

– SignatZ0500A– EntersignaturedateatZ0500B


SECTIONI:ACTIVEDIAGNOSES

39

Sec8onI:Ac8veDiagnoses

•  Addressesmostcommonterminaldiagnoses– Entercodeforonlytheprincipaldiagnoses•  Mostcontributoryto6-monthlifeexpectancy•  Chieflyresponsibleforhospiceadmission

– Mustmatchclinicalrecordathospiceadmission•  Cer;ficateofTerminalIllness(CTI)•  No;ceofElec;on(NOE)•  Planofcare(POC)

COMPREHENSIVEASSESSMENTATADMISSION

HospiceandPallia;veCareCompositeProcessMeasure

41

17Hospice: HIS-Based Quality Measures | January 2017

Hospice and Palliative Care Composite Process Measure – Comprehensive Assessment

at Admission

• This QM reports the percentage of hospice patients who received all seven HIS care processes for which they are eligible at admission to a hospice.

• The measure is calculated using data from existing HIS-Admission items.

• Patient admissions occurring on or after April 1, 2017, will be included in the measure calculation.

• No new data collection will be required for this measure.


Care Processes Captured by the Composite Measure

Section of the HIS Corresponding QMsF: Preferences • Treatment Preferences (NQF #1641).

• Beliefs/Values Addressed (if desired by patient) (NQF #1647).

J: Health Conditions • Pain Screening (NQF #1634).• Pain Assessment (NQF #1637).• Dyspnea Screening (NQF #1639).• Dyspnea Treatment (NQF #1638).

N: Medications • Patients Treated with an Opioid Who Are Given a Bowel Regimen (NQF #1617).



at Admission

• This measure will provide consumers and providers with: o A single measure regarding the overall quality

and completeness of assessment of patient needs at hospice admission.

o A measure that can be used to meaningfully and easily compare quality across hospice providers.

o A measure that sets a higher standard of care for hospices.



at Admission

Conditional Measures:• Some patients may not qualify for the conditional measures

NQF #1637 Pain Assessment, NQF #1638 Dyspnea Treatment, and NQF #1617 Bowel Regimen.o For example: If screening indicates no dyspnea (J2030), the

patient is ineligible for a dyspnea treatment (J2040).• These patients will be eligible for the numerator as if hospices

completed the care processes of the conditional measures.o That is, the hospice would be given “credit” for completing the

comprehensive respiratory assessment.



at Admission



at Admission

Remember! • The numerator for this measure includes

patients who meet the numerator criteria for all of the individual components measures for which they are eligible.

• Completion should be based on what is documented in the hospice clinical record.


Calculation of the Composite Process Measure

• The calculation includes patient stays that meet the numerator criteria for all of the individual component quality measures for which they are eligible: 1. The patient/responsible party was asked

about treatment preferences.2. The patient and/or caregiver was asked

about spiritual/existential concerns.

SECTIONF:PREFERENCES

49

Sec8onF:Preferences(F2000CPR)

– Expressinglife-sustainingtreatmentpreferencesimprovespa;entandfamilysa;sfac;onwithcare.

– Ahospicepa;ent’spreferencemaychangeasdoesthepa;ent’scondi;on.•  IfpriorDNRorPOLSTexists,mustre-affirmpa;ent’spreference.

•  AskswhetherhospicediscussedCPRusepreferencewiththepa;ent/responsibleparty.

•  OKtoincludediscussionatpre-admissionaswellasduringadmission,basedonclinicalrecord.

•  Ifmul;plediscussionsappearindocumenta;on,enterthedateoftheearliestdiscussion.

•  ExamplesofotherLSTincludeven;latorsupport,tubefeeding,dialysis,bloodtransfusion,an;bio;cs,andIVfluids

Sec8onF:Preferences(F2000CPR&F2100OtherLST)

•  ChoosecorrectresponseaswithprioritemsinSec;onF.•  F2200excludesGIPandRespitelevelsofhospicecare.•  F3000Areligiousaffilia;oninadequatetocode“Yes.”•  Caregiverneednotbelegallyauthorizedrepresenta;ve.

