Disclaimer. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 2

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2 Disclaimer The information enclosed was current at the time it was presented. Medicare policy changes frequently; links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. Palmetto GBA 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 guide. This presentation is a general summary that explains certain aspects of the Medicare program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. All Current Procedural Terminology (CPT) only copyright 2014 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable Federal Acquisition Regulation/ Defense Federal Acquisition Regulation (FARS/DFARS) Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 2

3 Are we Related? January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 3

4 What is Hospice Care? Hospice care is an approach to treatment that recognizes that the impending death of an individual warrants a change in the focus from curative care to palliative care for relief of pain and for symptom management. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 4

5 Hospice Care from the Beginning The December 16, 1983 Hospice final rule (48 FR 56008) requires hospices to cover care for interventions to manage pain and symptoms. Clinically, related conditions are any physical or mental conditions that are related to or caused by either the terminal illness or the medications used to manage the terminal illness. Julia Harder, PharmD, CGP,. (2012). To Cover or Not To Cover: Guidelines for Covered Medications in Hospice Patients. The Clinician. 7(2), p1 3. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 5

6 Final Rule Definition of Illness An abnormal process in which aspects of the social, physical, emotional, or intellectual condition and function of a person are diminished or impaired compared with that person's previous condition. Mosby's Medical Dictionary, 8th edition, 2009, Elsevier January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 6

7 What is a Terminal Illness? As generally accepted by the medical community, the term terminal illness refers to an advanced and progressively deteriorating illness, and that the illness is diagnosed as incurable. When an individual is terminally ill, many health problems are brought on by underlying condition(s), as bodily systems are interdependent. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 7

8 Hospice Care In the December 16, 1983 Hospice final rule, regarding what is related versus unrelated to the terminal illness, we stated:... we believe that the unique physical condition of each terminally ill individual makes it necessary for these decisions to be made on a case-by-case basis. It is our general view that hospices are required to provide virtually all the care that is needed by terminally ill patients. Therefore, unless there is clear evidence that a condition is unrelated to the terminal prognosis, all services would be considered related. It is also the responsibility of the hospice physician to document why a patient s medical needs would be unrelated to the terminal prognosis. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 8

9 Related or Not? All body systems are interrelated; all conditions, active or not, have the potential to affect the total individual. The presence of comorbidities is recognized as potentially contributing to the overall status of the individual and should be considered when determining the terminal prognosis. Federal Register Volume 79, Number 163 (Friday, August 22, 2014) January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 9

10 Comorbidity The National Hospice and Palliative Care Organization (NHPCO) defines comorbidity as known factors or pathological disease impacting on the primary health problem and generally attributed to increased risk for poor health status outcomes. National Hospice and Palliative Care Organization: Standards of Practices for Hospice Programs, 2010 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 10

11 Terminal Illness CMS clinical leaders across several agency components as to the meaning of within the context of the Medicare hospice benefit. The clinical collaborative effort across CMS solicited comments on the following definition of terminal illness : Abnormal and advancing physical, emotional, social and/or intellectual processes which diminish and/or impair the individual's condition such that there is an unfavorable prognosis and no reasonable expectation of a cure; not limited to any one diagnosis or multiple diagnoses, but rather it can be the collective state of diseases and/or injuries affecting multiple facets of the whole person, are causing progressive impairment of body systems, and there is a prognosis of a life expectancy of 6 months or less. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 11

12 Related Conditions CMS clinical collaborative effort solicited comments on the following definition of related conditions : Those conditions that result directly from terminal illness; and/or result from the treatment or medication management of terminal illness; and/or which interact or potentially interact with terminal illness; and/or which are contributory to the symptom burden of the terminally ill individual; and/or are conditions which are contributory to the prognosis that the individual has a life expectancy of 6 months or less. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 12

13 Common End of Life Symptoms Pain Nausea / Vomiting Anxiety and Depression Constipation and Diarrhea Insomnia Agitation, Psychosis, Delirium Fluid Retention Appetite Loss Infections Oral / Pharyngeal Secretions Fatigue Dyspnea Wounds & Decubitus Ulcers Dyspepsia To Cover or Not To Cover (PART 2): Guidelines for Covered Medications in Hospice Patients Julia Harder, PharmD, CGP January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 13

14 Hospice Data January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 14

15 Locations of Care Q Codes Description Q Code Description Q5001 Q5002 Q5003 Q5004 Q5005 Q5006 Q5007 Q5008 Q5009 Hospice care provided in patient s home/residence Hospice care provided in assisted living facility Hospice care provided in nursing long term care facility (LTC) or non-skilled nursing facility (NF) Hospice care provided in Skilled Nursing Facility (SNF) Hospice care provided in inpatient hospital Hospice care provided in inpatient hospice facility Hospice care provided in Long Term Care Hospital (LTCH) Hospice care provided in inpatient psychiatric facility Hospice care provided in place not otherwise specified January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 15

16 Descriptive Statistics on National Hospice Utilization for 2011 Beneficiary Demographics All Episodes Patient Home Nursing Home Assisted Living < % 6.62% 3.89% 1.41% 65-< % 19.57% 10.40% 5.62% % 32.84% 28.41% 24.72% 85 > 47.34% 40.96% 57.30% 68.25% Medicare Hospice Payment Reform: Hospice Study Technical Report HHSM I January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 16

17 Principal Diagnosis on the First Day of the Episode Principal Diagnosis All Episodes Patient Home Nursing Home Assisted Living Lung & other chest cavity cancer 7.93% 10.70% 3.68% 2.60% Colorectal cancer 2.67% 3.49% 1.54% 1.17% Alzheimer s 5.00% 4.12% 7.56% 8.82% Non-Alzheimer s dementia Cerebrovascular accident Congestive heart failure 11.30% 7.64% 19.01% 20.53% 4.77% 3.16% 5.14% 3.04% 7.53% 8.06% 6.96% 7.45% Other heart disease 5.46% 5.88% 4.60% 5.76% Non-infectious respiratory disease 6.74% 8.07% 5.44% 4.72% January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 17

18 Principal Diagnosis on the First Day of the Episode Principal Diagnosis All Episodes Patient Home Nursing Home Assisted Living Failure to thrive adult 6.36% 5.30% 9.36% 10.05% Debility NOS 11.99% 10.36% 16.28% 20.72% Parkinson & other degenerative Pneumonias and other lung disease 2.20% 2.39% 2.59% 2.44% 2.34% 1.50% 1.20% 0.86% HIV/AIDS 0.07% 0.08% 0.07% 0.03% Chronic liver disease 1.17% 1.29% 0.78% 0.40% Chronic kidney disease 2.37% 1.87% 2.19% 1.13% January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 18

19 Comorbidities Per Episode Diagnosis All Episodes Patient Home Nursing Home Assisted Living 1 diagnosis 75.42% 73.11% 77.13% 77.67% 2 diagnoses 7.77% 8.27% 7.37% 7.68% 3 diagnoses 4.61% 5.05% 4.05% 4.27% 4+ diagnoses 12.20% 13.57% 13.57% 13.57% January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 19

