5 Stages of Hospice Denial. Objectives. NHPCO IDC New Orleans November Kathy Egan City, MA, BS, RN 1. What Are We Learning From Denials?

Transcription

1 What Are We Learning From Denials? Kathy Egan City, MA, BS, RN President Sagacity Services Inc. Objectives Upon completion of this program participants will be able to: 1. Identify current OIG and CMS areas of scrutiny. 2. Discuss six reasons for hospice audit denials and patterns of denials. 3. Identify three ways hospice programs can improve interdisciplinary documentation to minimize audit failures. 5 Stages of Hospice Denial 1. Deny your practices would be seen as deficient Our clinicians always follow best practices. We know how to provide/document best EOL care. 2. Deny your documentation would not support eligibility We only care for eligible patients. Our documentation is good enough. 3. Deny that good hospices get audited Only bad hospices will be audited. 4. Deny there is room for improvement 5. Deny you can proactively manage your risk Kathy Egan City, MA, BS, RN 1

2 What Have You Heard About Denials? OIG Report Vulnerabilities in Hospice Care July 2018 OIG Work Plan Duplicate drug claims (Medicare Part D) Overlapping hospice claims (Medicare Part A & B) Trends in Hospice deficiencies/complaints Frequency of nurse on site visits to assess quality of care Hospice s compliance with Medicare requirements Hospices Vulnerabilities/Recommendations Kathy Egan City, MA, BS, RN 2

3 Right care, right time, right place Fraud and abuse of Medicare reimbursement Claims data Integrated data bases Not eligible for hospice Not terminally ill Appropriate use of higher levels of care Length of stay, discharges, place of care CMS Targeted Probe & Educate The goal: to help you quickly improve. MACs work with you, in person, to identify errors and help you correct them. Many common errors are simple such as a missing physician's signature and are easily corrected. TPE is intended to increase accuracy in very specific areas. MACs use data analysis to identify: providers and suppliers who have high claim error rates or unusual billing practices, and items and services that have high national error rates and are a financial risk to Medicare. Targeted Probe & Educate Kathy Egan City, MA, BS, RN 3

4 Types of Audit Denials Technical Examples No date on EOB No Physician signature on EOB Attestation in wrong place on Certification of Terminal Illness Clinical Examples Care plan not matching visit activities Documentation does not meet medical eligibilty Summary from ZPIC 2014 Post payment Audit Total Reviewed 97 Total Approved 55 Approximately 57% of total claims reviewed Total Denied 42 Approximately 43% of total claims reviewed Denials 14 LOC GIP Denial 4 Technical Denial 24 Terminal Diagnosis Denial Kathy Egan City, MA, BS, RN 4

5 4 Technical Denials No F2F or Physician Narrative Certificate of Terminal Illness not dated No documentation to support physician services doc stated GIP for pain but in care plan goal stated as "to die at HH, where her husband died with same people who cared for him". 14 GIP Denials No skill or uncontrolled symptom noted, documented (10) COPD, no documentation of related disease progression/symptoms, no oxygen saturation levels, edema only once Admitted SOB which was quickly controlled, no ongoing Symptoms easily managed with usual meds given, no skilled care documented GIP for pain. No indications of pain out of control, consistently reported to have no pain, pain meds 2 x. 24 Terminal Diagnosis Denials Documentation not support terminal diagnosis, no documentation of dx related symptoms Did not meet criteria for terminal dx, Dementia but documented consistent ability to talk No documentation to support further disease progression cardiac, no report of symptoms related to admitting dx Not documenting to terminal dx or comorbidities, debility but no nutrition in care plan for wt loss Kathy Egan City, MA, BS, RN 5

6 24 Terminal Diagnosis Denials COPD, no documentation of related disease progression/symptoms, no oxygen saturation levels Dementia and able to speak No measurements (MAC, WTS), dementia with no indication of difficulty of speech, notes describe verbal interactions, noted at risk for infection but no documentation of same No documentation to symptoms of admitting dx, no MACs or Wts 24 Terminal Diagnosis Denials No documentation to symptoms of diagnosis, no oxygen sat measures Admitted for weight loss but not data to support, no wts during review period or over time, no symptoms reported, albumin on admit 3.8 Dementia and documented pt talks, no symptoms related to diagnosis, only one time documentation of edema Dementia, documented notes that she had conversations, ER note "unchanged chronic dementia" 24 Terminal Diagnosis Denials Debility only one wt without ongoing monitoring or comparisons to show wt loss, no other symptoms, stable vitals Dementia and CHF no indication of verbal impairment, no secondary conditions noted, no cardiac assessment or symptoms noted Dysphasia and on regular diet able Secondary to take meds orally, verbally clear, no O2 needed with secondary of COPD, no nutritional problems documented Primary Comorbid Kathy Egan City, MA, BS, RN 6

