Category / hospice

by Julianne Haydel

Survey Readiness


Because you are bright and shiny home health employees with enthusiasm to spare, it goes without saying that you are ready for survey all day, every day.  But just in case you fell behind, here’s a few tips on being ready when those cheerful surveyors come calling.

  1. Make sure your annual advisory meeting is held timely. There is nothing you can do when it’s time survey and your PAC meeting is six months late.
  2. Get your CLIA waiver updated if it within three months of expiration. If it is current, put the expiration date on your calendar with a reminder three months from the date.
  3. Plans of care for all patients should be current and updated and reflect the actual needs of your patients – not just what the computer thinks.
  4. Medication lists should be current. Obviously, you and your colleagues are checking meds on every visit but just in case it never hurts for the DON or QA nurse to spend an afternoon doing supervisory visits and checking medications.  If meds are okay, relax.  If you find errors, implement an agency wide plan to have the meds of all patients reconciled within a week.   After the initial medication campaign, follow up.
  5. Do the QA thing. At a recent Home Care of Louisiana meeting, the state agency responsible for whipping home health agencies in line gave a presentation about what they were finding on surveys.  Although tags were not frequently issued for Quality Assurance plans, almost every other tag could have been prevented by reading notes as they came into the agency against the plan of care.  Consider the difference between seeing a missed visit cross your desk compared to a chart with numerous missed visits.  You must read your charts if you want to know what is in them.
  6. Most importantly, call the physician.   Almost every survey with deficiencies includes at least one tag resulting from a change in the patient’s condition that was not communicated to the physician.  I have spoken with nurses who are unwilling to call physicians because they have been chastised in the past for ‘bothering’ physicians.  Communication is not the same as harassment.  If you reserve phone calls for emergent situations and fax or secured email for updates, everyone can be on the same page without overwhelming the physician.
  7. Consider a coding company. Although the primary purpose of The Coders is to ensure correct ICD-10 codes and OASIS responses, a registered nurse reviews the clinical records to determine what those codes and responses should be.  So, while we don’t specifically look for QA indicators, we notice the more serious omissions and make note of them for the agency.  Another side effect of a Coders contract is that our coders notice when assessments are incomplete or late.  Getting caught up can make an enormous difference for agencies with a backlog.

Notice what is not on the list.  There is no minimum standard for face-to-face encounters.  Surveyors may comment about excessive lengths of stay but rarely is a tag issued for redundant teaching or failure to provide reasonable and necessary services.  The state agencies do not pay your bills.  The hoops you must jump through for payment are in addition to the minimum standards for your state.

Some of you may know some people at an agency that is utterly unprepared for state survey.  If this is a long-standing problem, there is probably not much they can do in a short period.  On the upside, in the absence of patient harm and extreme irresponsibility on the part of the agency, the state will allow for an opportunity to clean up any messes in the form of an action plan.  Or they can pay a consultant to come in and have them write an action plan.  We prefer the latter but you won’t receive an invoice from the state surveyors.  Just saying.

Here’s what you don’t do.  Don’t call a consultant in the weeks before survey is due and expect them to make the changes required for a flawless survey.

by Julianne Haydel

Hospice Updates


I had the privilege of attending an educational session with Jamie Boudreaux with the Louisiana-Mississippi Hospice and Palliative Care Organization this week.  I highly recommend taking advantage of any opportunity that comes your way to attend any LMHPCO events.

During Jamie’s talk, he referenced numerous changes that were proposed for 2016 in Hospice.  After hearing so much about this exciting document, I couldn’t wait to read it.  You should read it, too and send your comments should you have any.

The highlights – or at least those points that we find interesting as coders and clinicians, are found below.  This is not an all inclusive account of the regulations and I strongly encourage you to read them for yourself.

Good News First

You are getting a raise.  It is projected that hospice payments will rise almost 2 percent.  But that’s not all.  Remember that talk about a U Shaped curve?  It isn’t exactly a ‘U’ but you now have a change in how you will be paid.