20 Hospice Level of Care Hospice Level of Care Routine Home Care (RHC) Continuous Home Care (CHC) General Inpatient Care (GIP) Inpatient Respite Care (IRC) All Episodes Patient Home Nursing Home Assisted Living 86.45% 99.39% 92.81% 99.38% 6.18% 6.82% 5.14% 10.69% 22.27% 0.56% 6.88% 0.40% 3.40% 0.61% 6.52% 0.12% January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 20

21 Hospice Benefit Periods & Days Benefit Period All Episodes Patient Home Nursing Home Assisted Living 1 benefit period 2 benefit periods 3 benefit periods 4+ benefit periods 60.65% 55.54% 50.59% 37.70% 11.70% 13.99% 12.52% 14.29% 5.11% 5.86% 6.07% 7.36% 22.53% 24.60% 30.81% 40.64% January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 21

22 Hundreds Discharge Status of Hospice Beneficiary: Overall and by Site of Service Discharge Status All Episodes Patient Home Nursing Home Assisted Living Died in hospice Alive and in hospice as of 12/31/2011 Discharged from hospice Alive after discharge Discharged from hospice Died after discharge % 60% 50% 40% 30% 20% Discharged Alive/Deceased Discharged Alive /Not Deceased Alive In Hospice Died While in Hospice Average number of days until death % 0% All Patient Home Nursing Home Assisted Living January 2015 Source: 2011 Medicare hospice claims. Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (J11 MAC) 22

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24 Number of J11 Hospice Providers 81X 1,704 Total

25 Number of J11 Hospice Providers 82X 196 total

26 Number of J11 Hospice Beneficiaries 81X 372,936 total 80,000 70,000 69,282 60,000 59,874 50,000 40,000 30,000 20,000 10,000 16,696 6,872 23,508 21,521 13,303 8,508 13,144 8,290 24,843 4,531 30,181 14,627 15,203 10,484 32,725 0

27 Number of J11 Hospice Beneficiaries 82X 35,433 total 8,000 7,000 7,300 6,000 5,000 5,156 4,000 3,000 2,000 1, ,719 1,238 2,462 3,135 1, ,159 2, ,450 2,406 1,456 2,

28 J11 Aggregate Length of Stay Median LOS Mean LOS Median Cancer LOS Mean Cancer LOS Median Non cancer LOS Mean Non cancer LOS Number of Benes Number of Claims Kentucky ,140 21,675 All ,033 1,065,926 % Cancer % Non cancer % SSI % Alzheimers % Mental % Other Heart % Benes with Multiple Providers % Bene with Discharge Disbursement per Bene Covered Days per Bene Kentucky , All , January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 28

29 Non-Cancer Length of Stay (NCLOS) Rates NCLOS Rates are calculated using the following formula: Number of non-cancer beneficiaries with LOS >210 Total number of non-cancer beneficiaries The units are per 100 beneficiaries Values range from 0 to 1 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 29

30 NCLOS Rates 2014H

31 NCLOS Rates 2014H

32 2005_Jul-Dec 2006_Jan-Jun 2006_Jul-Dec 2007_Jan-Jun 2007_Jul-Dec 2008_Jan-Jun 2008_Jul-Dec 2009_Jan-Jun 2009_Jul-Dec 2010_Jan-Jun 2010_Jul-Dec 2011_Jan-Jun 2011_Jul-Dec 2012_Jan-Jun 2012_Jul-Dec 2013_Jan-Jun 2013_Jul-Dec 2014_Jan-Jun NCLOS Data by State and Region Southeast Kentucky North Carolina South Carolina Tennessee January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 32

33 J11 and State Disbursement State Provider Disbursement 2014H2 Provider Disbursement 2014H1 Provider Disbursement 2013H2 Prov. Count 2014H2 Prov. Dis. per Provider 2014H2 Bene Count 2014H2 KY 81X KY82 X 60,269,490 59,080,775 66,018, ,348,305 8,508 10,095,563 8,328,606 9,348, ,442,223 1,600 J11 81x J11 82X 3,838,640,375 3,600,537,764 3,836,969,589 1,704 2,252, , ,369, ,040, ,401, ,241,684 35,433 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (J11 MAC) 33

34 J11 and State Disbursement State Prov. Dis. per Bene 2014H2 Prov. Dis. per Bene 2014H1 Prov. Dis. per Bene 2013H2 Billed Charge 2014H2 Covered Charge 2014H2 Claim Count 2014H2 KY 81X 7,084 7,342 8, ,223, ,039,980 18,276 KY 82X 6,310 5,608 5,997 26,945,589 26,282,740 3,399 J11 81x J11 82X 10,293 9,903 10,455 7,073,496,860 7,033,546,550 1,046,235 6,868 6,640 7, ,605, ,164,170 76,175 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (J11 MAC) 34

35 Live Discharges January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 35

36 Live Discharges Previous research suggests that: Majority of live discharges (79%) are because the patient condition has improved or stabilized. 7% leaving hospice to pursue aggressive treatment. 12% was the patient or family decision to leave hospice care. Medicare Hospice Payment Reform: Hospice Study Technical Report HHSM I January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 36

37 Live Discharges ,497 discharges among 3,489 hospice providers. 18% were live discharges. 18.5% of live discharges were admitted to an acute care hospital within 2 days of discharge. 16.1% were readmitted to hospice within 2 weeks. (MedPAC, 2011) January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 37

38 Variation in the Rate of Live Discharges Medicare Hospice Payment Reform: Hospice Study Technical Report HHSM I January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 38

39 Live Discharges Analysis shows that among those 3,033 hospice programs with at least 30 discharges in 2010: Nearly one-fourth of these live discharges occurred within 19 days of hospice admission. Overall, 49.2% of discharged hospice patients are dead within six (6) months of the discharge. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 39

40 J11 and State Live Discharge Data Summary Length of Stay (Days) Target Discharges Denom Discharges Percent , , ,841 94, ,505 51, ,367 69,

41 30 Day Live Discharge Provider State Target Discharges Denom Discharges Percent AL , MS 346 5, NM 175 3, SC , OK 304 8, LA 325 9, TX 1,310 46, GA , TN , IN , OH , NC , IL , FL 1,172 58, KY 152 9, AR 118 7,

42 90 Day Live Discharge Provider State Target Discharges Denom Discharges Percent MS 463 2, AL 835 4, SC 692 4, NM 187 1, OK 382 2, NC 755 6, GA 664 5, IL 697 6, TX 1,400 13, LA 324 3, OH 872 8, FL 1,482 14, IN 382 4, TN 390 4, KY 219 2, AR 136 1,

43 180 Day Live Discharge Provider State Target Discharges Denom Discharges Percent MS 411 1, AL 709 2, SC 585 2, NM IL 689 3, IN 363 2, OH 829 4, NC 615 3, LA 293 1, KY 198 1, OK 267 1, FL 1,280 8, TX 1,217 7, GA 505 3, TN 313 2, AR

44 181 + Day Live Discharge Provider State Target Discharges Denom Discharges Percent MS 320 1, KY 188 1, AL 500 3, SC 469 3, NM 127 1, IN 256 2, LA 261 2, NC 404 3, AR 105 1, GA 464 4, OH 591 6, OK 227 2, TN 248 2, TX 1,036 11, IL 360 3, FL 1,012 11,

