STATE HOSPICE ORGANIZATION AND PALMETTO GBA COALITION MEETING SUMMARY

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Jennifer Barker
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1 STATE HOSPICE ORGANIZATION AND PALMETTO GBA COALITION MEETING SUMMARY For meeting held on August 19, 2010 Included in this report: NCLOS audits update on status Various other audit types (ZPIC) Palmetto audits 2010 CAP discussion MAC Update Palmetto Points Change Request discussion Update from Dr. Feliciano on LCDs, ICF system and Going Beyond Diagnosis Q: How would a hospice report visits and location codes for Routine Home Care in the Hospice Inpatient Facility? find out below!

2 STATE HOSPICE ORGANIZATION AND PALMETTO GBA COALITION MEETING SUMMARY August 19, 2010 The following is a summary of the information gathered at the meeting. It includes data from the conversations, dialogue and discussion as well as information provided in any handouts. No information provided in this summary is intended for legal or operational advice but merely as information for planning and awareness. This summary is created entirely by the Georgia Hospice and Palliative Care Organization s coalition member in attendance at the time of the meeting and statements have not been evaluated or approved by Palmetto or the other members of the coalition. Questions submitted to Palmetto GBA by hospice coalition members with the responses provided will be published separately when they are made available electronically from Palmetto GBA. NCLOS audits update on status Most recent NCLOS rates are available on the website ( State_2half2009.pdf/$FIle/NCLOS_Rate_Slides_by_State_2half2009.pdf ) No additional discussion regarding NCLOS specifically but did mention again in discussion of audit activity Various other audit types Discussion focused on Zone Program Integrity Contractor (ZPIC) audits. These audits are designed to zero in on Medicare and Medicaid providers in detection of fraud and abuse, protect the Medicare benefit in various applications (DME, home health, hospice, etc) and work with law enforcement in investigating complaints associated with program integrity up to and including recovery of funds from providers found out of compliance through administrative action and discipline. The ZPIC hot spots are currently identified as California, Florida, Texas, Illinois, and New York. A member of the coalition shared information regarding recent ZPIC activities in Texas as follows: 10 hospice programs were selected based on CAP and NCLOS probe placement 1 program provided 33 records going back up to 3 years 16 of those records were reviewed for eligibility but only one 2 week time span was reviewed in the course of the audit for each record (a snapshot) o Most disturbing result is that the auditor can then EXTRAPOLATE the results of the audit findings to apply broadly to the entire agency s claims for that time period (for this agency, the auditor claimed that 97% of the hospices claims should be denied for ineligibility) This finding was based on such things as no pain documented for 2 weeks leading reviewer to conclude patient was not terminally ill There is an appeal process but it is lengthy and a bit murky still. In discussing with Palmetto, they confirm that they are involved in the audit processes for external audit agencies only as far avoidance of overlapping edit or review periods or in support of audit functions such as claim adjustment. CMS directs all audit activity and issues guidelines according to the individual contracts. Palmetto is responsible for review of any redeterminations that are requested as a result of denials made by ZPICs or other audit entities.

3 Palmetto audits 2010 There are currently 18 providers remaining on Corrective Action Plans across Palmetto s region. Focus for Palmetto review program is currently aimed at providers who meet the following three conditions: Exceeded the hospice CAP Exceeded the NCLOS rate for all providers Exceeded the ALOS for all beneficiaries (regardless of diagnosis) CAP discussion 2008 CAP report is completed and the 2009 CAP report is about 25% completed final results for top 10 CAP overpayments (based on dollar amount) by state: State Total Providers % with Overpayment Total CAP overpay amt Mississippi % $46,251,404 Alabama % $29,935,493 South Carolina 61 38% $21,505,624 Oklahoma % $20,326,358 Texas % $10,287,961 Georgia 95 22% $7,742,502 North Carolina 65 6% $6,014,879 Florida 36 11% $5,167,947 Louisiana % $4,322,715 Arizona 8 63% $4,114,067 MAC Update Palmetto was awarded the RHHI jurisdiction 11 with MAC region C but this has been challenged again and they are expecting final procurement announcement by 9/9/10. This MAC award has been challenged twice and awarded to Palmetto both times. Further announcements will be forthcoming based on next award determination as indicated. Palmetto Points Palmetto provided information about the Online Provider Services (OPS) system that is designed to meet the needs of providers in real time online format with ease of navigation and access to information that was previously conveyed via fax or mail. The OPS application will allow providers to check eligibility, claims status, remittances and look at financial information pertinent to the provider s status. Providers with current EDI enrollment agreements on file with Palmetto can participate now. Providers who do not yet have EDI on file must visit and follow the links to access EDI enrollment information. Palmetto provided a snapshot of its performance against measures established by CMS: o Claims processing CMS Standard 95% of all claims processed within 30 days of submission Palmetto performance = 99.7% o Appeals CMS Standard 100% of redeterminations completed in 60 days Palmetto performance = 100% o Provider Contact Center Average Speed of Answer CMS Standard callers will wait on hold < 120 seconds

