4/24/17. Today s Presenters. Disclaimer. Nursing Documentation-Supporting Terminal Prognosis

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1 Nursing Documentation-Supporting Terminal Prognosis Today s Presenters Corrinne Ball, RN, CPC, CAC, CACO Provider Outreach and Education Consultant J6.provider.training@anthem.com 2 Disclaimer National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the CMS website at 3 1

2 No Recording Attendees/providers are never permitted to record (tape record or any other method) our educational events This applies to our webinars, teleconferences, live events and any other type of National Government Services educational events 4 Acronyms Acronyms used in this presentation can be viewed on the NGSMedicare.com website. On the Welcome page, click on Provider Resources > Acronyms. 5 Objectives This session will provide information on the Medicare hospice benefit and nursing documentation to support Medicare coverage. 6 2

3 Agenda Nursing documentation Four levels of service Routine home care Respite care Continuous home care General inpatient care Scenarios 7 Coverage To be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being terminally ill. An individual is considered to be terminally ill if the medical prognosis is that the individual s life expectancy is six months or less if the illness runs its normal course. *CMS IOM Publication , Medicare Benefit Policy Manual, Chapter 9, Section 10, Requirements- General 8 Beneficiary Notice of Election Identification of the particular hospice that will provide care to the individual; The individual s or representative s (as applicable) acknowledgment that the individual has been given a full understanding of hospice care, particularly the palliative rather than curative nature of treatment; The individual s or representative s (as applicable) acknowledgment that the individual understands that certain Medicare services are waived by the election; The effective date of the election, which may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement. An individual may not designate an effective date that is retroactive; and 9 3

4 Beneficiary Notice of Election The individual s designated attending physician (if any). Information identifying the attending physician recorded on the election statement should provide enough detail so that it is clear which physician or NP was designated as the attending physician. This information should include, but is not limited to, the attending physician s full name, office address, NPI number, or any other detailed information to clearly identify the attending physician. The individual s acknowledgment that the designated attending physician was the individual s or representative s choice. The signature of the individual or representative. 10 Physician Certification of Terminal Illness A written certification must be obtained no later than 2 calendar days after hospice care is initiated (that is, by the end of the third day) If the hospice cannot obtain a written certification within 2 calendar days, it must obtain an oral certification within 2 calendar days 11 Oral Physician Certification Documentation An oral statement documented in the patients medical record needs to include: A statement that the patient is terminally ill, with a prognosis of 6 months or less Signature and date of author diagnosis (suggested) Statement the patient will be admitted into hospice care (suggested) 12 4

5 Documentation 13 Definition of Nursing Nursing is a healthcare profession focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life from birth to death 14 Documenting the Appropriate Patient Answering the question? Why hospice, why now? History, progression of illness, recent changes, current status Should show acuity or trajectory that supports the sixmonth prognosis Documentation should support the physician s certification of terminal illness 15 5

6 Why Now? What triggered the hospice referral at this time? Hospitalization Symptoms exacerbation Changes in condition Needs for additional care Comorbidities 16 General Terms that Do Not Support Decline Appears to be losing weight Ate 50% of meal Shows slow decline Stable Eating well 17 How do you know? Anytime you use a description like: Cachectic, anorexic, nonambulatory, dyspnea (at rest or on exertion),weight loss, poor appetite, fragile, failing, weaker Always follow up with as evidenced by.. to fully describe what you see 18 6

7 Documenting Objective Measures Measurable objectives: Weights Mid arm circumference Abdominal girths Food and fluid intake Labs Signs and symptoms 19 Supporting Prognosis: Course of Care Visit notes must: Continuously and consistently support the terminal prognosis Contain vital signs, weights, body mass measurements, food intake, lab values and/or other objective data Refer to goals identified in the plan of care 20 Levels of Care Documentation 21 7

8 Levels of Care Description Revenue Code Unit=Time Routine Home Care unit = 1 day Continuous Home Care unit = 15 minutes Inpatient Respite Care unit = 1 day General Inpatient Care unit = 1 day 22 Levels of Care Routine home care Paid for each day the patient is under the care of the hospice and not receiving one of the other categories of hospice care Paid without regard to the volume or intensity Supporting documentation of terminal prognosis 23 Routine Home Care Expect to see Clinical findings describing vital signs, weight loss or gain, fevers, wound status, etc. Interventions provided and the response of the beneficiary and family The trajectory of the terminal illness Services that are consistent with the plan of care 24 8

