TO CARE IS TO SHARE: MEDICARE CLINICAL HOSPICE UPDATES FROM CGS 2018 ANNUAL CONFERENCE OSAGE BEACH, MO S ANDY DECKER RN BSN Disclaimer This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings Medicare policy changes frequently, and links to the source documents have been provided within the document for your reference The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide 2 Hospice Clinical Resources CMS Hospice Benefit Policy Manual (Pub 100-02, Chapter 9) http://wwwcmsgov/regulations-and- Guidance/Guidance/Manuals/downloads/bp102c09pdf 3 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
CGS Hospice Clinical Denials September 2017 February 2018 Reason Code Description % of All Denials 5PM01 5PC08 5PC09 5PC01 Terminal Diagnosis Not Supported Face-to-Face Encounter Invalid Hospice Plan of Care Invalid Physician narrative Missing/Invalid 55% 8% 8% 7% 4 56900 Medical Records Were Not Received 6% Documenting Terminal Status 6 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
Effective Documentation of Terminal Status Decisions are reliant upon documentation Results in a full denial for the submission Documentation must be legible Medical necessity is always based on the patient s condition Is it the patient or the documentation? Make the reviewer see the patient 7 The reviewer isn t allowed to read between the lines 7 Effective Documentation of Terminal Status Documentation is expected to show significant changes in the beneficiary s condition and plan of care Always include admission assessment Decline must be evident in documentation Chart or graph may be helpful Graphs can show trends, even though the visit to visit changes may seem minimal 8 8 Effective Documentation of Terminal Status Documentation must paint the picture, especially for longterm hospice patients, or those with chronic illness and general decline Use quantifiable values and measurements to show changes 9 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
Weight Document patient s weight at least monthly and more often if possible Take weights in consistent fashion Time of day Clothing Consistency in relation to meal time Show prior and current weights Don t - loss of 4 pounds in since last weighing Do Patient went from 132 pounds on December 14, 2017 to 128 pounds on January 5 th, showing a loss of 4 pounds (3%) in 22 days 10 Measurements Upper arm/girth/leg measurements starting at admission Even if able to weigh patient Shows trend if suddenly unable to weigh Include policy in documentation that shows how and where measurements are taken Be consistent! 11 Weights and Measurements 8% weight loss in 180 days 200 pounds = 16 pounds in 180 days to 194 pounds 150 pounds = 12 pounds in 180 days to 138 pounds 100 pounds = 8 pounds in 180 days to 92 pounds 90 pounds = 7 pounds in 180 days to 83 pounds 12 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
Weights and Measurements November 2014 she weighed 180 pounds MAC 128 inches March 23, 2015 she weighed 1745 pounds MAC 125 inches She has lost the majority of her body fat 13 Weights and Measurements June 2014 July 2014 Aug 2014 Sept 2014 Oct 2014 Nov 2014 Dec 2014 1122 pounds 1168 pounds 1171 pounds 1209 pounds 1016 pounds 988 pounds 1048 pounds No mention of edema in charting 14 Weights and Measurements Dec 29 Jan 19 Feb 2 Feb 9 Feb 16 109 pounds 1058 pounds 1040 pounds 1088 pounds 1040 pounds No documentation of edema 15 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
Weights and Measurements 5 3 female 121 pounds Clothes hanging on body; wasting; cachexic BMI 214 (Normal is 185 249) 16 Weights and Measurements 2+ pitting edema to BLE Patient states elevating legs minimizes edema Due to patient s inability to bear weight, they have been unable to weigh her recently Last weight was 128 pounds, 4 months ago Intake currently 50%, decreased from 75% 17 Weights and Measurements September 2014 105 inches December 2014 975 inches March 2015 95 inches April 2015 23 cm 18 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
Weights and Measurements Admitted to hospice September 5, 2014 October 1, 2014 March 20, 2016 July 10, 2016 February 11, 2017 February 29, 2017 105 pounds 1145 pounds 122 pounds 1235 pounds 127 pounds 19 Weights and Measurements June 30, 2016 252 October 2016 2398 37cm December 2016 243 March 2017 235 36cm May 2017 223 35cm 20 Weights and Measurements 12/14 244 cm Left 01/15 25 cm Left 02/15 236 cm Left 03/15 23 cm Left 04/15 214 cm Left 05/15 23 cm Left 21 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