45 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 45

46 The Health Information Supply Chain January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 46

47 Examples of Links in the Chain Referral Screening Admission Notice of Election (NOE) Certification Face-to-Face (F2F) Encounter Documentation Plan of Care (POC) Patient Visits Documentation of Visit Coding Billing January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 47

48 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (J11 MAC) 48

49 Eliminate Improper Payments Examples of improper payments are: Payment to an ineligible recipient Payment for an ineligible service Any duplicate payment Payment for services not received Payment for an incorrect amount January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 49

50 J11 Hospice Medical Review Top Denial Reason Codes 81X Denial Code Description Count of Claims Denied by Bill Type Denial Rank Code 1 5CF36 Not Hospice Appropriate CFNP No Plan of Care Submitted Auto Denial - Requested Records not Submitted CF01 General Inpatient Services Not Reasonable and Necessary CFH2 No Certification Present CFH9 Physician Narrative Statement Not Present or Not Valid CFTF Face to Face Encounter Requirements Not Met CFH6 Initial Certification Not Timely CNOE No Valid Election Statement Submitted CFH7 Subsequent Certification Not Timely CF36 Not Hospice Appropriate Percent of Claims Denied to Total Claims Denied by Bill Type 2 5CFNP No Plan of Care Submitted January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 50

51 J11 Hospice Medical Review Top Denial Reason Codes 82X Denial Code Count of Claims Denied Percent of Claims Denied to Total Claims Denied by Bill Type Denial Rank Code Description by Bill Type 1 5CF36 Not Hospice Appropriate CFNP No Plan of Care Submitted CFTF Face to Face Encounter Requirements Not Met January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 51

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53 Kentucky Medical Review Statistics QTR 1 Denial Code Denial Description Claims Denied Charges Submitted Charges none Paid 1 $0.00 $1, January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 53

54 Kentucky Medical Review Statistics QTR 2 None processed January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 54

55 Kentucky Medical Review Statistics Denial Code 5CFH9 Denial Description Claims Denied Charges Submitted Charges Physician Narrative Statement Not Present or Not Valid 1 $5, $5, January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 55

56 Kentucky Medical Review Statistics Denial Code 5CFNP Denial Description Claims Denied Charges Submitted Charges No Plan of Care Submitted 1 $ $ January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 56

57 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 57

58 Top Errors Identified No POC Submitted Not Hospice Appropriate Physician Narrative Statement not Present or Not Valid Auto Denial No Valid Election Statement Submitted Certification Errors January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 58

59 No POC Submitted The claim has been fully or partially denied as documentation submitted for review did not include a POC for all or some of the dates billed. The hospice must submit POCs for dates of service billed when responding to the Additional Documentation Request (ADR) request. All dates billed must be covered by a POC. If more than one POC covers the dates of service in question, submit all the related plans of care for review. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 59

60 No POC Submitted The POC must contain certain information to be considered valid. This includes: Scope and frequency of services to meet the beneficiary s/family s needs. Beneficiary specific information, such as assessment of the beneficiary's needs, management of discomfort and symptom relief. Services that are reasonable and necessary for the palliation and management of the beneficiary s terminal illness and related conditions. The POC must be reviewed, revised and documented as frequently as the beneficiary's condition requires, but no less frequently than every 15 calendar days. For 30 day billing, POC review should be in the record at least twice. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 60

61 Not Hospice Appropriate The claim has been fully or partially denied because the documentation submitted for review did not support prognosis of six (6) months or less. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 61

62 Not Hospice Appropriate Submit documentation to provide clear evidence the beneficiary has a six (6) month or fewer prognoses which supports hospice appropriateness. Submit documentation which supports the coverage criteria outlined in the policies. Document any co-morbidity, which may further support the terminal condition of the beneficiary and the continuing appropriateness of hospice care. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 62

63 Physician Narrative Statement Not Present or Not Valid The claim has been denied as the physician narrative statement is not present or not valid. The physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of six (6) months. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 63

64 Physician Narrative Statement Not Present or Not Valid If the narrative exists as an addendum, in addition to the physician s signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum. Must include a statement with the physician signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patient s medical record or, if applicable his or her examination of the patient. Must reflect the patient s individual circumstances and cannot contain check boxes or standard language used for all patients. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 64

65 Auto Deny - Requested Records not Submitted Medical records were not received in response to an ADR in the required time frame: Monitor your claim status on Direct Data Entry (DDE) for the claims in status/location SB6001. Aim to submit medical records within 30 days of the ADR date (upper left corner of the ADR request). Claim will auto deny on day 46. Attach a copy of the ADR request to each individual record. If responding to multiple ADRs separate each response and attach a copy of the ADR to each individual set of medical records. Ensure each set of medical records is bound securely (e.g., rubber band, binder clips, etc.) so the submitted documentation is not detached or lost. Do not mail packages C.O.D. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 65

66 Methods of Submitting Medical Records Medical records may be submitted via: Online Provider Services (OPS) CD/DVD Fax Electronic Submission of Medical Documentation (esmd) Paper January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 66

67 No Valid Election Statement Submitted The services billed were not covered, as there was no valid signed election statement included with the documentation submitted for review. All election statements must include the following information: 1. Identification of the particular hospice which will provide care. 2. The beneficiary s or representative s acknowledgement that he or she has been given a full understanding of the palliative, rather than curative nature of hospice care, particularly the palliative rather than the curative nature of treatment. 3. Acknowledgement that certain Medicare services are waived by the election. 4. The effective date of the NOE statement, which may be the first day of hospice care or a later date, but may be no earlier than the date of the NOE statement. 5. The signature of the beneficiary or authorized representative. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 67

68 Certification Denials No Certification Present No Certification for Dates Billed Subsequent Certification Not Signed Initial Certification Not Timely Subsequent Certification Not Timely No Prognosis Statement January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 68

69 Certification Requirements The hospice must include the written certification which covers the dates of service billed with the medical records submitted for review. All dates billed must be covered by a certification. If more than one certification covers the dates of service requested, submit all the related certifications. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (J11 MAC) 69

70 Initial Certification For the first benefit period, the hospice must obtain, no later than two calendar days after hospice care is initiated, oral or written certification by the medical director or the physician member of the hospice interdisciplinary group and the beneficiary s attending physician. If one physician is serving in both capacities, this must be clearly identified on the certification. Written certification must be on file in the hospice beneficiary s record prior to submission of a claim to the MAC. The initial certification may be completed up to two weeks before hospice care is elected. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 70

71 Certification Certifications for subsequent benefit periods must be obtained no later than two days after the beginning of the new benefit period. Only one physician s signature is required on a subsequent certification. Verbal certification may be submitted; however, there must be documentation in the medical records to indicate the certification was obtained within the time frame indicated above. Verbal certification must be followed by a written certification, signed and dated by the physician prior to billing Medicare for the hospice care. If no verbal certification is present and the written certification is signed later than 2 days after the beginning of the benefit period, allowable days will begin with the date of the physician s signature. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 71

