Who am I? Disclosure. Certs/Recerts/Face to Face. Hospice Eligibility. Objectives 11/1/2015

Transcription

1 Who am I? Certification of Terminal Illness and Face to Face Encounters How to win the ADR Battle David M. Fedor D.O. FACP, HMDC November 3 rd 2015 UHPCO Conference Critical Care Physician for Intermountain Healthcare Medical Director: Palliative Care at McKay Dee Hospital System Medical Director of Palliative Care for Intermountain Healthcare Medical Director for Envision Hospice Hospice Medical Director Certified (HMDC) Disclosure Presenter has nothing to disclose. This will be free of any commercial bias or endorsement. Personal bias will likely be rampant Let us begin.. Certs/Recerts/Face to Face Lots to cover today I ll be quick---possibly I will leave time for questions I may wander the room I will try to avoid bad jokes---key word is TRY Objectives At the end of this session, participants should be able to: Describe the needed components to a Certification of Terminal Illness Statement (Narrative) Describe the needed components to a Face to Face statement. (Narrative) Learn to love documentation...or at least not hate it. Remember that I DID NOT make these rules Hospice Eligibility Medicare hospice coverage depends upon a physician s certification of a life expectancy of 6 months or less if the terminal illness runs its normal course Seems simple and straight forward. Seems... 1

2 Eligibility--Continued Eligibility--Continued The physician s clinical judgment must be supported by clinical information and other documentation that provide a basis for a life expectancy of six months or less Medical necessity must be evaluated and clearly and objectively documented in the clinical record Recognizing that determination of life expectancy during the course of a terminal illness is difficult, CMS established LCD guidelines ( medical criteria ) for determining prognosis for cancer and non-cancer diagnoses LCD= Local Coverage Determination Eligibility-Continued LCD guidelines Created to assist in determining eligibility based upon disease severity and burden of illness. Allows for decline of the beneficiary s condition be to a factor in determining prognosis. Many do not reflect current research or medical information on prognosis. Not the legal standard for hospice eligibility However, are followed by reviewers when reviewing an ADR This is REALLY ANNOYING ELIGIBILITY, CONT D Hospice coverage for patients not meeting LCD guidelines may be denied Some patients may not meet the criteria, yet are deemed hospice appropriate because of comorbidities or rapid decline Coverage for these patients may be approved on an individual basis This is where the narrative statement is paramount!!!!!!! DOCUMENTATION All certification (admission) and recertification documentation mustcontain enough information to support the patient s terminal status upon review (by an outside party such NGS, CGS, Palmetto). All clinical indicators of decline that form the basis for certifying / recertifying the patient should be documented. 2

3 DOCUMENTATION, CONT D Recertification for hospice care requires the same clinical standards be met as for initial certification. Documentation should paint a picture of why / how the patient is appropriate for hospice as well as the level of care being provided. Documentation should include observations and measurable data, not merely conclusions. DOCUMENTATION, CONT D Patients with long term survival in hospice, or apparent stability, can still be eligible for hospice benefits. If this is the case, sufficient justification for a less than 6-month prognosis should appear in the record. Inconsistent documentation should be specifically addressed and explained, including findings suggestive of a > 6-month prognosis. CASE EXAMPLE Mrs. Turner is an 88 yr. old with a diagnosis of dementia. She weighs 92 lbs., eats little and is totally dependent in all ADLs. She s not speaking and is sleeping a lot. She was hospitalized two weeks ago for a UTI. Is she hospice appropriate? Terminal vs. Custodial Is this patient receiving terminal or custodial care? If your documentation doesn t reflect a 6 month or less prognosis (usually evidenced by clinical decline) you are at risk for payment denial. Don t wait until the recertification date to discharge an ineligible patient. Distinguishing Chronically from Terminally Ill There was no indication in the submitted documentation that beneficiary s life expectancy was 6 months or less. There was no documentation of co morbidities that would have contributed to a short life expectancy. The documentation shows that the patient required full time custodial care, but not the services of Hospice. Comments extracted from a de-identified ZPIC finding CLINICAL ELIGIBILITY The clinical presentation for determining terminal status should include the following: Impairment in the structure and function of body systems Decline in activity and functional status Secondary conditions Comorbid conditions 3