9 Appropriate? 25 Poor Documentation to Support Terminal Prognosis Calvin is an 88 year male with a diagnosis of Parkinson's. Start of care date was 08/10/2016. Documentation reviewed for January 1-31, 2017 shows: Weight is 125lbs (soc wt: 135 lbs) Has poor appetite Totally dependent for all Activities of Daily Living (ADL s) Hospitalized 08/06/2016 for pneumonia Non-conversive Sleeps a lot 26 Qualitative Documentation January 1-31, 2017 the documentation shows: Has poor appetite- eating 3 to 4 bites of food with difficulty Drinks 2-3 sips of thickened liquids and aspirates easily Family reports patient sleeps 19 of 24 hours Totally dependent for all Activities of Daily Living (ADL s) Hospitalized 08/06/2016 for pneumonia Weights 08/10/ LBS 09/15/ LBS 27 9

10 Qualitative Documentation Weights (con t) 10/27/ LBS Comorbidities-CHF, Diabetes, Ischemic heart disease min per N/C Oxygen Saturation 12/05/16 92% on 2L per N/C 12/18/16 88% on 3L per N/C Blood Sugars family reports 12/08/2016 AM blood sugar 62 12/08/2016 HS blood sugar Levels of Care Continuous home care (CHC) Provided only during periods of crisis to maintain the beneficiary at home Beneficiary requires continuous care for at least 8 hours in a 24-hour period (midnight to midnight) More than 50% of care must be nursing by RN, LPN, or LVN Care need not be continuous Homemaker or hospice aide may supplement nursing Not intended to be used as respite care 29 Billing CHC for Nursing Claim Line Revenue Code HCPCS Code Units Service Date Q /5/2017 CHC is billed at 1 unit for every 15 minutes Example for 3/5/2017 Nurse- 6 hours = 24 units Aide- 2 hours=

11 Continuous Home Care Expect to see Appropriate documentation to support a crisis situation Billed at every 15 minutes you do not have to document every 15 minutes The breakdown of hours provided by the RN versus the home health aide (HHA), overlapping of any hours The care provided, interventions, responses, and any changes in the plan of care (POC) 31 Poor Documentation To Support Continuous Home Care 3/05/2017 7:15am Called to the home of Ms. Jones for increasing complaints of pain. Pain assessment performed, physician called, new orders received and noted. Administered morphine sulphate sublingual patient, increased anxiety noted and patient was given po Ativan. Morphine sulphate repeated. Patient is resting quietly without complaints of pain. Phenergan administered for vomiting. aide provided ADLs and turned and repositioned patient. Family given instructions on administering pain meds and repositioning patient. 32 Qualitative Documentation To Support Continuous Home Care 03/05/2017 7:15 a.m. Called to the home of Ms. Jones for increasing complaints of pain. Pain assessment performed, physician called, new orders received and noted. 7:45 a.m. Administered morphine sulfate sublingual. 8:10 a.m. patient having increasing anxiety, administered po Ativan 1mg. 8:50 a.m. patient continues to moan and call out, administered morphine sulfate sublingual. 9:20 a.m. patient vomited approximately 100 cc of yellow emesis. Administered phenergan suppository

12 Qualitative Documentation To Support Continuous Home Care 10:15 a.m. patient resting quietly without complaints of. 12:45 p.m. patient moaning, sublingual morphine administered. Respirations 14 and rales audible bilaterally. 1:10 p.m. patient restless and moaning, physician called and orders received to initiate a pain pump. 34 Qualitative Documentation To Support Continuous Home Care Documentation demonstrates the hospice aide provided personal care from 11:00 a.m. to 1:00 p.m. May document in narrative form or using charts or graphs The documentation needs to demonstrate the care provided and the time spent providing the care. 35 Levels of Care Inpatient respite care Provided only when necessary to relieve the family members or other persons caring for individual at home May only be provided in a Medicare participating hospital or hospice in patient facility, or a Medicare or Medicaid participating nursing facility Only on an occasional basis May not be reimbursed for more than five consecutive days at a time 36 12

13 Poor Documentation To Support Respite Care Documentation shows: 01/25/2017-Patient admitted to the inpatient unit for respite care while family is out of town. 02/17/2017-Patient admitted to the inpatient unit for respite care. 02/29/2017- Transferred to XYS nursing facility for inpatient respite care 37 Qualitative Documentation to Support Respite Care Documentation shows: 01/25/2017-Family out of town on vacation and respite care provided in a hospice facility. 02/17/2017-Patient s daughter is out of town on business, the caregiver sustained a fractured hip and was hospitalized. Patient was moved to a hospice facility for respite care. 02/29/2017- Patient s care needs have increased and the family is unable to provide the needed care. Will transfer to SNF for respite care until other arrangements can be made. 38 Multiple Inpatient Respite Stays in a Billing Period Claims submitted on or after July 1, Claims reporting respite periods greater than five consecutive days will be returned to the provider (RTP) Must report OSC M2 when more than one respite period occurs within the billing period 39 13