There are two factors that will increase your payment.  In the current system, due to the increased expenses in admitting a patient and establishing a care plan, a patient will be on service for approximately 21 days until the hospice breaks even.  As time goes by, the payment stays the same and hospice providers are collecting the same payment for long stretches of time when the patient has minimal needs.  This is traditionally when the hospice made money.  As death approaches, the costs usually increase again.

As such, two new provisions have been added.

During the first 60 days of hospice, payment will be at a rate (adjusted for your area) of $187.63

After day 60, per diem payment will fall to $145.21

Important:  An episode of hospice care is considered to be all episodes that are separated by no more than 60 days.  You cannot discharge and readmit a patient prior to 60 days and expect the higher rate.  Hospice providers who pick up patients from other hospices as in a transfer will be similarly unable to claim the higher rate.

But there’s more!

During the last seven days of care, hospices will be able to bill a Severity Intensity Add-on or SIA.  In addition to the hospice per diem rate, for Registered Nurse and Social Work visits during those last 7 days, an additional rate equivalent to the continuous care rate may be billed up to 4 hours.  That means that in addition to the daily rate, a hospice can receive almost $160.00 more.

There are conditions:

  • The additional rate is only available for Registered Nurse and Social Work visits.
  • The SIO is not available for patients in nursing homes.
  • The beneficiary is discharged due to death
  • The care occurs in the last seven days of life.

The reported reason for this change is to encourage providers to provide additional care when it is needed the most.  A full 20 percent of patients did not receive a visit on the day of death.

So that’s the good news.  Hospice providers will be receiving additional cash when expenses are the highest. Back to the beginning of the document where the news isn’t quite so exciting.

Background

Normally, we would not bore you with the background of any proposed regulations but in this case, the continual references to the 1983 hospice benefit rules probably indicate that some of the recent changes and proposed changes are an indication that hospices haven’t gotten it right, yet.

The tone of this document is well worth your time to read so you can heed the inherent warnings.

Attending Physician

The rule is one per patient.  The fact that over one third of patients have multiple physicians submitting claims indicating they are the attending physician results in Medicare paying the physicians when in fact, the hospice is the correct payor source.  Don’t get caught doing this.

A signed document is required when a patient chooses to change physicians.

The Joy of Scrutiny

Medicare is not mandating surveys to be conducted at least every three years as opposed to the every 6 year rule now.  Select hospices who have long lengths of stay can expect to find themselves on a private list where all claims for services past 180 days of admission are routinely reviewed.  Do not get on this naughty list.

Remember, the data exists for Medicare to look at the average length of stay in addition to the percentage of patients on service greater than 180 days.  That’s a really good number to keep handy, by the way.  You can have a lot of patients on service for a year or more offset by some short lived admissions so your average length of stay may be okay but you might still have far too many patients on service longer than would be considered reasonable and necessary.

Utilization

Obviously this is not a regulation but it is an indication of the overall ‘tone’ being set by document.

The number of Medicare beneficiaries receiving hospice services has grown from 513,000 in FY 2000 to over 1.3 million in FY 2013. Similarly, Medicare hospice expenditures have risen from $2.8 billion in FY 2000 to an estimated $15.3 billion in FY 2013

…..this increased spending is partly due to an increased average lifetime length of stay for beneficiaries, from 54 days in 2000 to 98.5 days in FY 2013, an increase of 82 percent.

Cost Savings?

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This chart shows how many dollars per day were spent on patients in the 180 days prior to hospice admission and how many days spent in the care of a hospice.  As it turns out, both of these numbers are critical for determining potential savings to the Medicare trusts.

On the vertical column, you can see the grand total of days a patient spent in hospice.  The horizontal line shows what the average daily cost of the patient was prior to admission.

This is Medicare’s work.  We do not agree with this method of cost analysis.  However, any differences of opinions regarding the formulas used do not account for $158,000 per patient with a diagnosis of Alzheimer’s Dementia which is about what it works out to be over 120 days.

The Medicare Hospice Benefit is not reducing healthcare costs in terminally ill patients. This is a problem folks.