72 Responding to a Hospice ADR Checklist Part One The checklist on Palmetto GBA s website a recommendation for what to include when responding to an ADR: Valid, signed notice of election Name of hospice providing care Understanding that the other Part A benefits for the terminal illness are waived Understanding of the palliative nature of hospice Effective date of election Signature Physician s certification to cover the dates of services billed: If more than one certification covers the dates of service in question submit all certifications for the dates of service billed. Prognosis statement If certification is a multipage document, number the pages (Example: Page 1 of 3 ) Physician narrative/face to face documentation/attestation If the narrative is a dictated addendum, include physician signature and date on that page Plan of care that covers the dates of service billed January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 72

73 Responding to a Hospice ADR Checklist Part Two If the beneficiary has expired, submit information regarding date and cause of death If General Inpatient Care (GIP) is provided: Submit the signed and dated physician s orders/updated plan of care Include discharge summary If Continuous Care is billed: Submit notes for all hours that care is rendered Include when Continuous Care began and ended Documentation to support coverage Submit documentation to support the Local Coverage Determinations (LCDs) Include documentation showing structural/functional impairments to support terminality Document all pertinent diagnoses that relate to the patient s terminal condition and hospice appropriateness Submit documentation related to comorbidities or change in the patient s medical condition Submit Advance Beneficiary Notice (ABN) if applicable January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 73

74 CERT Error versus MR Denial Review Contractor Insufficient Documentation CERT Hospice-MD certification/ recertification Hospice-Beneficiary election form Hospice-Plan of care Medical Necessity Hospice-Service documentation on billed DOS Though a valid ICD-9 code(s) was submitted, the ICD-9 code(s) alone was insufficient information No Documentation Submitted No documentation submitted Palmetto GBA Medical Review Certification denials Plan of care denials Notice of election denials Signature denials Not hospice appropriate Level of care denials Auto Deny - Requested Records not Submitted January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 74

75 CERT Error Breakdown Error Code Description Number of Claims with Errors Hospice-MD certification/recertification 7 Though a valid ICD-9 code(s) was submitted, the ICD-9 code(s) alone was insufficient information 1 Hospice-POC 1 Hospice-Service documentation on billed DOS 1 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 75

76 CERT Review 1 Billed was hospice home care for diagnosis of Alzheimer's Disease. Beneficiary was admitted to hospice care per family request with a weight of 170 lbs, Karnofsky score of 40, PPS of 40. FAST score not documented on initial nurse assessment. Beneficiary was confused and able to ambulate with a walker and assist. During the review claim period, it is documented that the weight is 160 lbs, Karnofsky score is 40, PPS is 40 and beneficiary is confused, incontinent of bowel and bladder and is bedbound requiring total care. Diet is pureed with 2-3 cans of Ensure per day. FAST score is 7F. There were no skin integrity issues other than a growth on top of the head. While beneficiary requires total care and has developed some Parkinson tremors of upper extremities. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 76

77 CERT Determination Submitted documentation does not support that this beneficiary was terminally ill. Her weight was stable. She was total care but showed no evidence of continued decline. There is no documentation of exacerbations of comorbid conditions. Documentation does not support that beneficiary is terminally ill. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 77

78 CERT Review 2 Dx: (Unspecified malignant neoplasm of lymph nodes, site unspecified). Documentation supports provision of services as billed and necessity of hospice. Beneficiary with non-hodgkin's lymphoma, increasing pain, recent rapid decline, PPS 40% FAST 7C, and multiple co-morbidities. Aggressive care not an option. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 78

79 CERT Review 2 Received: Certification of Terminal Illness Orders POC Initial Comprehensive Assessment (CA) Interdisciplinary Updates to POC and CA Visit Notes January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 79

80 CERT Determination Missing: beneficiary's Election of Hospice Benefit (EOB) enrollment form. Error Subcategory: SP - Hospice-Beneficiary election form. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 80

81 CERT Review 3 Submitted documents initiation of CHC on 06/29/20XX r/t caregiver burnout with return to Routine Home Care on 07/01/20XX at 1600/4 p.m. During period billed for CHC the beneficiary was not treated for acute crisis, nor did he require or receive skilled nursing services. The beneficiary was cared for by CNA and LPN; with documented eight (8) hours/ 32 UOS care by LPN. LPN documentation does not support provision of or need for CHC level of care. Submitted physician's narrative is missing statement which states narrative was composed after personal review of documentation or examination of beneficiary and does not identify specific clinical finding to support life expectancy of six (6) months or less. Physician's narrative statement was 'End Stage Failure to Thrive. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 81

82 CERT Determination Medically unnecessary Continuous Home Care (CHC) Services. Invalid certification of terminal illness (COTI). During period billed for CHC the beneficiary was not treated for acute crisis, nor did he require or receive skilled nursing services. Submitted physician's narrative is missing statement which states narrative was composed after personal review of documentation or examination of beneficiary and does not identify specific clinical finding to support life expectancy of 6 months or less. Even with valid COTI, CHC level of care not supported as R&N. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 82

83 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 83

84 GIP Admission Patients (in general) may be admitted for short-term general inpatient care when the physician and hospice interdisciplinary team believes the patient needs pain control or symptom management that cannot feasibly be provided in other settings. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 84

85 GIP Admission GIP is available to all hospice beneficiaries who are in need of pain control or symptom management that cannot be provided in any other setting. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 85

86 GIP Statistics Office of Inspector General (OIG) also has conducted several studies identifying inappropriate Medicare payments in hospice. OIG found that 82 percent of hospice claims for beneficiaries in nursing facilities did not meet Medicare coverage requirements. OIG, Medicare Hospice Care for Beneficiaries in Nursing Facilities: Compliance With Medicare Coverage Requirements, OEI , September January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 86

87 GIP Requirements GIP is not intended to be custodial or residential. Once a beneficiary s symptoms are stabilized, or pain is managed, he/she must return to a routine level of care. The beneficiary may remain in a facility due to safety, but Medicare will not pay for GIP unless the beneficiary is in need of this level of care, and it is clearly documented in the medical records. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 87

88 Symptom Changes Sudden deterioration requiring intensive nursing intervention. Uncontrolled nausea and vomiting. Pathological fractures. Respiratory distress which becomes unmanageable. Transfusions for relief of symptoms. Traction and frequent repositioning requiring more than one staff member. Wound care requiring complex and/or frequent dressing changes that can not be managed in the patient s residence. Severe agitated delirium or acute anxiety or depression secondary to the end-stage disease process requiring intensive intervention and not manageable in the home setting. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 88

89 GIP Payments Out of 3,583 hospices, Medicare paid more than $1 billion for hospice GIP in Most of which was provided in hospices inpatient units, as opposed to hospitals or SNFs. This is eight (8) percent of the total $13.7 billion that Medicare spent for all hospice care during the year. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 89

90 Medicare GIP Payments by Setting Hospice Inpatient Units: $738 million Hospitals: $280 million SNFs: $86 million Inpatient hospice Hospital SNF January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (J11 MAC) 90

91 NHPCO Facts and Figures Level of Care RHC 96.5% 97.1% GIP 2.7% 2.2% CHC 0.5% 0.4% IRC 0.3% 0.3% Level of Care RHC 94.1% 96.5% GIP 4.8 % 2.7% CHC 0.8% 0.5% IRC 0.3% 0.3% January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 91

