Hospice: Regulatory Necessities CTI/Election Statement/NOE Katie Wehri, CHPC Director of Operations Consulting Healthcare Provider Solutions kwehri@healthcareprovidersolutions.com 1 BACKGROUND 2 1
Background COMPLIANCE Conditions of participation Requirements for payment TPE Targeted Probe and Educate OIG Reports Medicare certification/recertification surveys CASH FLOW 3 Every Patient, Every Claim Certification of Terminal Illness (CTI) Valid election statement Notice of Election timely submission and acceptance Plan of care *Participation in the Hospice Quality Reporting Program (HQRP) 4 2
Certification of Terminal Illness (CTI) Purpose is for physician(s) to certify/recertify that a patient is terminally ill Eligibility component Technical component Timing Form components 5 CTI Concerns OIG Hospices Should Improve Their Election Statements and Certifications of Terminal Illness Current requirement is that medical director must consider at least the following Diagnosis of the terminal condition Other health conditions, related or unrelated Current clinically relevant information supporting all diagnoses 6 3
Sources of Clinical Information Source of clinical information to be used by certifying physicians in determining a patient s eligibility is not clear in the requirements Raises the question as to what clinical information the hospice medical director (or hospice physician designee) is relying on to support his or her certification that the individual is terminally ill and from where this information was obtained 7 Sources of Clinical Information CMS will be working with MACs to confirm if they are requesting comprehensive clinical information as part of medical review If not should such information be included in the ADRs 8 4
Reminder To Comply CMS reminded hospices of the need to comply with CTI requirements Re release of two MLNMatters articles SE 1628 SE 1631 Directed hospices to 2016 OIG report CMS Hospice Payment Systems booklet 9 Assessment of Compliance MAC through Targeted Probe & Educate (TPE) OIG Other CMS contractors CERT ZPIC/UPIC RAC CMS surveyors L667/418.102(b) L668/418.102(c) L676/418.104(a)(5) 10 5
Assessment of Compliance L667/418.102(b) Standard: Initial certification of terminal illness The medical director or physician designee reviews the clinical information for each hospice patient and provides written certification that it is anticipated that the patient s life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: (1) The primary terminal condition; (2) Related diagnosis(es), if any; (3) Current subjective and objective medical findings; (4) Current medication and treatment orders; and (5) Information about the medical management of any of the patient s conditions unrelated to the terminal illness. 11 Assessment of Compliance L668/418.102(c) Standard: Recertification of the terminal illness Before the recertification period for each patient, as described in 418.21(a), the medical director or physician designee must review the patient s clinical information 12 6
Assessment of Compliance L676/418.104(a)(5) Each patient s record must include the following: Physician certification and recertification of terminal illness as required in 418.22 and 418.25 and described in 418.102(b) and 418.102(c) respectively, if appropriate. 13 CTI TECHNICAL COMPONENTS 14 7
CTI Dependent on benefit periods Two 90-day periods Unlimited 60-day periods Verify the benefit period 15 PHYSICIANS Must certify 16 8
Initial certification of terminal illness (CTI) Attending physician (if any) AND medical director or physician member of the hospice s IDG Recertification Medical Director or physician member of the hospice s IDG ONLY 17 CTI Timeframe Oral or written CTI within two days after hospice care initiated (by the end of the third day) For recertification, within two days after the first day of the benefit period Can be obtained up to 15 days prior to the election (or recertification) of hospice care Written must be on file in record prior to submission of claim 18 9
CTI Content Verbal certification does not require a verbal narrative Verbal Certification Verbal Order 19 CTI Content The statement that the individual s medical prognosis is that their life expectancy is 6 months or less if the terminal illness runs its normal course Specific clinical findings and other documentation supporting a life expectancy of 6 months or less The signature(s) of the physician(s), the date signed, and the benefit period dates that the certification or recertification covers 20 10
CTI Content Brief Narrative physician s brief narrative explanation of the clinical findings that supports a life expectancy of 6 months Must be part of the certification/recertification form OR Must be an addendum to the certification/recertification form 21 CTI Content Brief Narrative Physician s Narrative, contd. If part of the certification or recertification form, then the narrative must be located immediately above the physician s signature If an addendum to the certification or recertification form, 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. 22 11
CTI Content Brief Narrative Supporting clinical justification of life expectancy of six months or less Reflect patient's individual clinical circumstances Synthesizes comprehensive medical information Incorporates findings from physician F2F encounter, if applicable Cannot contain check boxes or standardized language that is used for all patients 23 CTI Content Attestation Must include physician attestation statement Based on physician s review of patient s medical record, &/or Based on physician s examination of patient Non-certifying physician or NP attestation must indicate results provided to certifying physician for use in determining whether the patient continues to have a six-month life expectancy Statement must be located on certification/recertification form directly above physician signature & date 24 12