Live Discharges

The proposed regulations are very clear that nobody expects the live discharge rate to be zero.  Patients have the right at any time to revoke their election at any time.  Some patients start to get better especially after they have been taken off 25 medications designed to prolong their life.  They move and sometimes they just hate your hospice and revoke.

Based on the data within the proposed regulations, there can be no doubt that an above average live discharge rate strongly correlates with other undesirable characteristics of hospice provider.  The patients discharged alive are from providers that also have more long term, low maintenance patients.  Additionally, patients in these hospices cost Medicare more in terms of money spent for nonhospice care.

The proposed regulations reiterated the limited number of reasons that a provider can discharge a patient.  They are as follows:

    • death
    • revocation
    • transfer to another hospice
    • moving out of the hospice’s service area
    • discharge for cause,
    • patient no longer being considered terminally ill (that is, no longer qualifying for hospice services

When discharging for cause, ensure that all reasons are documented especially if a patient has been on service for a while.  When more than one neighborhood becomes unsafe on day 181 of a hospice episode of care, it makes for a pattern.

There are very few legitimate causes for discharge in hospice. and the regulations are clear that discharging patients due to cost is not approved by Medicare.

Comments from Providers

The data in the proposed regulations is stunning but the real damage comes from various and sundry anecdotes.  It is important for providers to understand what those who right the rules are thinking and how they are thinking.   Copied directly from the regs:

We have received anecdotal reports from non-hospice providers who have rendered care and services to hospice beneficiaries in which the non-hospice provider states that the care given was related to the terminal prognosis of the individual. These reports go on to say that they have contacted hospices to coordinate the care of the hospice beneficiary only to be told by those hospices that they disagreed with the non-hospice providers’ clinical judgment that the care was related to the terminal prognosis.

We have been told that hospices are refusing to reimburse the non-hospice provider for care related to the terminal prognosis.

non-hospice providers also informed us that the hospices told them to code the claim with a different diagnosis or to code condition code 07 (treatment of Non-terminal Condition for Hospice) or the modifier “GW” (service not related to the hospice patient’s terminal condition) on their claims to ensure that the non-hospice provider would consequently get paid through Medicare.

We have also received anecdotal reports from hospice beneficiaries and their families that they have been told by the hospice to revoke their hospice election to receive high-cost services that should be covered by the hospice, such as palliative chemotherapy and radiation.

In addition to publishing these comments, staff memos to employees of specific large hospices were included stating that their providers should go after the long term patients.

Terminal Prognosis

This is the last time that you should ever consider the words ‘terminal’ and ‘diagnosis’ together.  People do not have terminal conditions in isolation.  They have terminal prognoses.

All of the research and numbers that Medicare has presented all go to support their belief that hospices are not living up to their provider agreement which includes care for the diagnoses that is most likely to cause death and any and all other diagnoses that affect the patient’s comfort, are a result of the terminal prognosis or contribute to the severity of the prognosis.

Consider a patient who needs bypass surgery but because of diabetes, long term use of steroids for arthritis and a longstanding history of noncompliance due to a psychiatric illness, she is not a surgical candidate.  There is no one diagnosis that is terminal.  All of them play a role in his terminal prognosis and all must be addressed by the hospice.

Coding

You are making progress!  In the 2015 regulations it was noted that 72 percent of hospice claims had only a single diagnosis.  This year, for the 2016 update, the percentage of claims with only diagnosis is down to 49 percent.

In addition, because there has been confusion and discussion about the nature of the ‘terminal prognosis’, providers have been omitting diagnoses that are significant to the patient’s overall condition.

Since the inception of hospice, adherence to the International Classification of Diseases (ICD) has been mandated.  This means that the primary diagnosis and all diagnoses that affect the patient’s ability to respond to or participate in the plan of care are to be included.

Therefore, 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. This is in keeping with the requirements of determining whether an individual is terminally ill. This would also include 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.

