HOSPICE TARGETED PROBE & EDUCATE Melinda A. Gaboury, COS C Healthcare Provider Solutions, Inc.

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1 HOSPICE TARGETED PROBE & EDUCATE Melinda A. Gaboury, COS C Healthcare Provider Solutions, Inc. Targeted Probe and Educate October 1, 2017 Targets providers based on data Can be MAC-specific Providers will receive letter of notification If go through three rounds and do not reach acceptable error rate will be referred to CMS for further action (OIG or ZPIC likely) 2

2 Targeted Probe and Educate Charts requested: Timeframe for submission: Strongly encourage 30 days Timeframe for review: 30 days Up to three rounds of probe and educate Acceptable error rate Palmetto GBA 20% 3 Targeted Probe and Educate MAC will select the topics for review based upon existing data analysis procedures. The claim sample size for each round of probe review is limited to a minimum of 20 and a maximum of 40 claims TPE processes include provider specific education that will focus on improving specific issues without allowing other problems to develop along with an opportunity for the provider to ask questions. Education will be offered after each round of 20 to 40 claims reviewed.

3 TPE COMMON ERRORS 5 TPE PROCESS 6

4 Targeted Probe and Educate Tips for Success Providers targeted for TPE will receive a notification letter about the upcoming review and additional development requests (ADRs) will be used for the specific claims selected for review. Providers should ensure that medical records are submitted promptly upon request. Targeted Probe and Educate LOS with Non Oncologic Diagnosis This edit selects hospice providers who submitted claims with length of stay (LOS) >730 days and nononcologic diagnosis code LOS in LTC, NF or SNF This edit selects hospice providers who submitted claims with HCPC codes Q5003 (Hospice care provided in nursing long term care facility (LTC) or non skilled nursing facility (NF) and Q5004 (Hospice care provided in skilled nursing facility (SNF)), for any non oncologic diagnosis code and a length of stay greater than 180 days 8

5 Complete Review Packet Need to obtain all information on patient requested see checklist Perform both clinical and billing audit Compare that information with any previous audits which may have been completed Review ADR notice to determine if you have reviewed all requested information and if all copies were made Just a quick reminder of a hint to keep in mind when providing medical ADR responses or submitting appeal requests: MACs encourage all providers to submit your ADRs or Appeal Request using electronic submission Documentation to include with ADR Include documentation to support coverage under the Local Coverage Determinations (LCDs) for patients with non cancerous diagnoses. Include documentation showing structural/functional impairments to support terminality. Document all pertinent diagnoses that relate to the patient s terminal condition and hospice appropriateness. Documentation related to comorbidities or change in the patient s medical condition is considered an important part of the review process. Include any additional information that distinguishes the terminality of this beneficiary from others with the same diagnosis who are not terminal. Include documentation from all members of the interdisciplinary team members including the social worker, chaplain or volunteers. Non nursing documentation can help give the medical review team additional insight into the patient s medical condition. For example, if weight loss is documented, include the current weight and previous weight. Frequent assessments of the patient s condition and hospice appropriateness should be included in the submitted documentation. Ensure the submitted documentation distinguishes between exacerbation with stabilization and exacerbation with deterioration. If the documentation for the dates of service in question does not paint a clear picture of the patient s hospice appropriateness, you may also submit documentation for the month(s) prior to or subsequent to the dates of service requested.

6 Certification of Terminal Illness Requirements Written certification must be on file in the hospice beneficiary s record prior to submission of a claim to the Medicare contractor. If these requirements are not met, the payment begins with the day of certification If the written certification is not obtained within two calendar days, a verbal certification must be obtained within two calendar days, and the physician signature and date must be obtained before claim is submitted for payment The physician certification should include: Beneficiary name Six month prognosis statement Benefit period dates Physician(s) dated signature Name of staff member receiving the verbal certification and the date received (if applicable) For the first and second benefit periods, the physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of six months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms Certification of Terminal Illness Requirements For the third and later benefit periods, the medical director or nurse practitioner must conduct a face to face encounter to validate the beneficiary s need for hospice. The medical director or hospice physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms. If the narrative is part of the certification or recertification form, then the narrative must be located immediately prior to the physician s signature and date. If the narrative exists as an addendum to the certification or recertification form, in addition to the physician s signature and date on the certification or recertification form, the physician must also sign and date immediately following the narrative in the addendum. The narrative shall include a statement 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. The narrative must reflect the patient s individual circumstances and cannot contain check boxes or standard language used for all patients.