92 Percentages of GIP Stays and Medicare Spending on GIP by Setting 70% 80% 60% 50% 40% 30% 20% Hospice inpt unit Hospital SNF 70% 60% 50% 40% 30% 20% Hospice inpt unit Hospital SNF 10% 10% 0% 0% GIP Stays Dollars Spent on GIP OIG Analysis of CMS data, 2012 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 92

93 Percentage of GIP Stays Lasting More than 5, 10, or 21Days 35% 30% 33% 25% 20% 15% 10% 5% 0% 11% More than five days More than 10 days 2% More than 21 days OIG Analysis of CMS data, 2012 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 93

94 Average Length of Stay by Setting Calendar year Inpatient Units Hospitals SNFs OIG Analysis of CMS data, 2012 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 94

95 Summary of GIP Utilization GIP Utilization Total Number Beneficiaries with any GIP days in : 500,759 GIP stays (i.e., consecutive periods of GIP days) in : 553,397 GIP days in : 3,134,952 Source: All hospice claims 1/1/10 12/31/11. The last quarter of 2011 did not contain all final claims when this analysis was completed January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 95

96 Frequency of GIP Stays (Among Beneficiaries Who Had at Least 1 GIP Stay in ) Number of GIP Stays Number of Beneficiaries % 1 463, % 2 28, % 3 5, % , % Total 500, % January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 96

97 National Length of GIP Stays days, 10% 8-10 days, 10% 31 + days, 2% 1 day, 11% 2 days, 19% 5-7 days, 21% 3 days, 15% 4 days, 11% Source: All hospice claims 1/1/10 12/31/11. The last quarter of 2011 did not contain all final claims when this analysis was completed. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 97

98 Average Length of GIP Stays (Days) Across Service Sites ( ) All Inpatient Hospice Inpatient Hospital SNF Source: All hospice claims 1/1/10 12/31/11. The last quarter of 2011 did not contain all final claims when this analysis was completed January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 98

99 Share of GIP Days by Site of Service ( ) 1% 8% 25% 65% Inpatient Hospice inpatient Hospital Multi SNF Source: All hospice claims 1/1/10 12/31/11. The last quarter of 2011 did not contain all final claims when this analysis was completed. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 99

100 Site of Service before and After GIP Stay Site of service before First day of GIP Site of Service after last GIP day 23% 11% 65% Not in Hospice Hospice, at Home Hospice, Not Home 68% 4% 0 13% 15% Not in Hospice Hospice, at Home Hospice, not Home Deceased Source: All hospice claims 1/1/10 12/31/11. The last quarter of 2011 did not contain all final claims when this analysis was completed. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 100

101 Percent of Hospice Providers who Provided GIP by Provider Age 100% 80% 30% 23% 16% 17% 7% 3% 60% 40% 70% 77% 84% 83% 93% 97% No GIP Provides GIP 20% 0% 0-5 years 6-10 years years 16/20 years years 26 + years Source: All hospice claims 1/1/10 12/31/11. The last quarter of 2011 did not contain all final claims when this analysis was completed January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 101

102 Percent of Hospice Providers Who Provided GIP by Size 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 50% 50% Small RHC days 20% 80% Medium 3,500-19,999 days 4% 96% large 20,000 + RHC days No GIP Provides GIP Source: All hospice claims 1/1/10 12/31/11. The last quarter of 2011 did not contain all final claims when this analysis was completed January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 102

103 Percent of Hospice Providers Who Provided GIP by Provider Region 100% 17% 9% 20% 23% 80% 60% 40% 83% 91% 80% 77% No GIP Provides GIP 20% 0% Midwest New England West South January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 103

104

105

106 GIP Billing by State Provider State Hospice Totals Rev Code 0656 Totals Claims Beneficiaries Claims Beneficiaries KY 23,023 9,821 3,669 3,041 Palmetto GBA 1,154, , ,084 96,167 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (J11 MAC) 106

107 GIP Admits per 1,000 Beneficiaries State Admits per 1,000 Beneficiaries Q5004 Q5005 Q5006 Q5007 Q5008 Q5009 Total KY Palmetto GBA January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (J11 MAC) 107

108 GIP Billed Units per 1,000 Beneficiaries State Q5004 Q5005 Q5006 Q5007 Q5008 Q5009 Total KY , ,943.1 Palmetto GBA , ,442.0 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (J11 MAC) 108

109 Average Length of Stay per GIP Admit State Q5004 Q5005 Q5006 Q5007 Q5008 Q5009 Total Ky Palmetto GBA January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (J11 MAC) 109

110 GIP Care Documentation January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 110

111 Supporting Documentation Supporting documentation for symptom control may include: Sudden deterioration requiring intensive nursing intervention. Uncontrolled nausea or vomiting. Pathological fractures. Open wounds requiring frequent skilled care. Unmanageable respiratory distress. New or worsening delirium. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 111

112 Document Daily Why the Patient Still Needs GIP Pain, despite numerous changes to medication. Bleeding that won t stop. Nausea and vomiting, despite changes to medication. Terminal agitation, unresponsive to medication. Medication adjustment that must be monitored 24/7. Stabilizing treatment that cannot take place at home. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 112

113 Pain Documentation Pain requiring: Frequent evaluation by a doctor or nurse. Frequent medication adjustment. IVs or transfusions that cannot be administered at home. Aggressive pain management. Complicated technical delivery of medication requiring a nurse to do calibration, tubing, site care. Pain scale. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 113

114 Documentation Tips Discharge planning begins on admission and continues throughout the GIP stay. Document the team s efforts to resolve patient problems at the lowest level of care. Address discharge plans (or reason why the patient is still appropriate for GIP). Explain why care must be provided in the inpatient setting instead of at home or SNF (e.g., patient requires frequent RN/NP/MD assessment and titration of medications to control pain ). January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 114

115 Documentation Tips Describe the services provided. Each note stands on its own in supporting the level of care. Identify the context and the precipitating event that led to GIP status. Describe failed attempts to control symptoms that occurred prior to admission. Document care that patient s caregivers cannot manage at home (e.g., frequent changes in medication dose/route/schedule, IV medications). January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 115

116 Documentation Tips Identify specific symptoms that are being actively addressed ( uncontrolled nausea/vomiting; new delirium/agitation ). Document progress/context/changes including symptomatic imminent death that cannot be managed at home. Document patient s responses to interventions in the general inpatient setting. Were they effective? Are they still effective? January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 116

117 Don t Use patient is dying, end-of-life care general decline pain and symptom control or medication adjustment to justify GIP stay unless you also document why these actions cannot take place in the home. Document resolution of the precipitating event that led to GIP status without also documenting further criteria that maintains GIP status. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 117

118 Scenario 1 85-year old female with liver cancer; mets to the bone; and lung and a secondary diagnosis of dementia. Patient is bed-bound. She is incontinent of bowel and bladder and requires personal care throughout the day. Patient is lethargic but arouses to vigorous stimuli. The daughter request that her mother be transferred to an inpatient unit, she can no longer provide the care that is required. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 118