4 Palmetto performance = 47 second average o Provider Contact Center Busy Signal received CMS Standard <20% of callers will receive busy signal Palmetto performance = 1.2% of callers actually received busy signal o Medical Review Timeliness CMS Standard 100% completed in 60 days or less Palmetto performance = 100% o Provider Enrollment (855A) CMS Standard 90% completed within 90 days Palmetto performance = 99% completed within 90 days Provider deficiencies/issues identified in audits o These can be found on Palmetto GBA s website quarterly but the most recent are: Documentation submitted did not establish eligibility Physician narrative not present or not valid (when asked for further explanation of this, Palmetto advised that often they see one or two sentences with such things as, Patient is dying soon or Seems appropriate versus the CONTENT required to establish clinical representation of terminality) No certification for dates billed Change Request discussion CR 7080 (Timely Filing) issued to expand instructions detailed in CR CR 7080 lists the standards for dates of service used to determine timely filing. Advice from Palmetto was that providers should NOT hold on to claims when under Medical Review as this delays timely filing and the definition of timely filing is a CLEAN claim physically received. Even if the claim is held up in the review queue, if filed on time it will eventually be processed. CR 7026 (MSP and non MSP lines on claim) this CR does NOT apply to hospice claims CR 6698 (narrative and physician signatures) this CR was reviewed based on confusion regarding verbal certification and written certification with narrative documentation. Palmetto provided specific clarification stating the intent of the narrative is to justify the signature on the written certification of terminal illness. While a hospice may obtain a verbal certification from a hospice physician, it may well be a different physician who signs the CTI statement and writes the narrative. This practice is acceptable and within the context of common medical practice. It is NOT permissible for physicians to sign items for each other. The signature on the certification form is not an authentication of the verbal CTI but is a separate certification and the narrative is therefore a justification of THAT signature. Update from Dr. Feliciano on LCDs, ICF system and Going Beyond Diagnosis Dr. Feliciano provided a very detailed discussion regarding pending changes based on the ICF and Going Beyond Diagnosis focusing primarily on the internal systems changes necessary at the provider level to prepare clinicians for the level of documentation needed to support terminal illnesses going forward. The elements that support progression of disease and terminal decline include Body structures Body functions Activities Participation Environmental factors

5 In response to a question specifically posed regarding the use of Debility, Unspecified as a terminal diagnosis, he stated: Use of ICD 9 CM Debility, unspecified contributes no specific information to the cognitive processes required of hospice clinicians. The diagnosis is merely a place holder providing no added value to the care process. It would be of greater value to establish a more specific primary diagnosis and use identified secondary and/or co morbid conditions to frame decision making and communication around the management and palliation of the terminal condition. Much of the IAC s discussion has been focused lately on the development of the Neurologic Condition LCD and its pending publication set for September 2, Palmetto will have educational tools available to providers to assist in the incorporation of the ICF methodology for improved documentation around this disease group. Coalition Questions and Answers a complete list of the questions submitted to Palmetto by coalition members will be published by Palmetto when the edits are finalized. The summary below is only preliminary and intended to provide insight into the particular documented. Q: How would a hospice report visits and location codes for Routine Home Care in the Hospice Inpatient Facility? Effective for claims with dates of service on or after January 1, 2010, hospices are required to report additional detail for visits on their claims. Specifically, on a separate line on claims for all Routine Home Care (RHC), Continuous Home Care (CHC) and Respite care billing providers must report visits, along with their associated time per visit (in 15 minute increments) with the time reported using the associated HCPCS G code. When recording any visit or social worker phone call time, providers should sum the time for each visit or call, rounding to the nearest 15 minute increment and report in the unit field on the line level the units as a multiplier of the visit time defined in HCPCS description. Providers should not include travel time or documentation time in the time recorded for any visit or call (documentation completed DURING the course of the visit is acceptable except in Continuous Home Care no documentation completed outside the actual visit may be counted). For services provided on or after January 1, 2007, hospices must report a HCPCS code along with each level of care revenue code (651,652,655,656) to identify the type of service location where that level of care was provided. Hospices should use HCPCS code Q5006 for Inpatient Hospice Facility and Revenue Code 0651 for routine level of care and value code 61 should be furnished as well. Effective for claims on or after October 1, 2010, hospices will report Q5010 when RHC or CHC is provided in a hospice residential facility or a hospice facility which is certified to provide inpatient care.

CMS CR 6440: Additional Documentation on Hospice Claims Related Q&A s

CMS CR 6440: Additional Documentation on Hospice Claims Related Q&A s ID# 8901 - Published 02/13/2008 Updated 04/09/2010 What constitutes a patient care visit that is reasonable and necessary? A reasonable