HOSPICE FINAL RULE by SHARON HARDER, President - C3 Advisors, LLC

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FAQ: THE 2018 HOSPICE FINAL RULE 1 FAQ FREQUENTLY ASKED QUESTIONS ABOUT The 2018 HOSPICE FINAL RULE by SHARON HARDER, President - C3 Advisors, LLC and BETH NOYCE, RN, BSJMC, HCS-H, HCS-D, COS-C,

1 FAQ: THE 2018 HOSPICE FINAL RULE 1 FAQ FREQUENTLY ASKED QUESTIONS ABOUT The 2018 HOSPICE FINAL RULE by SHARON HARDER, President - C3 Advisors, LLC and BETH NOYCE, RN, BSJMC, HCS-H, HCS-D, COS-C, Consultant - Noyce Consulting The rapid and dramatic changes the hospice industry has experienced over the past several years continues with the publication of the 2018 Hospice Final Rule, officially titled the FY 2018 Hospice Wage Index and Payment Rate Update. The 2018 Hospice Final Rule was the subject of a webinar presented by Sharon Harder, President of C3 Advisors, LLC and renowned consultant Beth Noyce, RN, BSJMC, HCS-H, HCS-D, COS-C. This important webinar is available for on-demand viewing at kinnser.com/hospice2018. In this document, Sharon and Beth answers some of the most popular questions asked during the webinar. Hospice Compare Q: What data is Hospice Compare based on? What time period is represented in the data? A: Hospice Compare data is gathered from Hospice Item Set (HIS) information submitted by each hospice as part of the Hospice Quality Reporting Program (HQRP). This first release captured information submitted for discharges that occurred between October 1, 2015 and September 30, For more information on the data, please visit Hospice Compare s page About the Data at hospicecompare/#about/thedata. Q: How long will it take for a new hospice's data to show up on Hospice Compare? A: Hospice Compare will show data based on a rolling 12-month period. For a new hospice s data to show up, the hospice must have more than 20 hospice stays in the 12-month period being measured. What you need to do first is measure the census for the quarter in which the stays (measured as admissions to discharges) exceeded 20 and then project when that quarter s data will be made public. The data being shown currently (September 2017) is for the quarter ended September 30, 2016, so the data that is posted is about 12 months old. Q: Our non-profit hospice is listed as "other" on Hospice Compare. How do we get this changed? A: This information is probably coming from the Medicare Enrollment Application CMS- 855A that your organization filed. Section 2.B.1. on CMS-855A has a space for indicating the entity type. (See the illustration on the following page.) One of the choices is other, but that choice is very rarely used. If your organization is a not-for-profit corporation, the correct choice here would be Corporation. Then later you will be able to indicate how the corporation is registered with the IRS either as a proprietary (for-profit) organization or as a notfor-profit organization. Please check your last 855A filing and correct it if the answers to the questions in Section 2 are incorrect.

2 FAQ: THE 2018 HOSPICE FINAL RULE 2 Section 2.B.1. of the Medicare Enrollment Application (CMS-855A) Medications Q: When must hospice cover maintenance medications? A: The hospice must always cover maintenance medications, unless the hospice physician documents clear clinical evidence that the condition that the medication is treating is unrelated to the patient s terminal prognosis. Q: Is there a list of the medications hospices must cover? Can the medications be generic? What about medication supplies, like insulin syringes? A: There isn t a list of must-cover medications, but there s a lot of information available in the hospice final rules over the past few years that gives examples of more and more medications that CMS believes hospices should be covering. And yes, syringes would be included if required to provide any treatment that is either related to the terminal prognosis or for symptom control. Q: Our pharmacy manager states that diabetic medication does not necessarily relate to the terminal illness. Patients are diabetic long before they are diagnosed with a terminal illness. A: It is very true that many chronic illnesses, such as diabetes, are present long before a patient is considered terminally ill. However, the longstanding nature of chronic disease does not exempt it from either becoming terminal at some point or being integrally related to the terminal condition. This is the distinct point that CMS is trying to make when suggesting that hospices should be covering the medications for these conditions. Because there are many considerations involved including patient comfort, symptom management, and the patient s stage of terminal illness the decision as to whether longstanding, chronic conditions and the medications used to treat them are related to the terminal illness, either directly or indirectly, must be a patient-specific decision that is made by the hospice physician in concert with the patient s attending physician as applicable.