Sec8onF:Preferences(F2200Hospitaliza8on&F3000Spiritual/Existen8alConcerns)

SECTIONJ:HEALTHCONDITIONSPAIN&RESPIRATORYSTATUS

53



3. The patient was screened for pain within 2 days of the admission date and the patient reported they had no pain, or pain severity was rated and a standardized pain tool was used.

Sec8onJ:Pain•  J0900:DidtheRNscreenthepa8entforpain?A.  Duringtheini;alnursing

assessment?B.  Within2daysofthe

admissiondate?C.  Rankthepain’sseverityat

pa;ent’shighestpainlevelduringscreeningvisit.

•  J0900:DidtheRNscreenthepa8entforpain?D.Usingastandardizedtool?–  Entercodefortypeofstandardizedpaintoolused.4.Staffobserva;onalscales:•  Cri;calCarePainObserva;onTool(CPOT)

•  ChecklistofNonverbalPainIndicators(CNPI)•  PainAssessmentChecklistforSeniorswithLimitedAbilitytoCommunicate(PACSLAC)

•  PainAssessmentinAdvancedDemen;a(PAIN-AD).

Sec8onJ:Pain

•  J0905:Ispainanac8veproblem?– NewinHISversion2.00– Plannedforfuturemeasurerefinementofexis;ngqualitymeasures

– Addedtobegeralignwithclinicalprac;ce•  Doesscreeningshowthatpainneedsinterven;on?•  Providersgaveinputinthepast2yearsreques;ngthisitemthatappliesscreeningresultstopa;entcare.

Sec8onJ:Pain

•  J0905:Ispainanac8veproblem?– Documenta;onthatthepa;entistakingpainmedica;onissufficientevidenceofac;vepain

– TheRNmaydeterminepainisac;ve:•  Basedonpa;ent-specificassessmentfindings

•  Evenifnotpresentatthe;meofassessment

Sec8onJ:Pain



4. A comprehensive pain assessment was completed within 1 day of the initial nursing assessment during which the patient screened positive for pain and included at least five of the following characteristics: location, severity, character, duration, frequency, what relieves or worsens the pain, and the effect on function or quality of life (if applicable).

•  J0910:ComprehensivePainAssessment–  Ifpainscreenisposi;ve,didtheclinicianperformacomprehensivepainassessment?

– Selectallthatapplyfromtheop;onslisted.•  Markeachoneforwhichthecliniciandocumentedana$empttogathertheinforma;on–  Atleast5ofthe7paincharacteris8cslisted

•  Reportcanbefromthepa8entorcaregiver

Sec8onJ:Pain



5. The patient was screened for shortness of breath within 2 days of the admission date.

6. The patient declined treatment for shortness of breath or treatment for shortness of breath was initiated prior to the initial nursing assessment within 1 day of the initial nursing assessment during which the patient screened positive for shortness of breath (if applicable).

•  Shortnessofbreath,ordyspnea:– Prevalentandundertreatedindyingpa;ents– Limitfunc;onalabilityandcausedistress

– Screeningcapturespresence&severity,facilitatestreatment:•  Pharmacologicornon-pharmacologic•  Varieswith:

–  Severity–  E;ology–  Pa;ent/caregiverpreferences

Sec8onJ:RespiratoryStatus

•  Keydescriptors:Shortnessofbreath,SOB,dyspnea,heavybreathing,tripodposi;oning,pursedlips,puffing,pan;ng,pausetocatchbreath,unabletospeakwhileexer;ng,etc.

•  Evidenceforextrac;ngcorrectresponsestoJ2030shouldconsideranydocumented:–  Historicalreportofthepa;ent’sdyspnea,evenifnotpresentduringtheassessmentvisit

–  Pa;entreportofdistress/troublebreathing–  Clinicalsignsofdyspneaduringscreeningvisit–  Dyspnea/SOB/shortnessofbreathlimi;ngac;vity


•  J2030A:“1.Yes”=documenta;onmustshow:– Evalua;onforpresenceorabsenceofdyspnea,inanywayclinicallyappropriateforthepa;ent.

–  Ifthescreeningforshortnessofbreathfounddyspnea(J2030C=“1.Yes”),anddocumenta;onspecifiesitsseverity,suchasitseffectonthepa;ent’squalityoflife,enter“1.Yes”atJ2030A.