4 Eligibility Assessment Tools Functional performance measurement tools Karnofsky Performance Scale (KPS) Palliative Performance Scale (PPS) Functional Assessment Staging (FAST) ADLs New York Heart Association Classification (NYHA) Nutritional status measurement tools Weight scales Body Mass Index (BMI) Mid Arm Circumference (MAC) Cognition measurement tools Mini-Mental Exam FAST Painting the Picture Comparison charting Subjective writing Clear and detailed descriptions Avoid non descriptive phrases such as stable, appears weak, slow decline and replace with descriptions only up in chair for 1 hour before falls asleep Specific discipline s documentation Illustrate why beneficiary is considered terminally ill Tell a Story. Make me believe it! Documentation Admission Why hospice? Why now? Hospitalization Change in condition Decline Symptom exacerbation Additional care needs Compare to Local Coverage Determinations (LCDs) that best fits the patient Clarify all secondary and co-morbid conditions for consistent documentation Document impact on prognosis Use of standard assessment tools for the right diagnosis Second 90 day--documentation Why Hospice? Have benefit of days of documentation Why Still? Is there decline Is there disease progression Still compare to LCDs Use of standard assessment tools for the right diagnosis Comparison documentation Impact of terminal illness, co-morbidsand secondary conditions Hospice care is managing what symptoms LCDs Created in 1996 as a guide for physicians in determining hospice eligibility to be used in conjunction with clinical judgment Never intended to be used as public policy Intended to increase access, but has actually limited access Never validated Poorly predictive of prognosis Fox et al, JAMA 1999;282: Schonwetter, AmJHPM, 2003 LCDs These are NOT the end all be all. You can admit or recertify patients who don t meet enough criteria. You just have to be very specific in your narrative. Tell a story. I don t know the patient, and why they are Terminally ill. MAKE ME SEE WHAT YOU SEE. 4

5 More things to watch for Will Plan of Care Impact Prognosis? Dialysis, transfusions, discontinued? Antibiotic use? UGH!!!!! Is focus really comfort or is every effort being made to address reversible problems and prolong survival? If they are on for CHF. Treating a Pneumonia is not supposed to happen. Survival and Comfort after treatment of Pneumonia in Advanced Dementia Antibiotics improved survival, regardless of route Average adjusted increase in survival;273 days Comfort scores highest in untreated patients More aggressive care associated with increased discomfort May need to clarify goals of care Family, LTC staff may think antibiotics improve comfort in advanced dementia As do many clinicians Givens JL et al. Arch Int Med. 2010;170: Certification of Terminal Illness The medical director, or physician member of the IDG, must certify and (if necessary) recertify that the beneficiary is terminally ill 42 C.F.R The purposeof the physician certification isto be a check on inappropriate use of hospice benefit (either elected before patient has been maximally treated ifhe/sheso desires; or electedfor care of a chronic, rather than terminal, condition) CTI Continued All members of the IDG can provide input, it is only the medical director or physician member of the IDG that retains responsibility for certifications Certifying and recertifying the terminal illness is the function of the medical director or physician member of the IDG, and the patient s attending physician, not the entire IDG. The contributions of the other members of the IDG should be considered when making the recertification decision. CTI Continued Before certification the physician should look at the following: The primary terminal condition Any secondary conditions Current subjective and objective findings Current medications and treatment orders Information about any unrelated medical issues. CTI-Continued Things to look at: Is disease terminal? Is disease maximally treated? Are there secondary conditions? Are there comorbid conditions? Is the disease progressive? At what rate? What is the functional status? What is the trajectory to death for this disease? Are there psychosocial factors involved? What are the goals of care? What has changed in the last 1 month, 6 months? 5

6 CTI-Continued Must be signed by: Med Dirand Attending. Narrative by Hospice Physician Must have certification dates Must have the attestation statement. I have composed... CTI What CMS says: This synthesis should not be a simple restatement of the medical record facts, but instead sets out the physician s rationale as to how the facts justify the prognosis Our intent is for the physician to justify his prognosis, rather than simply sign a form. While our regulations have always required the physician to perform this sort of review, we believe often the physician relies too heavily on the hospice staff for the prognosis determination in both certification and recertification. DO NOT SAY Ptis terminally ill with 6 months or less--- Because the staff told me so Because the DON said so They seem sick Because I am a Physician Because...They need the services Would you certify this patient for Hospice? 88yo female nursing home resident with advanced Alzheimer s Dementia, FAST 7E, has had poor PO intake with weight loss of 13 pounds in 2 months (wtnow 97). Her meds must be crushed and given in pudding Comorbidities CAD, afib, PVD, COPD, HTN, Answer NO Not enough info to determine Terminal Illness vs. custodial care. If that was your narrative.you would FAIL an ADR. (That was taken from a Failed ADR) Recertsand Face to Face Physician Face to Face Exam Recert-Visit: Patient's Name Date of Visit Recertification Period Dates or Benefit Period Summarize pertinent clinical findings and other info, preferably in narrative form. Templates/check boxes discouraged 6

7 Face to Face Visit In visit note, document: Signs and symptoms of disease progression, using LCD criteria (document to hospice diagnosis) Functional status current and changes Cognitive status current and changes Nutritional status current and changes (include % weight loss in past 6 months and BMI) Physical exam, pertinent to hospice diagnosis Pertinent/recent lab work; if any Patient/family goals of care. Recertification Narrative For second 90 or Sub 60 Identify hospice diagnosis, and document to LCD criteria. List secondary and comorbid diagnoses. Precisely define the disease specific changes, as well as the functional, cognitive, nutritional decline seen in the patient in the past 6 months Not patient weaker and sleeping more but patient was ambulating with walker 3 months ago and now requires 2 people plus a Hoyer lift for transfers from bed to chair Document pertinent physical findings and laboratory studies. TELL A VERY DETAILED STORY Narrative--Continued Refer to your face to face visit in the narrative. Mention that you examined the patient. DO NOT cut and paste from other staff notes. Ok to Cut and Paste from your Face to Face. Highlight signs of disease progression. Patients dyspnea has worsened to the point where she can only speak 1-2 words at a time without stopping. This is worse than her previous recertification period when she could speak full sentences Narrative--Continued Example of Bad narrative statement: Ptcontinues to lose weight, and needs more assistance with ADLs. She is sleeping more, and has declined. That will not pass muster. Not specific, does not show WHY she has 6 months or less to live. Also, if in Sub 60 Mention an exam Narrative Good Or Bad? 101 year old man with advanced dementia Eating poorly, losing weight Sleeping more Staff reports less active, worsening Continues to decline Narrative Narrative: A spoken or written account of connected events; A Story Previous Bad Narrative No data No relationship to LCD criteria No medical need. No goals of care 7