Level of pain Pain 0-10 scale is preferable, but may not be workable Consistent method of pain measurement is key Expressed in the way patient/caregiver understands Colors Small, Medium, Big Wong-Baker FACES Pain Rating Scale 22 Pain Type of pain Body language!!! Document any extenuating circumstances Examples: Wound care just completed, ready for pain meds, etc 23 Responsiveness Responsiveness Does the patient react to your presence? Is the patient frightened of you? Does the patient remember you from last visit? Does the patient remember why you re there? Unresponsive Respond to touch? Smell? Light? Fades in and out of alertness? 24 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
ADLs Levels of Activities of Daily Living (ADL) dependence What can they do SAFELY? Examples getting in/out of shower, ambulate while carrying food Are they impulsive? 25 Vital Signs Respiration rate, blood pressure, pulse, temperature, etc Graph easily shows change Does patient have a response to the procedure? 26 Strength Ask the patient to squeeze your hands Is there a difference from last visit? Can the patient raise their hands to yours? Can they lift a nearby object? Is the patient able to stand? Assisted or unassisted How long? Safely? 27 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
Lucidity Can the patient carry on a lucid conversation? If you change the subject abruptly can they still follow along? Can the patient make decisions? Simple or complex Current events Inside or outside their world 28 Intake/output I s and O s Make sure the serving size is appropriate and consistent Check for dehydration Is there a system in place to measure output that is workable for the patient/family? Is the patient offered food that they like and is appropriate for them? Appetite persistent or changing? 29 Aspiration Observed? By whom? Recurrent? Mild choking vs aspiration Aspiration pneumonia must be confirmed by physician 30 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
Fatigue Meet you at the door? Too tired to get out of chair? Recurrent? Too tired for self grooming? Too tired to prepare food or eat? No longer does favorite tasks? Is hobby neglected? 31 Agitation New Variable levels Unable to participate i t in conversation New? Increased? How easily is the patient agitated? 32 Skin Broken skin vs fragile skin Stage wounds whenever possible Redness? Itching? Pale or flushed? Diaphoretic? 33 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
Effective Documentation of Terminal Status Pitfalls in terminal prognosis documentation: Paradigm shift for medical professionals Have been trained to show improvement not decline Amount and detail dependent upon situation Chronic, deteriorating condition vs rapid progression Chronic, deteriorating condition may depend upon small details Rapid progression may be focused on only one symptom 34 Effective Documentation of Terminal Status Obtain history and physical information May come from more than one source Different sources may have different focus Dietician, emergency room staff Recent hospital stay? Lives or lived at facility? What does caregiver or family memer notice? 35 35 35 Effective Documentation of Terminal Status Use functional scale, as appropriate and always tell what changed to make change in status Karnofsky Performance Scale (KPS) 30%, 40%, 50%, etc Don t average numbers Palliative Performance Scale (PPS) 30%, 40%, 50%, etc Don t average numbers 36 36 36 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
Effective Documentation of Terminal Status Use functional scale, as appropriate and always tell what changed to make change in status Functional Assessment Staging (FAST) New York Heart Association (NYHA) Should be determined by physician 37 37 37 Effective Documentation of Terminal Status Don t forget documentation from the interdisciplinary group (IDG) meetings Information from other staff members May have different perspectives Different staff members see patient at different times and in different circumstances Example nurse compared with social worker or chaplain Aides have valuable information See patient at most vulnerable 38 38 38 Effective Documentation of Terminal Status Use numbers Use observations and data, not conclusions Clinical indicators of decline Weight loss, infections, changes in mobility, etc Review terminal admitting diagnosis still appropriate? Reassessment is ongoing Remember quality versus quantity 39 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