I have heard of denials because patients were admitted to psychiatric facilities that billed Medicare because the patient’s ‘terminal diagnosis’ was not psychiatric in nature.  I suspect this has happened numerous times because psychiatric conditions are mentioned more than once in this document.

We will monitor compliance with required coding practices and collaborate with all relevant CMS components to determine whether further policy changes are needed or if additional program integrity oversight actions need to be implemented.

Let the last sentence of the section on coding resonate loudly on your priority list.  We can and will code for you.  You can learn ICD-10 coding or you can outsource to another company.  Alternatively, we can help with appeals, Focused Medical Review, or ZPIC audits.  The choice is yours but if you’ve ever been through that kind of regulatory scrutiny before, you would not choose non-compliance.

There is more – so much more but try digesting this first and we’ll keep an eye on the final release and do our best to summarize it for you.

by Julianne Haydel

This Just (snuck) In!


Hospice Providers, take note

To be quite honest, I have never seen a ‘no code’ list in hospice.  If anything, I would expect to see a ‘full code’ list as any code status besides DNR would be the exception.

And yet, there is a new list of codes that hospices may not use when determining the primary reason for hospice care.   A list of codes at the end of this document will be automatically returned to providers when used as a principle code for hospice for claims billed after October 1.

This information comes from CMS change request 8877 which also contains very important information about the Notice of Election.

Home Health Providers:

An updated Local Coverage Determination has been published by Palmetto GBA for Alzheimer’s Dementia.  Among the insightful gems included in this guidance is the following passage begging the question of, ‘does someone have too much time on their hands?’

Behavioral disturbances often complicate the medical management of beneficiaries with Alzheimer’s disease. At baseline many individuals with Alzheimer’s disease manifest activity limitations in such domains as communication and self-care. The occurrence of behavioral disturbances, if not addressed in a comprehensive and systematic manner, may further compromise the activity limitations present at baseline – resulting in sub-optimal clinical outcomes.

Wow.  I’m glad we cleared that up.  Seriously, look how often the word, ‘baseline’ is used.  If you really want to get paid, consider using the FAST scale to stage Alzheimer’s on admission and recert.  There are also numerous documentation requirements.  Please review and document accordingly.

If you recall, numerous claims once denied for Face-to-Face documentation are now being denied for lack of both long and short term goals.  The reference to short and long term goals is listed as the Physical Therapy LCD.  I am quite certain that the Alzheimer’s documentation LCD will be used in the same way.

Both of these regulations will take place on October 1.  Be ready.

 

The Hospice No Code List

290.0 Senile Dementia Uncomplicated
290.10 Presenile Dementia Uncomplicated
290.11 Presenile Dementia With Delirium
290.12 Presenile Dementia With Delusional Features
290.12 Presenile Dementia With Delusional Features
290.13 Presenile Dementia With Depressive Features
290.20 Senile Dementia With Delusional Features
290.20 Senile Dementia With Delusional Features
290.21 Senile Dementia With Depressive Features
290.3 Senile Dementia With Delirium
290.3 Senile Dementia With Delirium
290.40 Vascular Dementia Uncomplicated
290.41 Vascular Dementia With Delirium
290.42 Vascular Dementia With Delusions
290.43 Vascular Dementia With Depressed Mood
290.8 Other Specified Senile Psychotic Conditions
290.9 Unspecified Senile Psychotic Condition
293.0 Delirium Due To Conditions Classified Elsewhere
293.1 Subacute Delirium
293.81 Psychotic Disorder With Delusions In
293.82 Psychotic Disorder With Hallucinations In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.83 Mood Disorder In Conditions Classified Elsewhere
293.89 Other Specified Transient Organic Mental Disorders Due To Conditions Classified Elsewhere
294.20 Dementia, Unspecified, Without Behavioral Disturbance
294.21 Dementia, Unspecified, With Behavioral Disturbance
294.8 Other Persistent Mental Disorders Due To Conditions Classified Elsewhere
294.8 Other Persistent Mental Disorders Due To Conditions Classified Elsewhere
310.0 Frontal Lobe Syndrome
310.1 Personality Change Due To Conditions Classified Elsewhere
310.2 Postconcussion Syndrome
310.89 Other Specified Nonpsychotic Mental Disorders Following Organic Brain Damage
310.9 Unspecified Nonpsychotic Mental Disorder Following Organic Brain Damage
by Julianne Haydel