14 Levels of Care General inpatient care Is allowed when the patient s medical condition warrants a short-term inpatient stay for pain control or acute or chronic symptom management that cannot feasibly be provided in other settings May only be provided in a Medicare participating hospital, SNF or inpatient facility 40 General Inpatient Care Expect to see The medication adjustments or other stabilization treatments Supporting documentation that the family can no longer provide care 41 Documentation That May Support GIP Level Of Care Pain requiring: Complicated technical delivery of medication requiring a registered nurse (RN) for calibration, tubing changes, or site care; Frequent evaluation by physician/nurse; Aggressive treatment to control pain; Frequent medication adjustment 42 14

15 Documentation That May Support GIP Level Of Care Symptom changes such as: Sudden deterioration requiring intensive nursing intervention; Uncontrolled nausea and vomiting; Pathologic fractures; Respiratory distress which becomes unmanageable; Open lesions requiring frequent skilled care; Traction and frequent repositioning requiring more than one staff member; 43 Documentation That May Support GIP Level Of Care Complex wound care requiring complex dressing changes; Severe agitated delirium or acute anxiety or depression secondary to the end-stage disease process requiring extensive intervention. Imminent death: Requiring skilled nursing care for pain or symptom management. Note: imminent death without a need for aggressive symptom management is not a reason for GIP. 44 Caregiver Breakdown Caregiver breakdown is the loss of the individual s support structure and should not be confused with the coverage requirements for medically reasonable and necessary care for pain and symptom management that cannot be managed in any other setting 45 15

16 Scenario A 67 yo male patient with diagnosis of stage IV pancreatic cancer. Patient resides at home with his wife who is the primary caregiver. Patient has been having increasing bouts of pain with vomiting. Patient is receiving sublingual morphine every 2 hrs for break through pain and phenergan suppositories for vomiting. Patient is alert and conversive. At 2:00 a.m. the wife calls the hospice nurse to report that the pain medication is not relieving the pain. 46 Poor documentation to support General Inpatient Care 07/02/2016 2:15 a.m. patient experience pain, medication administered without relief. Patient is exhibiting severe pain. Physician notified, new orders received and noted. Ambulance called to transport patient to the inpatient unit. 07/03/ :15 a.m. visit note-patient admitted to hospice facility for inpatient care due to uncontrollable pain. Met with family and they are pleased with the care. Patient s symptoms are controlled with the initiation of a pain pump. Assessment completed and noted. 47 Qualitative Documentation To Support General Inpatient Care 07/02/2016 2:15 a.m. Patient experiencing pain not relieved by sublingual morphine. Physician called and new orders noted to transfer patient to the inpatient unit for initiation of pain pump. Ambulance called and patient transported. The patient s wife is unable to meet the increased needs of the patient, and has no other family members for support. 07/03/ :15 a.m. Nursing staff reports the patient s pain is only minimally controlled with pain pump. Patient has had several episodes of vomiting and given phenergan IV. Patient is non-responsive except to painful stimuli. Moans frequently. Patient requires two for turning, repositioning and performing personal care. Assessment completed and noted. Oxygen was initiated at 2 Liters via nasal cannula for Oxygen saturations of 88%. O2 sat is 98% on 2L/per min

17 GIP Documentation Documentation to include for GIP level of care: Medication administration record Inpatient nursing and/or physician notes Documentation must support the services that were necessary for the inpatient admission 49 CERT A/B MAC Outreach & Education Task Force 50 CERT A/B MAC Outreach & Education Task Force The goal of the A/B MAC Outreach & Education Task Force is to ensure consistent communication and education to reduce the Medicare Part A and Part B error rates. A joint collaboration of the A/B MACs to communicate national issues of concern regarding improper payments to the Medicare Program. Partnership to educate Medicare providers on widespread topics affecting most providers and complement ongoing efforts of CMS, the MLN and the MACs individual error-reduction activities within its jurisdictions Disclaimer: The CERT A/B MAC Outreach & Education Task Force is independent from the CMS CERT team and CERT contractors, which are responsible for calculation of the Medicare fee-for-service improper payment rate

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