119 Scenario 1 Continued Her medication regimen includes Morphine Sulphate twice daily with sublingual morphine for break-through pain q two hours prn. The patient has required increasing amounts of morphine for break-through pain over the past two days. She is having increased periods of agitation and anxiety. The patient begins having grand mal seizures and is started on Intravenous medications to control the seizure activity. The patient is mottled and has developed Cheyne-Stokes respirations. She requires frequent suctioning and monitoring. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 119

120 Scenario 2 72 year old female patient who resides in a nursing facility. Patient has a hospice diagnosis of End-Stage Alzheimer s and comorbidities of Type II diabetes, congestive heart failure, and renal disease. The patient is aphasic and lethargic. Patient requires frequent turning, mouth care, and personal hygiene. Patient has mottling in all extremities, and nail beds are cyanotic, Cheyne-Stokes respirations with a respiratory rate of ten. Pulse is 106 and thready. Blood pressure inaudible. Slight rales noted bilaterally. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 120

121 Scenario 3 75 year old male patient with a diagnosis of end stage Alzheimer's/dementia and comorbidities of type II diabetes, and CHF. Patient has a Stage IV decubiti on the coccyx, which is oozing copious amounts of foul smelling drainage. Patient has spiked a temp of (R). B/P 124/56 P 102 R 26. Patient is aphasic, but moans frequently. Wound cultures are obtained. Roxanol is administered every two hours. Patient begins vomiting and Phenergan is administered per rectum. Dressing changes to the decubiti are required every four hours. The patient is on an air mattress and requires two for turning and repositioning every two hours and prn. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 121

122 Pulmonary Patients Documentation to Support the Terminal Illness January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 122

123 How Significant is the Problem? January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 123

124 State Level January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 124

125 Chronic Obstructive Pulmonary Disease (COPD) Adult Prevalence by Sex and State 2011 State Total Male Female Count Adjusted Percent Count Adjusted Percent Count Adjusted Percent Alabama 350, % 143, , % Arkansas 175, % , % Florida 1,165, % 482, , % Georgia 501, % 197, , % Illinois 584, % 234, , % Indiana 401, % 150, , % Kentucky 325, % 138, , % Louisiana 232, % 98, , % Mississippi 181, % 79, , % New Mexico 94, % 37, , % North Carolina 497, % 199, , % Ohio 675, % 280, , % Oklahoma 241, % 105, , % South Carolina 267, % 93, , % Tennessee 446, % 154, , % Texas 1,000, % 445, , % United States 14,688, % 6,048, ,639, % Source: Centers for Disease Control and Prevention. National Center for Health Statistics. Behavioral Risk Factor Surveillance System, Analysis by the American Lung Association Research and Health Education Division using SPSS software. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 125

126 Prevalence Rate January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 126

127 Respiratory Conditions State Total Population Pediatric Asthma Adult Asthma COPD Lung Cancer Alabama 4,8222, , , ,011 3,609 Arkansas 2,949,131 62, , ,804 2,112 Florida 19,317, ,915 1,252,606 1,165,344 12,370 Georgia 9,919, , , ,524 6,655 Illinois 12,875, , , ,567 8,865 Indiana 6,537, , , ,337 4,781 Kentucky 4,380, , , ,984 4,395 Louisiana 4,601,893 93, , ,904 3,435 Mississippi 2,984,926 73, , ,015 2,301 New Mexico 2,085,538 37, , , North Carolina 9,752, , , ,543 7,131 Ohio 11,544, , , ,214 8,368 Oklahoma 3,814,820 80, , ,199 2,662 South Carolina 4,723,723 94, , ,362 3,150 Tennessee 6,456, , , ,410 5,089 Texas 26,059, ,998 1,302, ,708 15,224 American Lung Association Epidemiology and Statistics Unit Research and Health Education May 2014 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 127

128 Diseases of the Respiratory System 81x Provider Disbursement 2014H2 Provider Disbursement 2014H1 Provider Disbursement 2013H2 Prov. Count 2014H2 Prov. Dis. per Provider 2014H2 Bene Count 2014H2 Prov. Dis. per Bene 2014H2 Prov. Dis. per Bene 2014H1 Prov. Dis. per Bene 2013H2 Billed Charge 2014H2 Covered Charge 2014H2 Claim Count 2014H2 KY 1,629,741 1,606,765 1,422, , ,326 6,301 5,690 3,436,612 3,427, TOTAL 8,034,693 6,912,452 6,666, ,032 1,829 4,393 4,061 4,301 16,497,471 16,311,522 2,867 82x Provider Disbursement 2014H2 Provider Disbursement 2014H1 Provider Disbursement 2013H2 Prov. Count 2014H2 Prov. Dis. per Provider 2014H2 Bene Count 2014H2 Prov. Dis. per Bene 2014H2 Prov. Dis. per Bene 2014H1 Prov. Dis. per Bene 2013H2 Billed Charge 2014H2 Covered Charge 2014H2 Claim Count 2014H2 KY 382, , , , ,640 3,369 3, , , TOTAL 22,668,840 21,496,456 23,543, ,554 2,710 8,365 8,252 8,969 45,409,307 44,880,847 6,693 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 128

129 Diseases Of The Respiratory System 81x Provider Disbursement 2014H2 Provider Disbursement 2014H1 Provider Disbursement 2013H2 Prov. Count 2014H2 Prov. Dis. per Provider 2014H2 Bene Count 2014H2 Prov. Dis. per Bene 2014H2 Prov. Dis. per Bene 2014H1 Prov. Dis. per Bene 2013H2 Billed Charge 2014H2 Covered Charge 2014H2 Claim Count 2014H2 KY 6,842,662 6,360,296 8,019, , ,087 8,677 10,348 13,576,194 13,573,862 1,911 TOTAL 82x 58,907,455 55,882,679 54,688,215 1,101 53,504 10,013 5,883 5,469 5, ,184, ,585,362 18,336 Provider Disbursement 2014H2 Provider Disbursement 2014H1 Provider Disbursement 2013H2 Prov. Count 2014H2 Prov. Dis. per Provider 2014H2 Bene Count 2014H2 Prov. Dis. per Bene 2014H2 Prov. Dis. per Bene 2014H1 Prov. Dis. per Bene 2013H2 Billed Charge 2014H2 Covered Charge 2014H2 Claim Count 2014H2 KY 1,185, ,097 1,079, , ,317 7,412 7,936 3,122,685 3,051, TOTAL 6,912,452 6,666,402 6,406, ,706 1,702 4,061 4,301 4,152 14,340,750 14,117,860 2,542 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 129

130 Introduction Cells in the body require oxygen to survive. Vital functions of the body are carried out as the body is continuously supplied with oxygen. Without the respiratory system exchange of gases in the alveoli will not be made possible and systemic distribution of oxygen will not be made possible. Anatomy and Physiology of Respiratory System By Daisy Jane Anetipuesto RN MN June 7, 2011 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 130

131 What is COPD? COPD is a type of obstructive lung disease characterized by chronically poor airflow. It typically worsens over time. The main symptoms include shortness of breath, cough and sputum production. Vestbo, Jørgen (2013). "Definition and Overview". Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Global Initiative for Chronic Obstructive Lung Disease. pp January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 131