7 Important points of Hospice Documentation on visit notes Patient s condition Status of the family or caregiver The environment of care Description of care/services provided The patient s pain & symptom presentation and associated interventions and evaluations Reference to functional status using recognized tools (PPS, Karnofsky, FAST) Communication with the physician and other team members The observed or verbal patient/family response(s) to interventions and care Support for terminal prognosis Admission Changes in condition to initiate the hospice referral Diagnostic documentation to support terminal illness Physician assessments and documentation A date of diagnosis A course of the illness The patient s desire for palliative, curative care Records that show a trajectory of decline

8 Support for terminal prognosis throughout care Changes in the patient s weight Diagnostic lab results Changes in pain (type, location, frequency) Changes in responsiveness Skin condition (turgor) Changes in the level of dependence for ADLs Changes in anthropomorphic measurements (abdominal girth, upper arm measurements) Changes in vital signs (RR, BP, pulse) Changes in strength Changes in lucidity Changes in intake/output Increasing ER visits or hospitalizations Hospice PEPPER target areas Live Discharges Not Terminally Ill Live Discharges Revocations Live Discharges LOS Days Long Length of Stay CHC in Assisted Living Facility RHC in Assisted Living Facility RHC in Nursing Facility RHC in Skilled Nursing Facility Claims with Single Diagnosis Coded Episodes with no GIP or CHC Long GIP Stays

9 Home Health Agency PEPPER Compare Targets Report, Four Quarters Ending Q4 CY 2015 Visit PEPPERresources.org The Compare Targets Report displays statistics for target areas that have reportable data (11+ target count) in the most recent time period. Percentiles indicate how a home health agency's target area percent/rate compares to the target area percents/rates for all home health agencies in the respective comparison group. For example, if a home health agency's national percentile (see below) is 80.0, 80% of the home health agencies in the nation have a lower percent/rate value than that home health agency. The home health agency's Medicare Administrative Contractor (MAC) jurisdiction percentile and the state percentile values (if displayed) should be interpreted in the same manner. Percentiles at or above the 80th percentile for any target area indicate that the home health agency may be at a higher risk for improper Medicare payments. The greater the percentile value, in particular the national and/or jurisdiction percentile, the greater consideration should be given to that target area. Target Average Case Mix Description Proportion of the sum of case mix weight for all episodes paid to the HHA during the report period, excluding LUPAs and PEPs, to the count of episodes paid to the HHA during the report period, excluding LUPAs and PEPs Average Number of Proportion of the count of episodes paid to Episodes the HHA during the report period, to the count of unique beneficiaries served by the HHA during the report period Non LUPA Payments High Therapy Utilization Episodes Proportion of the count of episodes paid to the HHA that did not have a LUPA payment during the report period, to the count of episodes paid to the HHA during the report period Proportion of the count of episodes with 20+ therapy visits paid to the HHA during the report period (first digit of HHRG equal to 5 ), to the count of episodes paid to the HHA during the report period Target Count/ Percent/Ra Home Health Agency National Home Health Agency Jurisdict. Home Health Agency Amount te %ile %ile State %ile Sum of Payments Not Calculated $753, % $747, % $111,702 Hospice PEPPER

10 19 Speaker Information Melinda A. Gaboury, COS C Chief Executive Officer Healthcare Provider Solutions, Inc. 810 Royal Parkway, Suite 200 Nashville, TN

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