–  Ifscreeningfounddyspnea/shortnessofbreath,butthedocumenta;onlacksitsseverity,enter“0.No”,andskiptoN0500.


•  J2040B:Dyspneatreatmentini;a;on:– Dateoffirstorderreceivedtobeginorcon;nuescheduledorPRNtreatmentfordyspnea,unlesspa;ent/caregiverinstructedtobegintreatmentatalaterdate.•  Wrigen,ordocumentedverbalorder•  StandingorderOKonlyifperformed•  OKifmedica;onorderedtoalsotreatothersymptoms

OR– Datethatthefirstnon-medica;oninterven;ontotreatdyspneawasperformed•  Suchasfans,posi;oning,pa;enteduca;on,etc.


•  J2040C:Treatmenttype(s)forSOBini8ated– Markalltreatmentstherecordshowswereini8atedonthedatespecifiedinJ2040Btotreatdyspnea.

– OnlyincludetreatmentswithintendedpurposetotreatSOB,evenifalsoimplementedtotreatothersymptoms.


•  J2040C:Treatmenttype(s)forSOBini8ated1.  Opioids

•  Ifthepa;entreceivedopioidsdocumentedastreatmentforshortnessofbreath,evenwhenalsoprescribedforotherreason(s),suchaspaincontrol.

•  Requiresorderreceivedbyhospice


•  J2040C:Treatmenttype(s)forSOBini8ated

2.OtherMedica;ons–  Clinicalrecordmustspecifypurpose(s)ofallmeds.

–  Commonmedstotreatdyspneaincludebronchodilators,inhaledcor;costeroids,oralsteroids,diure;cs,benzodiazepines.

•  Some;mesprescribedforothersymptomsaswell

•  Recordmuststatethataninten;onofthemedica;onistotreatSOB


•  J2040C:Treatmenttype(s)forSOBini8ated3.Oxygen

•  Ifoxygenwasini;atedonthedatespecifiedinJ2040B4.Non-medica;onimplemented,atleastinpart,totreatdyspnea•  Forexample,fans,posi;oning,relaxa;ontechniques,andeduca;onaboutenergyconserva;on


SECTIONN:MEDICATIONS

70



7. There is documentation that a bowel regimen was initiated or continued, or why a bowel regimen was not initiated within 1 day of a scheduled opioid being initiated or continued (if applicable).

Sec8onN:Medica8ons

•  Code“1.Yes”foranopioid:– AtN0500Aifanorderexistsforascheduledopioid;– AtN0510AifanorderexistsforaPRNopioid.

•  Entertheverbal(whenpermiged)orwrigenorderdateatN0500BandN0510B.– Notthefirst-dosedate.

•  Code“0.No”ifnosuchorderisfound.–  Followtheskippagern.

•  SkipN0520ifthepa8entisnotreceivingopioidtherapy.

Sec8onN:Medica8ons

•  Bowelregimenoritsclinicalcontraindica;on…-Canappearasanyreferencetoavoidingcons;pa;on-Foundinvariouspartsofpa;entrecord-MayrequirethoroughchartreviewtodetermineaccurateresponsesforN0520-Consultwithclinicianifunsureofcorrectresponse

•  Bowelregimenelementexamples,whichifmen;onedaspartofbowelprogram,eitherscheduledorPRN,qualifytocode“2.Yes”atN0520A:– Laxa;vesorstoolso2eners– Highfibersupplements– Enemas– Suppositories– Dietary&hydra;oninterven;on– Exercise

Sec8onN:Medica8ons

•  Bowelregimencontraindica;onexamplesqualifytocode“1.Nobutthereisdocumenta;onofwhybowelregimenwasnotini;atedorcon;nued”atN0520A:–  Bowelobstruc;on/ileus– Diarrhea– Nobowelfunc;on–  Colostomy/ileostomy– Nausea/vomi;ng–  Recentabdominalsurgery– NPO/takingnothingbymouth–  Pa;entofferedbowelregimen,butrefusedtreatment

Sec8onN:Medica8ons

SECTIONO:SERVICEUTILIZATION

HospiceVisitsWhenDeathisImminent

Sec8onO:ServiceU8liza8on

•  CMS:– “Captureswhethertheneedsofahospicepa2entandfamilywereaddressedbythehospicestaffduringthelastdaysoflife,whenpa;entsandcaregiverstypicallyexperiencehighersymptomandcaregivingburdensandthereforeandincreasedneedforcare.”–  ConferenceonHospice:HIS-BasedQualityMeasures,January2017

•  CompleteSec;onOonlyifpa;entwasdischargedduetodeath.– A2115=01,Expired.