Effective Documentation of Terminal Status Common errors include: Documentation by various disciplines do not show same level of decline No measurable signs/symptoms presented for comparison Documentation does not support terminal status Documentation shows hospice benefit being utilized as long-term care benefit 40 Fast 7F PPS 20 ***************************************************************** Lying in bed, staring straight ahead with no eye contact or movement with gurgling noises, occasional grunt and drooling Very thin, no edema Falls asleep while feeding 42 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
Client s appetite is fair ********************************************************************* She typically has something quick to fix for breakfast such as a frozen waffle, eats leftovers for her lunch, and her daughter brings her supper 43 The patient babbles nonsensical phrases or word salad She parrots the sentences of others Her words may be understood at times, but are rarely appropriate or pertinent She was sleeping longer hours On admission she was sleeping 16 hours and by this review she is sleeping 20 hours per day She dozed off during conversations or assessments 44 04/22/12 (Admit) Intake 50%; Incontinent B/B, SOB with minimal exertion, requires assist with 6/6 ADLs PPS 30% 96 pounds 04/02/15 Intake less than 50% at meals Incontinent of bowel and bladder at times SOA with minimal exertion including eating and talking FAST 6E PPS 30% 95 pounds 45 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
When answering a question, she gets on to a track in which she counts, says shut up, that s the way it is and repeats that mantra several times for all oral conversation She is animated, voluble, rapid speaking, multiple words at a rapid clip without evidence of dyspnea 46 Patient is sitting in her w/c or lying in her bed 90% of the day She tries to get up by herself and is too weak and unsteady which is leading to falls Max assist with two to get from bed to wheelchair Patient will ambulate behind w/c on occasion 47 April 30 th (spiritual) No physical pain/discomfort reported at this visit May 1 st (nurse) PPS 60% May 2 nd (physician) PPS 30% progressive dyspnea at rest with pursed lip breathing 48 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
Patient has persistent nausea 4-6 days per week Continues to use (medication) for treatment with mixed effectiveness Poor appetite affected by nausea Spend most of days in bed due to nausea and weakness (Primary dx ES heart disease) 49 Recently patient has had an increase in sleep and lethargy and a decrease in appetite 50 Patient has taken a turn for the worse per family 51 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
86 y/o patient with Alzheimer s Patient frail with sunken temples, hollow cheeks, muscle wasting Very sleepy during visit rouses to voice and returns immediately to sleep Staff reports patient sleeps 18-20 hours per day Patient is completely dependent for 6/6 ADLs Bed to chair existence with assist of 2 to pivot from chair to bed Patient continues to lose weight down 13 pounds in past 5 months 52 Pain intensity: Mild What makes pain worse: movement What makes pain better: Medications, limiting activity Frequency: Intermittent Quality: dull Pain level is: Acceptable to patient 53 Patient refused examination Small wound on coccyx 54 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
ES Cardiac Heart rhythm: irregular without pattern Pitting Edema 2+ RLE E Wheezes B Diminished SOB 55 Female with overall decline Frail in appearance with sunken eyes and mild temporal wasting Skin is thin and fragile and she bruises easily Increased weakness 56 Feeds self, but uses utensils inappropriately Had two infections in past 3 months Treated with antibiotics ***************************************************************** Unable to feed self 57 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
Patient sleeps 8 to 10 hours per day He is able to feed himself, but does better with finger foods His appetite is fair He has had a 6 pound weight loss over the past 3 months He also had a 2cm decrease in the measure of his right upper arm from October to December Episodes of low blood pressure 58 Staff Documentation Staff Documentation Social Work Assessment Summary: 85 y/o Caucasian female dcd from SNF 5/22 then returned to hospital on 5/25 Pt had begun decline with confusion, many falls and constant uti s Ps was dx d with a cute (sic) resp failure d/t asp pna Dgtr/mpoa chose hospice for comfort care only Family very supportive of patient and each other Patient s spiritual needs have been met and faith is family s strength 60 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
