ATTENDING PHYSICIAN ORDERS AND COVERAGE Patient s Choice of Attending Physician: CMS defines the hospice Attending Physician as either: a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he or she performs that function or action a nurse practitioner who meets the training, education, and experience requirements The definition also sets out the requirement that the patient identifies the Attending Physician at the time he or she elects to receive hospice care as having the most significant role in the determination and delivery of the individual's medical care. There are several specific Conditions of Participation to note: 418.52(c)(4) Patient s rights. The patient has the right to choose his or her Attending Physician. 418.24 (b)(1) Content of election statement. The election statement must include the following: The individual or representative must acknowledge that the identified attending physician was his or her choice. 418.24(f) Changing the attending physician. To change the designated attending physician, the individual (or representative) must file a signed statement with the hospice that states that he or she is changing his or her attending physician. o (1) The statement must identify the new attending physician, and include the date the change is to be effective and the date signed by the individual (or representative). o (2) The individual (or representative) must acknowledge that the change in the attending physician is due to his or her choice. o (3) The effective date of the change in attending physician cannot be before the date the statement is signed. 418.64(a)(3) Core services. Requires that if the Attending Physician is unavailable, the Hospice Medical Director, Hospice Contracted Physician, and/or Hospice Physician employee is responsible for meeting the medical needs of the patient. Choosing an Attending Physician at Start of Care: The election statement must include identification of the particular Attending Physician that will provide care to the individual. The individual or representative must acknowledge that the identified Attending Physician was his or her choice. Change of Designated Attending Physician: 1
If a patient, or patient s representative, wants to change his or her designated Attending Physician, the patient, or patient s representative, must identify the new Attending Physician in enough detail so that it is clear which physician or NP was designated as the new Attending Physician. To change the designated Attending Physician, the individual (or representative) must file a signed statement that states that he or she is changing his or her Attending Physician. The statement must identify the new Attending Physician, and include the date the change is to be effective and the date signed by the individual (or representative). The individual (or representative) must acknowledge that the change in the Attending Physician is due to his or her choice. The effective date of the change in Attending Physician cannot be before the date the statement is signed. For this process the following forms are to be completed: HOS4028 - Change in Patient Information CC3032 - Notification of Change in Attending Physician The Attending Physician: When a physician refers a patient to hospice care this does not mean the referring physician is the Attending Physician. If the Election statement is not completed as required: the hospice cannot bill Medicare if CMS finds the election statement to be incomplete or not completed correctly it could require the hospice to pay back any monies received that are tied to the election The patient s designated Attending Physician (if any), including information identifying the Attending Physician is clearly recorded on the Election of Benefit statement so that it is clear which Physician or Nurse Practitioner (NP) is designated as the Attending Physician. This information will include, but is not limited to: the Attending Physician s full name NPI number any other detailed information to clearly identify the Attending Physician NOTE: The patient-selected physician may decline the role of being the Attending Physician, in which case the program must rapidly return to the patient and have them make another selection. If a patient, or patient s representative, want to change his or her designated Attending Physician, the patient, or patient s representative, must file a signed statement with the hospice, which identifies the new Attending Physician in enough detail so that it is clear which physician or NP was designated as the new Attending Physician and acknowledge that the change is due to his or her choice. 2
If the hospice does not document a change in Attending Physician correctly CMS could deny payment for affected days the program and may also be at risk for survey deficiencies. Note: A Nurse Practitioner may not certify the patient s terminal illness even if they will be serving as the patient s Attending Physician. (CMS, CR 2750, 2003) The Attending Physician Coverage: The program should receive the verbal and written certification from the physician the patient has chosen to be the Attending Physician. Under rare exception and with up-line review during the admission process, Dr. A can give Verbal Certification for Dr. B and Dr. B can sign the written Certification of Terminal Illness, if there is strong evidence (documentation in the clinical record), that there is a coverage agreement between the physicians and documentation that he or she is covering for that physician. The following is required: