June 16, 2011 Hospice Coalition Q & As Page 1 of 13

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1 To: Hospice Coalition Members From: Palmetto GBA Provider Outreach and Education Date: June 16, 2011 Location: Palmetto Room II, GPC Building Columbia, SC Time: 12:30 PM Number: Pass code: # Attachment A: Snapshot Report Attachment B: ICF Checklist Attachment C: Going Beyond Diagnosis Case Scenario Parkinson s Disease Attachment D: NCLOS Rate Table by State Second Half of 2010 Attachment E: Appeals Report Attachment F: ANSI 5010 Updates Attachment G: Palmetto GBA EDI Updates Attachment H: Five Year Hospice Cap Overpayment Report By State Attachment I: ICD-9 code updates for the January June Hospice NCLOS Rate Reports 1) If a patient is discharged or revokes from Hospice and then chooses to re-elect the hospice benefit, would the hospice have to do an initial certification (i.e. two physician signatures) or would only one physician signature be required as in a recertification? Would it be different if it were two different hospices? Certification of the terminal illness by the medical director of the hospice or the physician member of the hospice IDG, and the individual s attending physician if the individual has an attending physician, is needed only on the first 90-day period. If the patient should re-elect the benefit, he/she would be electing into the second 90-day or subsequent 60-day period. This regulation applies to either the same hospice or a different hospice as the election periods are posted and stored on the Common Working File (CWF). 2) Change Request (CR) 7337, which was implemented on 3/23/2011, discusses the circumstances under which an ambulance transfer on the date of hospice election will be covered by the Medicare ambulance benefit as follows: The hospice Interpretive Guidelines for 42 CFR (a), published via a Survey and Certification letter (S & C 09-19, Advance Copy-Hospice Program Interpretive Guidance Version 1.1), require that the initial assessment be conducted in the location where hospice services will be provided. The plan of care is developed from that initial assessment and from the comprehensive assessment. Ambulance transports to a patient s home which occur on the June 16, 2011 Hospice Coalition Q & As Page 1 of 13

2 effective date of the hospice election (i.e., the date of admission), would occur prior to the initial assessment and therefore prior to the plan of care s development. As such, these transports are not the responsibility of the hospice. Medicare will pay for ambulance transports of hospice patients to their home, which occurs on the effective date of hospice election, through the ambulance benefit rather than through the hospice benefit. In order to meet the requirement that the initial assessment be conducted in the location where hospice services will be provided, the initial assessment for patients being transferred from a hospital to an inpatient hospice facility also does not occur until the patient arrives at the hospice facility, which is the location where care will be provided. The plan of care is then developed from the initial and comprehensive assessment as stated above. The concern is that the statement above only mentions that an ambulance transport to the patient s home on the day of hospice election is covered by the ambulance benefit. The same circumstances apply to a patient being transferred to a hospice facility, so would that transport be covered by the ambulance benefit as well? Does the same rule apply to any location prior to admission? ADDITIONALLY - Comments from the Hospice Condition of Participation preamble, page of 2008 published in the Federal Register June 5, 2008 states: Comment: Many commenters asked us to define the phrase patient s home or patient s residence as a house, apartment, SNF/NF, ICF/MR, assisted living facility, adult home, shelter, foster home or any other place where a patient lives. Response: We are unable to develop a single definition of the terms home or residence at this time. We will consider these suggestions for future rulemaking. In sections like (c) (5) language by CMS states that it is the hospice s responsibility to provide services to residents of a SNF/NF or ICF/MR at the same level and to the same extent as those services would be provided to patients residing in their own private homes. Regardless of where a patient resides, a hospice is continually responsible for furnishing core services. This occurs throughout the new CoPs in other sections that speak to issues around the beneficiary s home and hospice s responsibilities. It appears CMS is inferring that beneficiaries should not be considered differently for hospice and related requirements due to place of residence. Furthermore CMS goes on to state in this section and other sections We believe that this new requirement will help to ensure consistent, high quality hospice care for all hospice patients, regardless of their place of residence. Our interpretation would be that the ambulance should be paid for by CMS in the situation where hospice is going to be immediately involved regardless of the beneficiary s residence. Is this correct? In this scenario, the patient has not yet elected the Hospice Medicare Benefit (HMB). Therefore, since the ambulance service occurred prior to the assessment for hospice, the ambulance services would be covered under the Medicare Part B ambulance benefit. Change Request (CR) 7337 and the Hospice Conditions of Participation (COPs) are June 16, 2011 Hospice Coalition Q & As Page 2 of 13