3 FAQ: THE 2018 HOSPICE FINAL RULE 3 Q: How does a hospice formulary of covered medications affect the issue of covering all medications related to a terminal illness or to manage symptoms? Some examples are antidepressants for depressed patients or anti-seizure medications for glioblastoma patients that are outside our formulary. A: Each patient s prescribed medications must meet his/her needs. If the drugs on the hospice s formulary are not providing necessary relief or palliation of symptoms, the hospice must provide alternative medications to address the patient s needs. CMS expects hospice providers to arrange for non-formulary drugs as necessary to meet patient needs and outcomes. The exception to this rule is when the patient or his/her family requests a specific, named medication that is not on the formulary and the hospice physician determines that another medication that is included on the formulary will suffice. In that case, if the patient or patient s family will not accept the substitution, the hospice would not be expected to cover the cost of the medication. The hospice s obligation, in this set of circumstances, would be to communicate the fact that the hospice will not cover the medication due to the availability of an alternate medication and that the specific medication would also not be covered under Part D. In this instance, the patient would be financially responsible for payment. (RN) and/or social worker up to a combined maximum of four hours per day (sixteen 15-minute units). Social worker phone calls are not counted for purposes of SIA payments. Likewise, licensed vocational nurse (LVN) and licensed practical nurse (LPN) visits are not counted for purposes of SIA payments. Q: Is the service intensity add-on maximum of four hours a daily maximum? Can we charge four hours daily that are split between RN and a social worker for the last seven days at the continuous care rate? A: There is a four-hour or 16-unit maximum per day. SIA payments apply only to routine home care. Continuous care services, even though delivered in a patient s home, are not eligible for the add-on payment. Q: Is the SIA increase paid when both an LPN and a medical social worker (MSW) visit occurs on the same day? A: If there is both an LPN visit and a separate social worker visit on the same day, the add-on would be calculated only on the time spent by the social worker up to the four-hour maximum. Q: Is the visit to pronounce death counted as one of the nursing visits in the last days of life? A: No. Only those visits performed while the patient is alive count toward the SIA payment. Service Intensity Add-On Q: How does the service intensity add-on work? A: Service intensity add-on (SIA) payments are automatically calculated at the time of payment based on two factors: 1) the discipline of the visiting staff member and 2) the aggregate time per day for the last seven days of life. Within the patient s last seven days of life (post-mortem visits are excluded), SIA payments are calculated, per day, for each routine home care visit made by a registered nurse The HEART Patient Assessment Q" What is the HEART Patient Assessment? When will it go into effect? Will it replace the Hospice Item Set? Or is it more like a survey? A: The Hospice Evaluation & Assessment Reporting Tool (HEART) is an assessment tool currently being developed for future implementation that will standardize elements of the comprehensive hospice patient assessment. It will replace the Hospice Item Set (HIS) but not the CAHPS. CMS wants input from hospice providers while developing this tool.