7 24 Terminal Diagnosis Denials Admit failure to thrive requires BMI less than 22 and none documented on admit or after, one wt 112 and no further wts, no height to calculate BMI, no MACs COPD with no documentation of COPD symptoms, cyanosis, chest tightness, chronic cough, secretions, no O2 saturation measures Admit for dementia without comorbid or secondary dx, no symptoms documented related, and not meet FAST 7 24 Terminal Diagnosis Denials Debility with secondary Alzheimer's, Breast Cancer, HTN no report of symptoms of HTN or blood pressures noted, no evidence of FAST Stage 7, lost wt prior to 150 without any further wts to compare or show wt loss, impaired nutrition not on care plan Admit Alzheimer's no FAST score and patient verbal, no comorbid or secondary dx 24 Terminal Diagnosis Denials Alzheimer's with FTT, HTN no wtsor MACs to show decline or wt loss, 1st narrative says 30 pound loss but NH records contradict and say pt wt stable, pt verbal and taking walks outside every day, no documentation of any S & S of cardiac issues Cachexia contradictory information re: wt loss prior to admit, admit note said lost 14 pounds in few months prior to admit but records showed only 1 pound, no wts or MACs documented, verbal and ambulatory Kathy Egan City, MA, BS, RN 7

8 24 Terminal Diagnosis Denials AFTT, Alzheimers, Diabetes, CAD, UTI no serial wts on chart to determine severity of AFTT, no MACs, nutrition/hydration not on care plan, per F2F had HTN but no blood pressures documented and no evidence of any complications from HTN, no blood sugars noted, no cardiac symptoms, no symptoms of UTI, POC does not address primary or secondary diagnosis on care plan General Reasons Noted for Denials Could not determine due to poor documentation denied No measures, data, descriptors Statements of judgement without proof (wt loss) Substandard care Care plan not matching dx or care provided Care could have been provided in another setting (not reflective of specialty of EOL) General Reasons Noted for Denial Ignoring primary, secondary, co morbid, general decline When LCD, secondary/co morbid not strong denied due to lack of documentation to general decline indicators Any indicator to say other information is inaccurate Pt. with Alzheimer s Took pt. for walk in garden If they could walk, not at FAST 7c. Kathy Egan City, MA, BS, RN 8

9 What Have We Learned? # 1 Documentation is more critical than ever! New standard of information needed to support/advocate for ongoing care Care and documentation needs to reflect best practices for EOL (palliative end stage disease and preparation for death/life closure) Why hospice? Why now? Clinicians document like they did in other settings, during acute/chronic care Clinicians are not reflecting the specialty of hospice care Bringing This Back Mom, you hospice people are just not normal! Kathy Egan City, MA, BS, RN 9

10 The Real Story Pt. with Alzheimer s Documentation: Took pt. for walk in garden Reason for denial: If they could walk, not at FAST 7c. What Have We Learned? # 2 General Decline Matters! What does it look like? Weight Nutrition Weakness Fatigue/Sleep Ambulation/Movement/What can do not do Self care/need for Assistance Interactions/Speech/Language/ Burden Patient/Caregiver/QOL Closure What Have We Learned? # 3 Describe what you see. Appears weaker. Decreased appetite. No. Assumptions, conclusions, judgments, summarizing without descriptors. Kathy Egan City, MA, BS, RN 10

11 What Have We Learned? # 4 Why Hospice? EOL Care? P/F experiences of disease/caregiving/dying process Educating on what to expect as pt progresses P/F discussions and decision making What care do they want/not want Fluids/foods/antibiotics Where they die/how they die/who they want there Advanced directives/poas Life/relationship closure, legacies, forgiveness, love Burden illness/caregiving/quality of end of life Loss and grief during and after death What Have We Learned? # 5 Use Quantitative Data, Descriptors, Pre/post Pain ratings other symptom ratings 1 10 Vital signs chart over time Weights, BMI, MACs I & O changes over time/dates/%/type foods, need for thickening, fluids Responses/reactions if unable to communicate Descriptors can walk 10 ft from bed to bathroom with SOB and 3 minute recovery time needed, on admission could walk 30 feet to kitchen with slight SOB and less than one minute recovery time Documentation Examples Think like an auditor! Rate Each Example = poor, not patient/family specific, lacks details 2 = some good content and needs improvement 3 = great description that supports eligibility and describes the p/f experiences Kathy Egan City, MA, BS, RN 11