3 addressing issues once the beneficiary has elected the hospice benefit. Ambulance providers may contact their Part B Carrier or MAC for assistance. Reference: Medicare Coverage Manual, Pub , Chapter 10 Ambulance Services. The direct link is: Specific references to this issue may be found in Section and Section 20. 3) If a face-to-face visit is done by the hospice physician or nurse practitioner (NP), and it is clearly stated that the patient meets criteria for recertification in the visit note, can this be used as the verbal recertification if the recertification form is signed later than two days after the recertification date? With the introduction of the face-to-face encounter requirement, the hospice recertification has become a multifaceted process. The face-to-face encounter has been added as an additional component to the requirements that are already in place for a recertification. When one or more components of the recertification are missing, the certification is incomplete. The hospice should have a process in place which ensures that all elements of the recertification are complete, including a process for communicating a verbal or oral recertification. If the hospice cannot obtain written certification within 2 calendar days, it must obtain oral certification within 2 calendar days. If the oral certification was obtained, it should be noted as such in the documentation. As well, the complete written certification must be on file in the hospice patient s record prior to submission of a claim to the Medicare contractor. As a reminder, nurse practitioners cannot certify or re-certify a terminal diagnosis or prognosis of 6 months or less. Providers are encouraged to review the Medicare Benefit Policy Manual (CMS Pub , Chapter 9, Section 20.1) regarding updates to Timing and Content of Certifications. This section of the manual explains all the components and timeframes necessary to meet the requirements for a recertification. 4) Hospices have been educated that the criteria for general inpatient level of care do not include caregiver crisis or psycho-social issues; however, these are still part of the criteria for general inpatient level of care per the Medicare Benefit Policy Manual as shown below (emphasis added). Medicare Benefit Policy Manual Chapter 9 - Coverage of Hospice Services Under Hospital Insurance (Rev. 141, ) Medicare covers two levels of inpatient care: respite care for relief of the patient s caregivers, and general inpatient care, which is for pain control and symptom management. June 16, 2011 Hospice Coalition Q & As Page 3 of 13

4 General inpatient care may be required for procedures necessary for pain control or acute or chronic symptom management that cannot feasibly be provided in other settings. Skilled nursing care may be needed by a patient whose home support has broken down if this breakdown makes it no longer feasible to furnish needed care in the home setting. General inpatient care under the hospice benefit is not equivalent to a hospital level of care under the Medicare hospital benefit. For example, a brief period of general inpatient care may be needed in some cases when a patient elects the hospice benefit at the end of a covered hospital stay. If a patient in this circumstance continues to need pain control or symptom management, which cannot be feasibly provided in other settings while the patient prepares to receive hospice home care, general inpatient care is appropriate. Other examples of appropriate general inpatient care include a patient in need of medication adjustment, observation, or other stabilizing treatment, such as psycho-social monitoring, or a patient whose family is unwilling to permit needed care to be furnished in the home. Would a hospice be penalized for billing general inpatient level of care for a patient whose care system breaks down until arrangements could be made to place the patient in long-term care, or when a patient falls into one of the other categories highlighted above? Two examples are provided, but there could be many others. Example #1: An 86 year old female with a terminal illness who is bed bound and cannot take her own medications, requires pain medication to be given every 4 hours (and prn medication is given for break through pain) in order to keep the patient s pain managed. The patient s caregiver has had a heart attack, is placed in CCU, and there are no other family or friends to take care of this patient. A neighbor calls hospice explaining what as happened, agrees to stay with the patient until someone from hospice arrives. Upon hospice s arrival, the patient is transported to a hospice inpatient facility so she can continue on her current pain regimen in order to keep her pain managed. Medication administration requires a licensed nurse, so this is a skilled need. It is several days before the caregiver/poa is well enough to discuss placing the patient in a long-term care facility, but attempts to work through this process are well documented. Since this patient s home support broke down and the patient required a skilled level of care, are the days in the hospice inpatient center billable at the general inpatient rate? Example #2: A 68 year old male with newly diagnosed stage four (4) lung cancer expresses suicidal thoughts and describes a plan. When the social worker attempts to address these issues, he becomes agitated and verbally abusive. He has a history of mental illness and depression, lives alone, and has no close family or friends. His pain is moderate and controlled with oral medications which he is able to manage. He is admitted to the hospice inpatient center for psycho-social monitoring of his suicidal ideations. After two days of monitoring the patient, the IDG decides a psychiatric consult is needed, and it is provided on day three. The psychiatrist recommends an inpatient psych unit. The patient gets angry at the hospice for calling in a psychiatrist and revokes the hospice benefit. Are the three days the hospice monitored him for his suicidal ideations billable at the general inpatient rate? June 16, 2011 Hospice Coalition Q & As Page 4 of 13