THE Hospice Quiz


If you own or work at a hospice, there has never been a better time to make sure that you understand the rules and regulations just like Medicare intended.  The quiz below is a very basic quiz designed for you and your staff or co-workers to take to ensure that you are not denied payment or worse,  step on a regulatory landmine.

by Julianne Haydel

Hospice Medications – Who Pays for What?


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Hospice Providers, it’s time to take your head out of the sand!  Medicare keeps writing long memos about who pays for what medications and I still keep hearing that the hospice only pays for pain medications.  The information below was taken from the Medicare Memo issued last week.

  1. You don’t get to exclude all meds and care not directly related to the terminal condition. Supposedly this has always been the case.
  2. You cannot exclude medications that are used for the comfort and palliation of symptoms no matter what.  If a patient is admitted for end stage heart failure and has arthritis, you must pay for arthritis medications as well.
  3. Prior authorizations for Medicare Part D will be required and they must include the reason why the medication is not covered under the hospice benefit.
  4. Medications that are paid for after the patient elects the hospice benefit but before the pharmacy has been notified will fall into some sort of limbo land and the pharmacy will have to collect from the hospice – or the patient.  Any UFC fans out there?
  5. If a patient wants a specific drug that is not one your formulary and the patient refuses to try medications that are on your formulary, you can refuse to provide them.  Alternatively, you can provide them and bill the patient if you have a signed advanced beneficiary notice.
  6. Patients have the right to appeal your decision.

If you want to survive this maze, the first thing you need to do is to approve a formulary.  This is a list of drugs you may potentially be required to provide over and above the standing orders for pain meds.  Personally, I would start with one of those $4.00 drug lists from a chain drug store.  They all have one.

Hospice nurses must have frank discussions with patients and caregivers at the time of admission.  In truth, there is no way to determine if a medication is for palliative relief of symptoms until the patient is assessed.  In talking with patients and caregivers, the emphasis should be on symptoms.  Some individuals with diabetes are very uncomfortable when their blood sugar goes up beyond a certain point.  Other people can sport a blood sugar of 550 without symptoms.  Blood pressure is usually asymptomatic but strokes are not.  If a patient has suffered a prior neurological insult, the safest thing to do would be to find a cheap drug and treat it for less than 10.00 per month.

Nice hospice providers will alert their contracted pharmacy to a hospice admission as soon as it is known for sure that a patient will be admitted.  This will prevent those limbo drugs where everyone is fighting over who pays.  This process is recommended but not mandated (I think…) in the new CMS guidelines published last week.

People are funny about their medications.  If a patient refuses to try Prilosec and opts for Dexilant at 20 times the cost, work with the patient.  Ask for samples and assist the patient in getting the best price for the medication of choice.

Maybe the most disturbing aspect of the new guidance from CMS is the involvement of the patient and families.  Part D pharmacies are advised to bill family members for medications that were inappropriately filled.  Hospices with limited (if any) formularies will attempt to pass the cost off to the patient.  Although the patient has the right to appeal the logistics of a hospice patient or family member appealing to Medicare strike me as utterly incongruent with the fundamental purpose of hospice which is to allow a patient to die at home in peace.

I have not seen as yet the proposed consequences to a provider who simply tells the patient Medicare won’t cover something without explaining all of the details, alternatives, etc. I think good hospices will put a blank appeal form in the home folder for the patient.  Bad hospices will go out of their way to avoid telling patients and family members that an appeal is possible.

Meanwhile adopt a comprehensive formulary and start today advising the patient what you will pay for, the reason it will given (comfort) and what you will not be giving.  It may cost you a few patients but I guarantee those that don’t put these processes into place will lose more than a patient or two.

Good luck with all this, you hear?