132 COPD Diagram of the lungs and airways with an inset showing a detailed crosssection of normal bronchioles and alveoli. Damaged by COPD with an inset showing a crosssection of damaged bronchioles and alveoli. d+lungs.jpg January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 132

133 What is Dyspnea? The American Thoracic Society defines dyspnea as: "A subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. American Heart Society (1999). "Dyspnea mechanisms, assessment, and management: a consensus statement". Am Rev Resp Crit Care Med 159: doi: /ajrccm ats898. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 133

134 Global Initiative for Chronic Obstructive Lung Disease (GOLD) The GOLD grading system, formerly referred to as the stages of COPD, defines the disease according to its severity. COPD is graded by spirometry. Spirometry helps your doctor diagnose the disease and determine the amount of lung damage that is present in your lungs. It also serves as a guide to the initial approach of COPD treatment. Stages of COPD The Stages of COPD Define the Disease According to Severity By Deborah Leader, RN January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 134

135 Spirometry Two main components are measured to make the diagnosis: Forced expiratory volume in one second (FEV1), which is the greatest volume of air that can be breathed out in the first second of a breath. Forced vital capacity (FVC), which is the greatest volume of air that can be breathed out in a single large breath. Young, Vincent B. (2010). Blueprints medicine (5th ed.). Philadelphia: Wolters Kluwer Health/Lippincott William & Wilkins. p. 69 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 135

136 GOLD I: Mild COPD In GOLD I, Mild COPD, there may be mild airflow limitation but you may be unaware that lung function has started to decline. Forced expiratory volume in one second (FEV1) will be greater than or equal to 80% of the predicted normal values with an FEV1/FVC that is less than 70 percent. May not yet have any COPD symptoms, or you may have symptoms of chronic cough and excessive mucus. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 136

137 GOLD II, Moderate COPD During GOLD II, Moderate COPD, airflow limitation worsens and you may start to notice symptoms, particularly shortness of breath upon exertion along with cough and sputum production. FEV1 will be anywhere between 50% and 79% of the predicted normal values and your FEV1/FVC will be less than 70 percent. It is during this stage most people typically seek medical treatment. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 137

138 GOLD III, Severe COPD Once the disease has advanced to GOLD III, Severe COPD, limitation of airflow significantly worsens, shortness of breath becomes more evident and COPD exacerbation is common. FEV1 will be between 30% and 49% predicted and FEV1/FVC will be less than 70 percent. If you reach this stage, you may notice a decrease in your activity tolerance and an increase in fatigue-ability. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 138

139 GOLD IV, Very Severe COPD By the time a COPD patient reaches GOLD IV, Very Severe COPD, their quality of life is greatly impaired and COPD exacerbations are life threatening. Airflow limitation is severe (FEV1 less than 30% predicted or less than 50% predicted and your FEV1/FVC will be less than 70 percent). Chronic respiratory failure is often present at this stage, and may lead to complications with your heart, such as cor pulmonale and/or eventually, death. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 139

140 GOLD Spirometry Criteria for COPD Severity I. Mild COPD II. Moderate COPD III. Severe COPD IV. Very Severe COPD FEV1/FVC < 0.7 * FEV1 > or = 80% predicted FEV1/FVC < 0.7 * FEV1 50% to 79% predicted FEV1/FVC < 0.7 * FEV1 30% to 49% predicted FEV1/FVC < 0.7 * FEV1 < 30% predicted or FEV1 < 50% predicted with chronic respiratory failure At this stage, the patient is probably unaware that lung function is starting to decline. Symptoms during this stage progress, with shortness of breath developing upon exertion. Shortness of breath becomes worse at this stage and COPD exacerbations are common. Quality of life at this stage is gravely impaired. COPD exacerbations can be life threatening. From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) Available from: January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 140

141 What is Emphysema? Emphysema is a long-term, progressive disease of the lungs that primarily causes shortness of breath due to over-inflation of the alveoli (air sacs in the lung). In people with emphysema, the lung tissue involved in exchange of gases (oxygen and carbon dioxide) is impaired or destroyed. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 141

142 Pathologic Changes in Emphysema Destruction of septal walls of alveoli. Loss of elastic recoil. Destruction of vascular bed. Fusion of adjacent alveoli producing large abnormal airspaces (blebs or bullae). January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 142

143 Common Signs and Symptoms Shortness of breath, especially with activity Constant coughing, sometimes called smoker s cough Feeling like you can t breathe Excess mucous production Fatigue Decreased appetite Wheezing Chest tightness Anxiety, depression January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 143

144 Emphysema Emphysema Normal lungs Chronic obstructive lung disease ( COPD) / Emphysema Arcot Chandrasekhar, M.D. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 144

145 Pulmonary Bullae Pulmonary bullae are focal regions of emphysema with no discernible wall which measure more than 1 cm in diameter. Thin wall (< 1 mm), usually considered larger than blebs (> 2 cm). Stern EJ, Frank MS. CT of the lung in patients with pulmonary emphysema: diagnosis, quantification, and correlation with pathologic and physiologic findings. AJR Am J Roentgenol. 1994;162 (4): AJR Am J Roentgenol (abstract) - Pubmed citation 2. Collins J, Stern EJ. Chest radiology, the essentials. Lippincott Williams & Wilkins. (2007) January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 145

146 Pulmonary Blebs Small subpleural thin walled air containing spaces. Not larger than 1-2 cm in diameter. Hansell DM, Bankier AA, Macmahon H et-al. Fleischner Society: glossary of terms for thoracic imaging. Radiology. 2008;246 (3): January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 146

147 Functions of the Respiratory System January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 147

148 Going Beyond Diagnosis International Classification of Functioning, Disability and Health: Impaired Body Structures Impaired Body Functions Activity Limitations Participation Restrictions Environmental Factors January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 148

149 Functions of the Respiratory System Respiration functions: Respiration Rate Respiratory Rhythm Depth of Respiration Respiration Functions, Other Specified Respiration Functions, Unspecified International Classification of Functioning, Disability and Health World Health Organization b4 CHAPTER 4 FUNCTIONS OF THE CARDIOVASCULAR, HAEMATOLOGICAL, IMMUNOLOGICAL AND RESPIRATORY SYSTEMS January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 149

150 Respiration Functions Functions of inhaling air into the lungs, the exchange of gases between air and blood, and exhaling air. Inclusions: Functions of respiration rate. Rhythm and depth. Impairments such as apnea. Hyperventilation. Irregular respiration. Paradoxical respiration and bronchial spasm and as in pulmonary emphysema. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 150

151 Respiration Rate Impairments in rates. Too fast (tachypnea). Too slow (bradypnea). Absence (apnea). According to vital sign data published by the University of Virginia Health System, breathing rate is normal at 15 to 20 breaths per minute for an average adult at rest, and abnormal above 25 or below January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 151

152 Respiratory Rhythm Functions related to the periodicity and regularity of breathing: Cheyne-stokes respiration Respiratory rhythm is irregular, characterized by alternating periods of apnea and hyperventilation. Respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal depth and rigidity. Gradually, breathing slow and becomes shallower, climaxing in second period of apnea before respiration resumes. Respiratory Patterns by Daisy Jane Antipuesto RN MN February 17, 2011 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 152