5 In accordance with the plan of care, patients may be admitted for short-term general inpatient care when the physician and hospice interdisciplinary team, based on the patient s condition, believes the patient needs pain control or acute chronic symptom management that cannot feasibly be provided in other settings. The length of stay for a short-term general inpatient level of care should be based on the patient s condition, acute need, and the event(s) that initiated the admission. Documentation should support the hospice's decision to place the patient in the GIP level of care. Additionally, this issue will be taken to CMS for further clarification. 5) Medicare states you can only bill for an NP if the patient selects him or her as his/her attending provider. However, we are seeing more NPs used as a consulting provider and submitting claims to the hospice for reimbursement. Can the hospice submit a claim for an NP as a consulting provider and then pass the reimbursement back to the provider? The only Nurse Practitioner (NP) services that may be separately billed under the Hospice Medicare Benefit are those performed as the attending physician. 6) When is it appropriate to issue the patient the Notice of Medicare Provider Non-Coverage and the Advanced Beneficiary Notice (ABN)? Should they be issued together when the patient is discharged from hospice due to no longer eligible or should you only give the ABN when you know they are going to appeal? The ABN (Form CMS-R-131) will likely be given less frequently for the hospice benefit than in other settings. The three situations that would require issuance of the ABN to a hospice patient are: Ineligibility because the beneficiary is not terminally ill as defined in 1879(g)(2) of the Act. Specific items or services that are billed separately from the hospice payment, such as physician services, are not reasonable and necessary as defined in either 1862(a)(1)(A) or 1862(a)(1)(C). The level of hospice care is determined to be not reasonable or medically necessary as defined in 1862(a)(1)(A) or 1862(a)(1)(C), specifically for the management of the terminal illness and/or related conditions. Hospice providers must use expedited determination ( Generic ) notices in accordance with 1869 of the Act when required. Expedited determination notices are given to beneficiaries when all Medicare covered services are being terminated for coverage reasons, so beneficiaries are alerted to their right to obtain an independent, immediate Quality Improvement Organization (QIO) review of the decision to end coverage. The expedited determination notice and the ABN must be issued together only when all covered care is being terminated for coverage reasons and the beneficiary is expected to continue receiving non-covered care. No ABN is required if no further services will be provided. June 16, 2011 Hospice Coalition Q & As Page 5 of 13