12 Documentation Examples CTI Patient has a history of end stage COPD. Since his last certification, having increasing SOB with exertion. He also gets SOB with conversation. He does use his nebulizers a minimum of 4 times a day and uses continuous oxygen. He is significantly visually impaired secondary to glaucoma and when he is able to get up and move short distances and he has to touch the furniture for balance. His palliative performance scale is 50%. His Reisberg FAST stage is 6a. Confirmed the face to face encounter with pt, continues to require hospice services at this time. Rate 1, 2, or 3? Why? Documentation Examples CTI This is an 84 year old male with end stage lung disease secondary to COPD caused by chemical burns to his lungs. The patient's overall condition continues to slowly decline and he's had an increasing amount of time that he spends in bed up to 20 hours a day versus at his last certification. He also has begun to use Ativan on a more regular basis and also morphine tablets periodically for increasing anxiety and air hunger. He continues to use his nebulizer treatments 4 5 times a day. He's having increasing help with his ADLs as he is unable to ambulate just a few feet with a walker before touching the wall, before he has to sit down to catch his breath. His PPS is 40% and his mid arm circumference is between 26 to 27. He has become unsteady to try to stand on a scale, therefore the mid arm circumference will be used going forward. He continues to have increasing shortness of breath, when trying to speak only uses 3 5 words before he has to stop to catch his breath. He continues to use oxygen 2 3 L on a 24 hour basis. Based on his current clinical condition and knowing the normal course of his disease he has less than 6 months to live. Rate 1, 2, or 3? Why? Documentation Examples Rate 1 3 Certification of Terminal Illness 94 y.o. female with colon cancer. She has slow decline in cognition and functional status, poor appetite, SOB on exertion, needs assistance with ADLs. Rate 1, 2, or 3? Why? Kathy Egan City, MA, BS, RN 12

13 Documentation Examples Rate 1 3 Certification of Terminal Illness 98 y.o. with end stage heart with functional decline. Pt hospitalized with recent pneumonia. Decreased intake and increased weakness. PPS 40, more assist with ADLs. Expected to live less than 6 months. Rate 1, 2, or 3? Why? Documentation Examples Rate 1 3 Certification of Terminal Illness 93 y.o. female admitted with Alzheimer s disease and co morbidities COPD and AFIB. Pt had recent pelvic fx and decline. Pt on home O2 ATC and had recent UTI. Pt has hired CNA to assist with/adls and has had decline in functional capacity. Has hx of DVT w/ivc filter in place. Rate 1, 2, or 3? Why? Problems with GIP Documentation Causing Possible Denials No documentation of what did not work to support need for higher LOC Long stays Inappropriate use (no need for higher LOC) No discharge planning from admission GIP Daily documentation did not support ongoing need for higher level of care Used for caregiver breakdown when symptoms managed with hospice POC. Kathy Egan City, MA, BS, RN 13

14 GIP Documentation Examples Rate 1, 2, or 3? Why? Patient in general inpatient unit for end of life care for Alzheimer s and COPD. This is day 3 of patient in GIP unit. Patient is comfortable. No chest pain, no dyspnea, no fever, good appetite. No signs and symptoms of disease present. Family wants them to remain GIP. GIP Documentation Examples Rate 1, 2, or 3? Why? Hospitalist referred to hospice for GIP care so admitted for respiratory distress. Pt O2 sat 92% on 2 liters O2. Will continue to monitor. Patient s daughter feels patient is getting better care at hospice unit instead of nursing home. Daughter assured she did not have to worry about discharge as long as her Mom continued to decline. GIP Documentation Example Rate 1, 2, or 3? Why? Mr. R has continued to grow more restless, thrashing, and calling out continuously. His pain is rated at a 9/10 within one hour of pain medication. His respirations are 36/min and his is gasping with shallow breathing. He states he is feeling chest tightness and is diaphoretic. His records at the nursing home indicate he has been getting his medications as ordered, with several PRN doses given but no relief and increased restlessness. Kathy Egan City, MA, BS, RN 14

15 GIP Documentation Group Exercise Mrs. L GIP direct admit to hospice in hospital from ER. (handout) IDT group of 3 5 people Read admission note Rate 1 3 and why Does this patient meet GIP criteria? What is good in the note? How could it be improved? Documenting Eligibility with Slow Decline All changes that show progression towards death Data over time, graphs showing small changes (VS) Burden of illness Burden of caregiving Patient/family quotes Comparisons over time from admission, few months, weeks EOL preparation, education, decisions, family agreement, differences, closure of relationships, preparation for life after death for caregiver, current loss/grief Documenting Eligibility with Slow Decline What is being managed with Hospice POC? What can pt. do as a result? Pt able to visit with grandchildren after addressing children s fear of seeing grandma ill. Adding nebuelized morphine decreased severity of SOB How is caregiving experience different? CG can now sleep for four hours at night CG stress relieved now that patient is not anxious all the time Kathy Egan City, MA, BS, RN 15

16 Proactive Approach Documentation training Teach language of eligibility guidelines LCD Disease Specific Secondary/Co morbid General decline Burden of illness and caregiving End of life preparation, decisions, education, closure Nothing is normal describe p/f experiences, not disciplines perspectives or conclusions Develop, communicate standards & hold accountable Practice pre bill audits all disciplines It Takes the IDT Everyone s eyes, ears, minds, and hearts are needed to tell the patient s and family s story. What is next for you? Kathy Egan City, MA, BS, RN 16

17 Thank you for attending and participating. Kathy Egan City Kathy Egan City, MA, BS, RN 17