8 Narrative 2 Good or Bad Illegible Signature must be legible---or have it printed below. Narrative 3 Sub year old man with end-stage dementia. Comorbidities are myocardial infarction, osteoarthritis and contractures of multiple limbs. Patient is non-ambulatory except for limited transfer with assistance, non-verbal except for occasional single words, incontinent of stool and urine and requires extensive assist for all ADLs. He has lost weight from 121 lbsto 113 lbs (6.6%)despite vigorous feeding Narrative 3 with current BMI 19. Last albumin was 2.4 two months ago. He is progressively lethargic and sleeps more than 16 hours per day. Recent fever suggested aspiration. Based on his declining function, deplete nutritional status, weight loss and comorbidities, life expectancy is less than 6 months if disease runs its normal course. Good? Bad? Why or why not? Lastly: Narrative 3 Did this narrative pass an ADR? Narrative 3 Did NOT pass ADR. Fails to include the clinical findings of WHY the Face to Face EXAM support a life expectancy of 6 months or less. Does not explain his declining function. Saying patient is declining is not enough Exam does not have to be comprehensive Must be mentioned 8

9 Example--Dementia Mr. S is completely dependent on staff for care. He is fearful of staff and notably uneasy and scared when I introduced myself and began the physical assessment. He spoke no intelligible words to me. Staff states he refuses care at times and requires Ativan frequently for agitation and unsettled behaviors. He can no longer feed himself or propel his own WC which he could do 4 months ago. Now leans to right when in WC and unable to hold himself upright. His dysphagia has worsened over the past 6 months and now consumes only 25% of meals. Current weight is 105 lbs, BMI of 21 with 10 lbweight loss over 6 month period. Good Points Shows that you examined the patient Relates his decline Able to propel WC four months ago now he cannot Leans to the right Shows that you saw him, and states that that finding is new. Documentation should: Be specific to that individual patient Have narrative notes to explain information noted on a checklist or EMR Use comment sections If checklist used Distinguish between exacerbation with stabilization and exacerbation with deterioration Illustrate progression of terminal condition Tell a story!! Documentation Errors Using words like stable, unchanged Document abnormal findings inconsistently Failure to regularly weigh or measure Obtain baseline measurements Hospice Aide does not document patient response Does not document how patient tolerates ADLs Generic documentation about ADLs 5 out of 6 Document how much assistance is needed with each ADL that requires assistance (min, mod, total) No consideration of intensity of care Patient has had no skin breakdown due to the 24 hour RTC attention provided by daughters turning ever 2 hours Failure to report injuries or falls Other thoughts What distinguishes the patient as terminal and not chronic Compare current to previous period Exacerbation and resulting decline/deterioration Purpose and need for aggressive palliative treatments Document decline Don t just say decline On admission show areas of decline At every recertification (at minimum) Get Aggressive in your Documentation I can t believe this patient is still alive She has not shown further measurable decline, because next decline is death LCD guidelines are not, as stated by CMS, admission or re-certification criteria, but serve only as guidelines. They do not trump physician judgement. If I were seeing this patient for the first time, they would absolutely qualify for hospice. CMS is terrible 9

10 Documentation Jives A very large area for ADR denials recently is documentation not agreeing. Example: Nurse states PPS is 50%, Physician states 40%. If no explanation given DENIAL Make sure your documenation tells the same story---and explain any differences. OR...DENIAL DENIAL DENIAL Compassion, Care, and Eligibility Remember hospice has an obligation to admit, certify and recertify only those patients who meet the guidelines set forth by Medicare (if Medicare is the payer). Patients who do not meet the guidelines (e.g. lack a 6 month prognosis) may have the same need as those who do. Even though you may want to provide services to these patients, you cannot base eligibility on patient need or on the amount of care provided. Important Points Tell a story Make it vivid Explain the terminality of the patient Remember your exam (Sub 60 s) Jive your Documentation Be aggressive Don t believe this is a Brief Narrative. Try the veal Tip your waitress Even if you do all that You may still get denied.. Be prepared to fight Be prepared to plead you case all the way to the Administrative Law Judge if you need to. Remember-----I didn t do this!!! That s it, That s all, There is no more! Thank you for your attention. Questions, Comments, Concerns? Hopes, Votes, Dreams, Ideas? 10