6 Reference: Medicare Claims Processing Manual Pub , Chapter 30 - Financial Liability Protections Special Issues Associated with the Advance Beneficiary Notice (ABN) Issued to Hospice Patients 7) CMS recently posted a power point presentation on Face-to-Face Requirements Affecting Hospice Recertification at FaceGuidance.pdf with one slide stating that When a NP performs the encounter, the attestation must state that the clinical findings of that visit were provided to the certifying physician, for use in determining whether the patient continues to have a life expectancy of 6 months or less, should the illness run its normal course. Prior suggested language was not as extensive and included the following recommendations: Clinical findings of that encounter have been provided to the certifying physician for use in determining continued eligibility for hospice care. Is the latter statement adequate or is the entire former statement needed? Where a nurse practitioner performed the encounter, the attestation must state that the clinical findings of that visit were provided to the certifying physician, for use in determining whether the patient continues to have a life expectancy of 6 months or less, should the illness run its normal course. Reference: Change Request (CR) 7337, release date March 2, 2011, implementation date March 23, 2011, 8) If the Common Working File (CWF) is inaccurate due to a prior hospice not entering its information timely, and we discover the patient is in their 3 rd or later benefit period weeks after admission to hospice, how is this to be managed if we had evidence that the CWF showed the patient was entering the 2 nd benefit period when admitted and we did not perform a face-to-face encounter visit prior to that admission? If a face-to-face encounter visit is performed when the hospice becomes aware of the newly corrected information, is that acceptable? Providers should have internal processes in place to verify the status of a Medicare beneficiary prior to accepting them as a patient. From this scenario, the provider verified in the Common Working File (CWF) that the patient was entering the 2 nd benefit period and no discharge date had been entered. Therefore, the provider would need to exercise due diligence to verify with the other hospice provider the status of the beneficiary since it was clear from the CWF that the billing from the first provider was incomplete and the true status of the beneficiary was unknown. 9) Since we can t use occurrence code 77 it is unclear what code to use when a patient is discharged due to a missed face-to-face encounter and the hospice chooses to continue to provide care for that patient without billing Medicare until the face-to-face visit can be completed. Will a code be created for this scenario? Palmetto GBA has not received any information to indicate that any new codes will be added to the hospice billing requirements when the face-to-face requirement is not met. CMS has stated that failure to meet the encounter timeframes results in a failure by the hospice to meet the patient s recertification of terminal illness eligibility requirement. June 16, 2011 Hospice Coalition Q & As Page 6 of 13

7 In addition, a discharge (81/824) claim would need to be submitted once the patient is discharged from the Hospice Medicare Benefit (HMB). The discharge claim should include occurrence code 42 with the date of discharge to end the hospice benefit period on the Common Working File (CWF) and update the revocation indicator along with remarks to indicate why the patient was discharged. 10) Please clarify what reason for discharge should be used when a face-to-face encounter visit is not completed timely as it doesn t clearly fall into one of the defined reasons for discharge [moves; no longer terminally ill; for cause (i.e. behavior disruptive, abusive, or uncooperative)]. If a hospice agency simply did not complete the face-to-face encounter timely or if a patient or family member refused to have the face-to-face encounter, providers can consider a discharge for cause. 11) Please explain the correlation between ICF and ICD 10. How should providers prepare to document using ICF in conjunction with ICD 10. Palmetto GBA recently launched a Going Beyond Diagnosis Blog. Providers are encouraged to access and participate with dialogue using the Blog. What follows is some of the information you will find when entering this Website: The ICF is a taxonomy (classification system) developed by the World Health Organization (WHO) to compliment its International Classification of Disease (ICD). The ICF provides domains and categories that, while important to healthcare providers, are not part of the ICD. Thus the ICF allows healthcare providers to literally go beyond the ICD taxonomy of diagnoses to capture and communicate clinically relevant, patient-centered data. While the ICF provides clinicians with a framework for identifying, organizing, and communicating the clinical care needs of their patient populations, it can also provide a framework for documenting adherence to administrative requirements. These administrative requirements are typically driven by healthcare third-party payers or quality initiatives. The utility of the ICF, however, is currently limited by its size (approximately 1400 codes) and the general lack of awareness among healthcare stakeholders of its existence. The World Health Organization (WHO) has developed 2 sets of codes; one for functionality (ICF) and one for diagnosis (ICDs both ICD-9 & ICD-10). The ICF supports ICD-10 by providing a functional description for the diagnosis. It is anticipated that with the development of ICD-11 that ICF will be merged with ICD-10. The World Health Organization (WHO) Website hosts an ICF Application and Training Tools for public use. Posted for downloading off of the Website is an ICF Checklist PDF file that can be used to record functional impairment using ICF categories for clinical purposes. June 16, 2011 Hospice Coalition Q & As Page 7 of 13