Documentation on the CTI that "Dr. A is On-Call for Dr. B who is unavailable. This should be avoided unless absolutely necessary. Physician Certification of Terminal Illness: The patient s designated Attending Physician and the Hospice Medical Director must both complete the Certification of Terminal Illness, if the patient is eligible, and it must be signed and dated prior to billing. The Hospice Medical Director that signs the written Certification of Terminal Illness and Attestation must be the same physician that writes the Narrative Statement which reflects the patient s individual clinical circumstances and must include a brief narrative explanation of the clinical findings that support a life expectancy of six months or less. It is possible that the Hospice Medical Director (Dr. A) that provides the Verbal Certification of Terminal Illness may be a different physician than the Hospice Medical Director (Dr. B) that completes the Narrative Statement. The following is required: o Documentation in the clinical record that Hospice Medical Director (Dr. A); who provided the Verbal Certification of Terminal Illness was unavailable, (i.e., emergency, out of town, out of country etc.) and there is a coverage agreement. o This should be avoided unless absolutely necessary and requires up-line review during the Admission Audit. For subsequent benefit periods, recertification may be completed up to 15 days before the next benefit period begins. If the written certification cannot be obtained within 2 calendar days, after a benefit period begins, a verbal certification must be obtained within 2 calendar days and the written certification obtained before it submits a claim for payment. 3
No more than 30 days prior to the third and subsequent benefit period recertification(s), a Hospice Medical Director or Hospice Nurse Practitioner (employed by the hospice) must have a Face-to-Face Encounter with the patient to gather clinical findings to determine continued eligibility for hospice. With continued eligibility, the Hospice Medical Director will sign a subsequent Recertification of Terminal Illness, at the beginning of each new benefit period. NOTE: Some states require the Attend Physician to also sign the Recertification of Terminal Illness. A verbal or written certification statement must be obtained from the Hospice Medical Director up to 15 days prior or within two (2) calendar days after the first day of each period. Signed and dated certifications must be present prior to billing for each recertification period. Physician Orders: A physician-patient relationship exists between a hospice physician and a hospice patient upon admission to the hospice. Orders may be accepted from Medical Doctors (MD) and Doctors of Osteopathy (DO) or a Nurse Practitioner who is identified by the patient/family at the time of election as the attending physician as permitted by state regulations. The above does not limit the ability to accept orders from other physicians for whom a physician-patient relationship exists and who are otherwise authorized by state law to provide orders. A licensed nurse may receive verbal orders from a physician or physician agent (for example, nurse practitioner, physician s assistant or other authorized member of the physician's staff or facility discharge planner). The order must include the name and credentials of the physician agent. The complete verbal order must be read back as written and verified with the person giving the order. The read back order and verification must be documented on the order. Orders must always be signed by the physician who gave the Verbal or Telephone Order. Level of Care Change: CMS clarifies in its comments that the Attending Physician status need not change when a patient enters GIP. If the Attending Physician is not available or declines to fulfill the duties of the Attending Physician when the patient is in an inpatient setting, the hospice physician fills in as required at 418.64(a)(3). This also applies when the Attending Physician does not have privileges at the inpatient facility. There must be clear documentation in the clinical record for situations where the attending is no longer willing or available to follow patient. The patient/representative must be informed that a new attending may be chosen and the requirements for changing the designated Attending Physician must be met. 4
Facility Patients: The Attending Physician at a Facility does not necessarily meet the definition of the Hospice Attending Physician. For instance, a nursing home patient s record may indicate that the Nursing Facility s Medical Director is the patient s Attending Physician; however, the hospice still needs to discuss this with the patient/representative and provide the patient the option of choosing an Attending Physician for hospice care. CMS also clarified that a patient can choose a Hospitalist to be the patient s Attending Physician for hospice care; however, the patient must be notified that Hospitalists only follow patients who are hospitalized. Resources: Senior Home Care Behavioral Health Program Manual, Web M.D., 1998-2012 Mayo Foundation for Medical Education and Research IN FOCUS: The FY2015 Hospice Payment Rule Part 2 Addition of Attending Physician to Hospice Election Form and Change of Designated Attending Physician, August 25, 2014 Initial Certification of the Hospice Terminal Illness, Compliance Tip Sheet 2010 National Hospice and Palliative Care Organization Gentiva Hospice Policy Manual, 03-10 Physician s Orders, revised 05/03/2013 5