4 FAQ: THE 2018 HOSPICE FINAL RULE 4 To get involved and learn more about HEART, please contact: Ila Broyles, Ph.D. End-of-life, Palliative, and Hospice Care Program ibroyles@rti.org RTI International 3040 E. Cornwallis Road PO Box Research Triangle Park, NC CAHPS Q: What's different about CAHPS in the 2018 Hospice Final Rule? A: The 2018 hospice final rule didn t change CAHPS for now. However, the final rule did finalize the plan to display the scores resulting from the previously submitted CAHPS on the new Hospice Compare website in January Agencies who apply annually, due to having fewer than 50 deaths in a year, will not be penalized for not submitting CAHPS data. On Hospice Compare, the data will be blank with a footnote explaining why. If an agency is exempt due to size or being too new to report, no penalty will be assessed. Q: We filled out exception status for CAHPS because we have fewer than 50 deaths per year. Should we be reporting this information somewhere? If you qualify for the exemption do you still get penalized for not reporting? A: If you have submitted the exemption, there is no need to report. However, be aware that the reporting exemptions are good only for a single year. Thus, you should re-evaluate the census at least annually and report when the patient mortalities exceed the threshold. Q: We are a small agency, and we are not getting a great response rate. How does that affect our reimbursement? A: Your agency s reimbursement and susceptibility to the payment reductions for lack of reporting is solely based on circumstances in your control. So even with a relatively low response rate, as long as the reporting requirement has been met in terms of reporting results, there would be no penalty. Misc. Other Topics Q: What are the key payment changes in the 2018 Hospice Final Rule? A: There are no major changes to payments for 2018 other than the 1% increase in the payment rates for each level of care and the corresponding increase in the aggregate cap amount. Q: What are the requirements for the Faceto-Face Encounter with a physician after the third certification period? A: The Face-to-Face Encounter requirements remain the same for the third benefit period and each subsequent benefit period. No more than 30 days prior to the third benefit period, the hospice is obligated to arrange for a Face-to-Face Encounter with the patient for the purpose of ensuring that the patient continues to be terminally ill and eligible for the hospice benefit. Encounters that are done within the 30-day time frame, even if they are on the first day of the benefit period, are considered timely. A hospice physician or nurse practitioner (NP) employed by the hospice must perform the encounter. Each encounter must be accompanied by a signed, dated attestation from the performing clinician as to his/her findings and provision of the encounter results to the certifying physician. If the encounter is not performed in a timely manner, the coverage of services to the patient would become the hospice s liability. It is not appropriate to discharge patients for whom the hospice fails to perform a timely encounter.

FAQ: THE 2018 HOSPICE FINAL RULE 5 Q: What s the required time frame for signatures from the primary care physician (PCP) and medical director on the initial Certification of Terminal Illness (CTI)?

care, some state regulations do impose limits. Please check your state s administrative code pertaining to hospice for the rules that apply to your organization.

5 FAQ: THE 2018 HOSPICE FINAL RULE 5 Q: What s the required time frame for signatures from the primary care physician (PCP) and medical director on the initial Certification of Terminal Illness (CTI)? A: While Medicare s rules do not include a specified time frame for obtaining signatures on the initial Certification of Terminal Illness (or any subsequent CTI, for that matter) and/ or orders for care, some state regulations do impose limits. Please check your state s administrative code pertaining to hospice for the rules that apply to your organization. Remember that, from Medicare s perspective, the most stringent set of rules will prevail. So if your state requires a time frame for obtaining signatures on certain types of documents, particularly certifications or orders, those rules will govern in a medical review or survey. In the meantime, Medicare regulations simply impose the requirement that the documents required for billing, including the applicable CTI(s), must be signed and dated and in the patient s medical record prior to billing for services. Please note that if the billing month spans more than one benefit period, both sets of required documents must be signed, dated, and present in the record prior to billing. about the authors Sharon Harder has over three decades of executive management experience in the health care industry. She has served in financial and operational leadership roles in a variety of health care organizations ranging from a major health care professional association to large post-acute health care providers. As President of C3 Advisors, LLC, Sharon engages with clients to develop and implement the strategic vision required to improve their profitability and competitive position in the rapidly transforming health care marketplace. Learn more at C3Advisors.com. Beth Noyce, RN, BSJMC, HCS-D, COS-C, HCS-H provides consulting, education, and auditing services to hospice and home health agencies, and affordable instant in-services for agencies at noyceconsulting.com. She has presented at UHPCO, NAHC, UAHC, DecisionHealth s Coding Summit, and many other seminars. She has served as a MAC medical reviewer. Her work with DecisionHealth includes publishing in Diagnosis Coding Pro, helping edit the ICD-9 Coding Manual, authoring multiple ICD-10 courses, editing updates for the HCS-H credential study guide, and more. The software that powers post-acute care sales@kinnser.com kinnser.com ABOUT KINNSER Kinnser creates the software solutions that power postacute care. From its headquarters in Austin, Texas, Kinnser leads the industry by consistently delivering the smartest, most widely used solutions for home health, private duty home care, therapy, and hospice. With an enduring focus on customer success, Kinnser helps post-acute care businesses reduce expenses, increase revenue, streamline processes, and improve care. For more information, visit kinnser.com or call toll free

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