8 (Please refer to Attachment B) 12) Please review the LCD for a patient with Parkinson s disease and other Neurological conditions. a. Utilizing a case study please work through a sample documentation of structural/functional impairments using the ICF for Parkinson s disease. b. Is there a decision tree type worksheet to use that would give more simple guidance? c. Is there a sample assessment form that hospices can use in educating clinical staff (with scoring parameters)? Please refer to the Palmetto GBA Website for a Case Scenario regarding Parkinson s Disease: (Attachment C) S01Parkinson2009.pdf 13) Should the face-to-face encounter documentation language be individualized or is a standardized format acceptable? The documentation should be individualized to reflect the clinical findings of the specific beneficiary. There may be some portions of the documentation that may lead the hospice to create a form. For example a form may be created which indicates a blank for the date of the encounter and the individual performing the encounter. 14) At a recent state meeting a Palmetto GBA representative discussed exceptional circumstances for the face-to-face evaluation. In the situation when admitting a patient over the weekend, that the face-to-face has to be conducted within 48 hours from the time of admission. For a Sunday admission at 2 pm the evaluation would have to be completed by Tuesday at 2 pm. We would like clarification that this is inaccurate. Change Request 7337 states, In such documented cases, a face-to-face encounter which occurs within 2 days after admission will be considered to be timely. The regulation does not specifically state 48 hours. 15) Please provide an update on the status of the current NCLOS medical review, the number of hospices currently under review and the stages of those reviews. We are currently reviewing providers based on three criteria: Exceeding the hospice cap Exceeding the NCLOS rate for all providers and Exceeding the average length of stay for all beneficiaries (regardless of diagnosis) in their state. This review was initiated in August 2010 with twenty-nine (29) providers selected. Six (6) providers were removed after the probe review was completed. Twenty three (23) June 16, 2011 Hospice Coalition Q & As Page 8 of 13

9 providers were progressed to complex review. Four (4) of those providers have now been removed from review with nineteen (19) providers remaining on complex review. 16) Please provide an update to the NCLOS rates for the Palmetto GBA region and by state for the last 6 months of 2010 and trends you are seeing. Palmetto GBA has found similar results when comparing the first 6 months (January June) of 2010 with the last 6 months (July December) of NCLOS Rates for the last 6 months of 2010 Diagnosis Southeast Southwest Category Gulf Coast Midwest All Regions ALS The Adult Failure to Thrive Syndrome Alzheimer's Disease & Related Disorders Heart Disease HIV Disease Liver Disease Pulmonary Disease Renal Disease Stroke & Coma All Categories NCLOS Rates for the first 6 months of 2010: Diagnosis Southeast Southwest Category Gulf Coast Midwest All Regions ALS The Adult Failure to June 16, 2011 Hospice Coalition Q & As Page 9 of 13

10 NCLOS Rates for the first 6 months of 2010: Diagnosis Category Southeast Southwest Thrive Syndrome Gulf Coast Midwest All Regions Alzheimer's Disease & Related Disorders Heart Disease HIV Disease Liver Disease Pulmonary Disease Renal Disease Stroke & Coma All Categories (See Attachment D NCLOS rates by State) 17) Please provide updates on which edits/probes are planned by Palmetto GBA for the remainder of When do you expect these to begin? Currently hospice review consists of beneficiary edits for not hospice appropriate, and referrals from other sources (CERT, OIG, etc.). Additional reviews have not been identified at this time. 18) Review the Appeals Report. Please refer to Attachment E. 19) What provider deficiencies are Palmetto GBA finding in their probes either technical or clinical? The top denials are noted below: 5CF36/5FF36 - Not Hospice Appropriate 5CFH9/5FFH9 - Physician Narrative Statement Not Present or Not Valid 5FFNP/5CFNP - No Plan of Care Submitted June 16, 2011 Hospice Coalition Q & As Page 10 of 13

11 56900 Auto Deny - Requested Records not Submitted 5CFH3/5FFH3 - No Certification for Dates Billed Please refer to the June 2011 Medicare Advisory for information on preventing errors noted above: June 2011 J11 Home Health and Hospice Medicare Advisory 20) Please provide: a. An updated Cap Report. Palmetto GBA is currently working on the 2010 hospice caps. To date, we have completed 323 out of 1,672 cap reviews or 19%. All of these reviews have been under the cap limitation. b. A MAC roll out update. The Jurisdiction 11 (J11) Implementation final segment will be completed on June 18, Palmetto GBA will continue to provide up-to-date information as all the HHH MACs are awarded and implemented. c. Update on the IAC activity. The IAC activity is under development for J11 MAC. d. Update on additional LCD activity All the updates, revisions and reconsideration requests are allowed starting June 18, There are no new LCDs in draft at this time. e. What is Palmetto s current state of readiness for 5010? Please see Attachment F. 21) What are the aggregate Cap overpayment demands by State for the most recent 5 year period? Please refer to Attachment H. 22) Please explain how the aggregate cap is calculated for a patient who is served in more than one cap year. Does the calculation change if two hospices are involved over the two cap years? Palmetto GBA has always counted a beneficiary s hospice care in accordance with the Medicare regulations. Currently, the regulations purport that the cap is to be June 16, 2011 Hospice Coalition Q & As Page 11 of 13