153 Respiratory Rhythm Kussmaul s respirations respirations are abnormally deep but regular, similar to hyperventilation. Rate is increased. Biot s respirations condition of CNS causes shallow breathing interrupted by irregular periods of apnea. Respiratory Patterns by Daisy Jane Antipuesto RN MN February 17, 2011 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 153

154 Depth of Respiration Functions related to the volume of expansion of the lungs during breathing. Inclusions: impairments such as superficial or shallow respiration. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 154

155 Respiratory Muscle Functions Functions of the muscles involved in breathing. Inclusions: Functions of thoracic respiratory muscles. Functions of the diaphragm. Functions of accessory respiratory muscles. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 155

156 Structure of Respiratory System Trachea Lungs Thoracic cage Muscles of respiration Structure of respiratory system, other specified Structure of respiratory system, unspecified International Classification of Functioning, Disability and Health World Health Organization 2001 CHAPTER 4 STRUCTURES OF THE CARDIOVASCULAR, IMMUNOLOGICAL AND RESPIRATORY SYSTEMS January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 156

157 Abnormal Chest X-ray Abnormal chest X-ray findings are usually not seen until COPD is severe. In this case, the X-ray may show: Flattening of the diaphragm, the large muscle that separates the lungs and heart from the abdominal cavity. Increased size of the chest, as measured from front to back. A long narrow heart. Abnormal air collections within the lung (focal bullae). January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 157

158 Hyperinflation Hyperinflation of lungs occur in asthma, emphysema and chronic bronchitis. Findings of hyperinflation are: Dark lung fields. Low set diaphragm in 11th or 12th posterior rib. Heart is vertical and narrow. This is the result of downward push of diaphragm by lungs. Flattened diaphragms in lateral chest. Infra cardiac air: Left diaphragm is seen in its entirety. Retrosternal air is increased. Increased AP diameter. Chronic obstructive lung disease ( COPD) / Emphysema Arcot Chandrasekhar, M.D. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 158

159 What are the x-ray findings of emphysema? Lungs are large and hyper inflated. Signs of hyperinflation are: Low set diaphragm. Flat diaphragm best determined by lateral chest. Hyper lucent lung fields. Increased AP diameter. Increased retrosternal air. Vertical heart. Signs of hyperinflation can be seen in emphysema, chronic bronchitis and asthma. We can call it emphysema only when hyperinflation is associated with blebs and paucity of vascular markings in the outer third of the film. Chronic obstructive lung disease ( COPD) / Emphysema Arcot Chandrasekhar, M.D. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 159

160 Lateral View Lateral chest is best to evaluate flattening of diaphragm, AP diameter and retrosternal air. This lateral chest shows: Increased AP diameter. Low set flat diaphragms. Hyper lucent lung fields. Increased retrosternal air. encroaching on heart density. Multiple blebs: Avascular zones surrounded by thin wall. Chronic obstructive lung disease ( COPD) / Emphysema Arcot Chandrasekhar, M.D. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 160

161 How to Read Suspected Case of COPD When it is darker that is when we consider COPD. Identify all the signs of hyper inflation. Look for signs of emphysema: Avascularity in the peripheral one third of lung. Zones of avascularity. Bleb walls. Chronic obstructive lung disease ( COPD) / Emphysema Arcot Chandrasekhar, M.D. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 161

162 Exercise Tolerance Functions Functions related to respiratory capacity as required for enduring physical exertion. Inclusions: Functions of Physical Endurance Aerobic Capacity Stamina Fatiguability January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 162

163 Activity Limitations : Self Care Washing Oneself Caring for Body Parts Toileting Dressing Eating Drinking January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 163

164 Activity Limitations: Mobility Changing a Body Position Transferring Oneself Walking January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 164

165 BODE Index The BODE Index is a tool used by health care professionals to help predict COPD mortality, meaning how long a person will live after diagnosis. Presumably, a higher BODE score correlates with an increased risk of death. Celli BR et al. The Body-Mass Index, Airflow Obstruction, Dyspnea, and Exercise Capacity (BODE) Index in Chronic Obstructive Pulmonary Disease. NEJM 2004;350:1005. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 165

166 The BODE Index FEV1 (% predicted) 6-Minute Walk Test (meters) MMRC Dyspnea Scale Body Mass Index > < 35 > < > 21 < 21 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 166

167 BODE Index: Airway Obstruction The degree of airway obstruction that is present in COPD patients is measured by a simple pulmonary function test known as spirometry. One part of the test measures forced expiratory volume in one second, or FEV1. There are numerous studies which confirm that FEV1 is a strong predictor of survival in the COPD patient. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 167

168 BODE Index: Body Mass Index (BMI) Body mass index, or BMI, is a tool that that allows you to measure the amount of body fat you have in relation to your height and weight. Low BMI (being too thin) has been associated with poor prognosis in patients with COPD. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 168

169 BODE Index: Dyspnea Dyspnea reflects a patient's perception of their own COPD symptoms and the degree to which one experiences dyspnea can actually be measured on a scale (the MMRC goes from 0 being the least breathless to 4 being the most). January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 169

170 BODE Index: MMRC Dyspnea Scale Grade Description of Breathlessness 0 I only get breathless with strenuous exercise I get short of breath when hurrying on level ground or walking up a slight hill. On level ground, I walk slower than people of the same age because of breathlessness, or have to stop for breath when walking at my own pace. I stop for breath after walking about 100 yards or after a few minutes on level ground. I am too breathless to leave the house or I am breathless when dressing. Stenton C (2008). "The MRC breathless scale". Occup Med 58 (3): doi: /occmed/kqm162. January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 170

171 BODE Index: Exercise Tolerance COPD, especially in its later stages, can dramatically affect a patient's ability to exercise. Reduced exercise tolerance is often measured in patients with chronic illness by the 6-minute walk test, and, along with BMI, is a factor that expresses the consequences of COPD that go beyond lung damage. COPD Life Expectancy Factors Influencing COPD Life Expectancy January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 171

172 Elizabeth G. Eakin; Pamela M. Resnikoff; Lela M. Prewitt; Andrew L. Ries; Robert M. Kaplan Chest. 1998;113(3): Validation of a New Dyspnea Measure : The UCSD Shortness of Breath Questionnaire January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 172

173 Modified BORG Dyspnea Scale January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 173

174 Meguro M, Barley EA, Spencer S, Jones PW. Development and validation of an improved COPD-specific version of the St George's Respiratory Questionnaire. Chest 2006;132: January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 174

175 Quality of Well-Being Scale The Quality of Well-Being Scale (QWB) is a general health quality of life questionnaire which measures overall status and well-being over the previous three days in four areas: physical activities, social activities, mobility, and symptom/problem complexes. Part 1- Acute and Chronic Conditions Part 2 Self care Part 3 Mobility Part IV Physical Activity Part V - Usual Activity Copyright 1996 by Robert M. Kaplan, Theodore G. Ganiats, and William J. Sieber January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 175

176 January 2015 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor 176