CTI Face to Face (F2F) Encounter Required for the third hospice benefit period and all subsequent benefit periods Must be conducted no more than 30 days prior to the start of the benefit period with limited exceptions Must be performed by hospice physician or NP 25 CTI F2F Encounter Exceptional Circumstance new hospice admissions in the third or later benefit period: exceptional circumstances may prevent a face-to- face encounter prior to the start of the benefit period In such documented cases, Encounter can occur within 2 days after admission If the patient dies within 2 days of admission without a face to face encounter, a face to face encounter can be deemed as complete ONLY IN EXCEPTIONAL CIRCUMSTANCE 26 13
CTI F2F Encounter Brief Narrative Narrative must explain why clinical findings from encounter support life expectancy of six months or less 27 CTI F2F Encounter Attestation Hospice physician or nurse practitioner who performs the encounter must attest in writing that he or she had a face-to-face encounter with the patient, including the date of the encounter IF a nurse practitioner performed the encounter attestation must state that the clinical findings of that visit were provided to the certifying physician, for use in determining whether the patient continues to have a life expectancy of 6 months or less, should the illness run its normal course 28 14
Attestation CTI F2F Encounter Attestation attestation, its accompanying signature, and the date signed, must be a separate and distinct section of, or an addendum to, the recertification form, and must be clearly titled 29 Illegible signatures/dates CTI F2F Encounter Some Common Problems Unsigned/undated documents Initial certifications aren t obtained from both attending physician (if one) and hospice physician Recertification not obtained from hospice physician Required components not placed in proper location/not titled properly 30 15
CTI F2F Encounter Some Common Problems Not utilizing the proper professional (e.g. NP is not employed, etc.) CTI completed prior to the 15 days before the start of the benefit period OR more than two days after the start of the benefit period 31 CTI F2F Encounter Late The patient must be discharged from Hospice Medicare Hospice continues to care for patient at no charge to patient Patient must be readmitted and all necessary documents must be completed again Elections Assessments, etc. 32 16
VALID ELECTION STATEMENT 33 Election Statement Purpose is for the patient to make the election of hospice care and to understand this election Waiver of traditional Medicare benefits Choice of attending physician Effective date Technical components 34 17
Election Statement Concerns OIG Hospices Should Improve Their Election Statements and Certifications of Terminal Illness Complete and accurate information Missing required information 35 Reminder To Comply CMS reminded hospices of the need to comply with CTI requirements Re release of two MLNMatters articles SE 1628 SE 1631 Directed hospices to 2016 OIG report CMS Hospice Payment Systems booklet 36 18
Assessment of Compliance MAC through Targeted Probe & Educate (TPE) OIG Other CMS contractors CERT ZPIC/UPIC RAC CMS surveyors L673/418.104(a)(2) 37 Assessment of Compliance L673/418.104(a)(2) Signed copies of the notice of patient rights in accordance with 418.52 and election statement in accordance with 418.24 418.24 addresses content of the election statement waiver of other benefits 38 19
No particular form Valid Election Statement Different than consents Not dependent on benefit periods Continues until election is terminated Discharged Revokes 39 Valid Election Statement Content The election statement must include the following items of information: Identification of the particular hospice that will provide care to the individual The individual s or representative s (as applicable) acknowledgment that the individual has been given a full understanding of hospice care, particularly the palliative rather than curative nature of treatment 40 20
Valid Election Statement Content The individual s or representative s (as applicable) acknowledgment that the individual understands that certain Medicare services are waived by the election The effective date of the election, which may be the first day of hospice care or a later date, but may be no earlier that the date of election statement. An individual may not designate an effective date that is retroactive 41 Valid Election Statement Content The individual s designated attending physician (if any) Information identifying the attending physician recorded on the election statement should provide enough detail so that it is clear which physician or Nurse Practitioner (NP) was designated as the attending physician This should include, but is not limited to, the attending physician s name and NPI number The individual s acknowledgment that the designated attending physician was the individual s or representative s choice 42 21
Valid Election Statement Content The signature of the individual or representative 43 Election Statement Waiver For the duration of an election of hospice care, an individual waives all rights to Medicare payments for the following services: (1) Hospice care provided by a hospice other than the hospice designated by the individual (unless provided under arrangements made by the designated hospice) 44 22