12 completed in the following manner with regard to counting beneficiaries (Reference - Publication , chapter 11, Section 80): The period for counting beneficiaries is different than the cap period. This period is referred to as the election period and is defined by regulation to be September 28th of the previous cap year through September 27th of the current cap year. In order for a beneficiary to be counted, either as full or fractional in the current cap year, the beneficiary must have made an initial election with the hospice provider during the period beginning September 28th of the previous cap year through September 27th of the current cap period. For example, regarding the 2010 cap period, only the initial elections made from September 28, 2009, through September 27, 2010, should be reported. Summary Cap Year = November 1 October 31 Beneficiary Election Period = September 28 September 27 Counting a Full Beneficiary A beneficiary is counted as one full beneficiary if they have not been counted previously in another hospice s cap or in another cap year for your hospice. Each beneficiary can only be counted in the initial year of election, even if there are breaks of service between periods of election. Counting a Fractional Beneficiary For a beneficiary that has received hospice care, previously or subsequently, from another hospice, no matter the cap period involved, each hospice provider will receive a prorated (fractional) count for that beneficiary. Example: Beneficiary is with Provider A for 10 days and then goes to Provider B for 30 days. It does not matter which cap period(s) are involved, both providers will receive a fractional allocation based on the number of days of care. Provider A will receive a beneficiary count of.25 = (10 Provider A)/(40 days of total hospice care) Provider B will receive a beneficiary count of.75 = (30 Provider B)/(40 days of total hospice care) Each provider will count their fractional allocation in the election period that they initially elected with their provider. For example, if the beneficiary in the above example elected with provider A on July 1, 2010 and with provider B on July 11, 2010, both providers would count their fractional election in the 2010 cap period because July 2010 is contained within the 2010 cap period of September 28, 2009 through September 27, But, if the beneficiary in the above example elected with provider A on September 18, 2009 and with provider B on September 29, 2009, Provider A would June 16, 2011 Hospice Coalition Q & As Page 12 of 13

13 count their fractional election in the 2009 cap period and Provider B would count their fractional election in the 2010 cap period. 23) Explain the process of the 81A/82A workaround, be specific with details. The work around for the 81A/82A applies to the certifying physician s NPI in the OTH PHYS field of the Direct Data Entry (DDE) system. Currently, as annotated on Palmetto GBA s Claims Processing Issues Log (CPIL), providers are unable to enter the NPI for the OTH PHYS field in DDE due to a system problem. A system fix will be implemented in December Therefore until the system fix is implemented, hospice providers are authorized to leave the entire OTH PHYS field blank. This would include removing any dashes or other characters that may automatically display in the OTH PHYS field. 24) Is there a way to get the questions posted soon and to let the coalition know? We strive to post the minutes to our website within a few weeks of the meeting or as soon as we are sure all issues that came up during the meeting have been clarified. We will notify the coalition leadership as soon as that process is complete. 25) Is there information regarding the incorporation of multi-state hospices to their new assigned MAC? CMS has not issued any new information regarding hospice MAC reassignments at this time. Rest assured we will share information when we receive it. 26) If an MD makes a mistake on the date line on a form, and attempts to correct it by writing over the date, do these corrections to the forms by the hospice MD need to be notarized? Providers and physicians should follow appropriate standards of legal medical documentation. The physician should NOT write over the date to make a correction when an error is discovered. One method to make a correction is for the physician to use one line to strike-through the original date, hand write the correct date beside the strike-through date, write his/her initials and date the correction was made. 27) Face-to-face the CWF has a limited amount of information available, and in a timely manner, when a hospice is trying to determine what benefit period the patient is in. Will the information the CWF offers be expanded at any time? The Centers for Medicare & Medicaid Services (CMS) has not conveyed any future plans to us concerning expansion of the CWF. June 16, 2011 Hospice Coalition Q & As Page 13 of 13