•  Includestwomeasuresofhospicevisitswhendeathisimminent.– Measure1addressescasemanagementandclinicalcare.

– Measure2givesproviderstheflexibilitytoprovideindividualizedcarethatisinlinewiththepa;ent,family,andcaregiver’spreferencesandgoalsforcareandcontribu;ngtotheoverallwell-beingoftheindividualandothersimportantintheirlife.


•  Ifpa;entwasnotreceivinghospiceservicesonanydayduringthe;meframeiden;fied,enterazeroontherowforeachdisciplineforthatday.


•  Measure1includedinHospiceComparecalcula;onofHospiceVisitsWhenDeathisImminentif:– Pa;entdischargeddead– Pa;entreceivedonlyrou;nehomecarehospiceservicesduringthefinal3daysoflife


•  Final3daysoflife:AnyCHC,GIP,orRespite?

–  Ifhospicecare<3daysbeforedeath,baseresponseonhospice-enrolleddays.

–  Ifyes,skiptoZ0400.–  Ifno,gotoO5010.


•  Enterthenumber(0–9)ofvisitsfromeachdisciplineprovidedoneachofthefinalthreedays.–  Dayofdeath(A0270)andtwodaysprior

–  In-personvisitstopa;ent&tofamilywhilepa;entlives

–  Providedbyahospice-affiliatedperson,paidorunpaid


•  Measure2includedinHospiceComparecalcula;onofHospiceVisitsWhenDeathisImminentif:– Pa;entisdischargeddead– Pa;entreceivedonlyrou;nehomecarehospiceservicesduringthefinal7daysoflife

– LOSwas>1day


•  Final7daysoflife:AnyCHC,GIP,orRespite?

–  Ifhospicecare<7daysbeforedeath,baseresponseonhospice-enrolleddays.

–  Ifyes,skiptoZ0400.–  Ifno,gotoO5030.


•  Enterthenumber(0–9)ofvisitsfromeachdisciplineprovidedoneachfinalday#4-7.–  Dayofdeath(A0270)isday1–  In-personvisitstopa;ent&tofamilywhilepa;entlives

–  Providedbyahospice-affiliatedperson,paidorunpaid


HospiceQualityUpdates•  CMSusesHQRPdatato:–  Informfurtherhospicepaymentreform–  Iden;fywhetherbeneficiariesandtheirfamiliesreceivehospicecareasintended

–  Iden;fyhospiceprovidersnotusingthehospicebenefitcorrectly•  Forexample,asalong-termcaresolu;onforseniorsineligibleforhomehealth

References•  FY2017HospiceProposed&FinalRules•  FY2015&2016HospiceFinalRules•  R3378CP•  hgps://www.cms.gov/Medicare/Quality-Ini;a;ves-Pa;ent-Assessment-Instruments/Hospice-Quality-Repor;ng/Extensions-and-Exemp;on-Requests.html

•  NAHC.org•  MBPMChapter9•  HospiceItemSetCMSWebpage•  HISManualbyCMS•  HISFactSheet•  HospiceQualityRepor;ngWebPage

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Extensions-and-Exemption-Requests.html

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html

https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/hospice-quality-reporting/hospice-item-set-his.html

https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/hospice-quality-reporting/downloads/his-fact-sheet.pdf

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/

http://www.nahc.org/

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c09.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2015-Transmittals-Items/R3378CP.html

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Hospice-Regulations-and-Notices-Items/CMS-1652-F.html

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Downloads/FY-2016-Final-Hospice-wage-index-.zip

https://www.federalregister.gov/documents/2015/04/30/2015-10169/medicare-program-fy-2015-hospice-wage-index-and-payment-rate-update-hospice-quality-reporting

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