Election Statement Waiver For the duration of an election of hospice care, an individual waives all rights to Medicare payments for the following services: (2) Any Medicare services that are related to the treatment of the terminal condition for which hospice care was elected or a related condition or that are equivalent to hospice care except for services (i) Provided by the designated hospice: (ii) Provided by another hospice under arrangements made by the designated hospice; and (iii) Provided by the individual s attending physician if that physician is not an employee of the designated hospice or receiving compensation from the hospice for those services. 45 Election Statement Common Problems Does not contain Name of the hospice Waiver Attending physician Acknowledgement of palliative nature of hospice care Signature of patient or legal representative 46 23
NOTICE OF ELECTION (NOE) NOTICE OF TERMINATION/REVOCATION (NOTR) 47 Notice of Election (NOE) Election Statement Notice of Election No prescribed form Signed by the patient Prescribed form Submitted to CMS NOT submitted to CMS 48 24
NOE Timely Filing Claim Type 8XA Must be filed within 5 calendar days after the hospice admission date Filed submitted and accepted Accepted not RTP d 49 NOE Electronic Processing CR10064 Accepting Hospice Notices of Election via Electronic Data Interchange Effective: January 1, 2017 Voluntary Guidance for vendors to create interface Overall intent: beneficiary status information to CWF faster 50 25
NOE Electronic Processing Updates to Medicare Claims Processing Manual, Chapter 11 Reasons for exceptions to the 5 day NOE submission Other sections added/updated NOTR Change of provider/transfer Change of ownership Corrections to admission date Occurrence code 56 Condition code D0 51 NOE Timely Filing Exceptions Fire, floods, earthquakes, or other unusual events that inflict extensive damage to the hospice s ability to operate; An event that produces a data filing problem due to a CMS or Medicare contractor systems issue that is beyond the control of the hospice; A newly Medicare-certified hospice that is notified of certification after the Medicare certification date, or is awaiting its user ID from its Medicare contractor; or Other circumstances determined by CMS to be beyond the control of the hospice. 52 26
Consequence: Provider liable days NOE Timely Filing Occurrence span code 77 used to identify the non-covered, provider liable days KX modifier with the Q HCPCS code reported on the earliest dated level of care line on the claim Denials are appealable 53 Notice of Termination/Revocation NOTR Claim type 8XB Must be filed within 5 days after the patient s discharge (live) unless the final claim is filed No consequence at this time Same four exceptions apply 54 27
NOE/NOTR Common Problems Not submitting timely Assuming that because the patient has been discharged/revoked and then elected hospice care again from the same hospice, it is not necessary to process the NOTR before the NOE Errors Start of care date Billing errors 55 PLAN OF CARE 56 28
Plan of Care As with any election, the hospice must fulfill all other admission requirements, such as certification or recertification, any required face-to-face encounters, or Conditions of Participation (CoP) assessments. 57 Plan of Care To be covered, services must be consistent with the plan of care Plan of Care Labeled and easily identifiable Contains all required components 58 29
Plan of Care Required Components Plan of care must be established before hospice care is provided Services must be consistent with plan of care Must be developed and periodically reviewed by: the IDG, in consultation with the attending physician, if any 59 Plan of Care Required Components Must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments Must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: Interventions to manage pain and symptoms A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Measurable outcomes anticipated from implementing and coordinating the plan of care. Drugs and treatment necessary to meet the needs of the patient. Medical supplies and appliances necessary to meet the needs of the patient. 60 30
Plan of Care Common Problems Not easily identifiable in the record Does not cover all dates being reviewed Not established by all necessary parties Not reviewed by all necessary parties Not reviewed timely 61 TARGETED PROBE AND EDUCATE 62 31
Targeted Probe and Educate October 1, 2017 Targets providers based on data Can be MAC specific Providers will receive letter of notification Charts requested: 20 40 Timeframe for submission: Strongly encourage 30 days Timeframe for review: 30 days Up to three rounds of probe and educate Acceptable error rate If go through three rounds and do not reach acceptable error rate will be referred to CMS for further action 63 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 non oncologic 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 64 32
PEPPER Target Areas Live Discharges Not Terminally Ill Live Discharges Revocations Live Discharges LOS 61 179 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 65 Resources CMS Benefit Policy Manual, Chapter 9 CMS State Operations Manual, Appendix M (L tags) Re release of MLNMatters articles SE 1628 SE 1631 HPS Alliance Members: CTI Audit Tool Election Statement Audit Tool 66 33
67 Katie Wehri, CHPC Director of Operations Consulting Healthcare Provider Solutions, Inc. 810 Royal Parkway, Suite 200 Nashville, TN 37214 615.399.7499 615.399.7790 info@healthcareprovidersolutions.com www.healthcareprovidersolutions.com 68 34