Staff Documentation Patient had complete bath, shampoo with mouth care on arrival 100% breakfast No other meals noted Food taken per self / fed Food taken per self / assist 61 Staff Documentation Spiritual notes Patient appears to be in discomfort Appetite looks very good 62 Staff Documentation Has new walk-in shower due to increased weakness Requires assistance with showers, where 6 months ago patient was able to get into a regular shower/tub combination without assistance 63 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
Staff Documentation SW Notes: Patient is unsteady, uses walker and 02 02 not mentioned anywhere else in chart 64 Staff Documentation Chaplain notes: Chaplain visited patient on (date) He did not get up to open the door which is unusual for him He appears thinner than at last visit, and more pale He has to rest frequently when speaking because he becomes short of breath Several times in the course of the conversation, he attempted to subtract numbers in order to figure out the years when various events took place Each time he became confused and gave up 65 Staff Documentation On April 27, patient had increased SOB to a self reported level of 10 He required a bed bath saying he was too wiped out for a shower On April 28 th he again had SOB with difficulty speaking having to stop every few words to take a breath He was diaphoretic His telephone was moved closer to his bed to minimize exertion SW I put away his groceries I had obtained for him at the food bank because he was too short of breath to do it He began to sweat as we talked I encouraged him to slow down and take his time April 28 66 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
Hospice Resources Hospice Clinical Resources CMS Hospice Benefit Policy Manual (Pub 100-02, Chapter 9) http://wwwcmsgov/regulations-and- Guidance/Guidance/Manuals/downloads/bp102c09pdf 68 Resources CGS HHH Medicare Bulletins http://wwwcgsmedicarecom/hhh/pubs/mb_hhh/indexhtml Published monthly (links to prior bulletins) Compilation of news for hospice and home health providers CGS ListServ messages http://wwwcgsmedicarecom/hhh/pubs/news/indexhtml Recent News Web page Timely access to current news and publications http://wwwcgsmedicarecom/medicare_dynamic/ls/001asp Join/Update Listserv 69 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
CGS HH&H Website: Educational Materials http://wwwcgsmedicarecom/hhh/education/materials/indexhtml 70 Hospice Clinical Resources http://wwwcgsmedicarecom/hhh/education/materials/pdf/ hospice_documentation_tool_h-021-01_07-2011pdf 71 Six Months or Less Terminal Prognosis http://wwwcgsmedicarecom/hhh/education/materials/pdf/ hospice_clinical_factors_recert_tool_h-020-01_07-2011pdf 72 72 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
Hospice Clinical Resources http://wwwcgsmedicarecom/hhh/coverage/hospice_cove rage_guidelineshtml 73 Six Months or Less Terminal Prognosis http://wwwcgsmedicarecom/hhh/coverage/coverage _guidelines/hospice_documentationhtml 74 74 Resources CGS Frequently Asked Questions http://wwwcgsmedicarecom/hhh/education/faqs/indexhtml 75 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
CGS HH&H Web page http://wwwcgsmedicarecom/hhh/indexhtml Click + for Quick Links Links to Hot Topics Navigation Menu NEW 76 Updated: CGS HH&H Website: Education & Resources http://wwwcgsmedicarecom/hhh/education/indexhtml NEW 77 Quick Resource Tools (QRTs) https://wwwcgsmedicarecom/hhh/education/materials/indexhtml 78 claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
Need More Training?? Be sure to check out our Online Education Center, https://wwwcgsmedicarecom/medicare_dynamic/education/001asp 79 CGS HH&H Website: News & Publications http://wwwcgsmedicarecom/hhh/pubs/indexhtml News & Publications: Recent News (ListServs), CGS Bulletin, EDI Connection, Join ListServ 80 STAY CONNECTED! DOWNLOAD our GoMobile app! VISIT our mycgs Web portal https://wwwcgsmedicarecom/mycgs! CHECK out our website! https://wwwcgsmedicarecom! REGISTER for our email notifications! https://wwwcgsmedicarecom/medicare_dynamic/ls/001asp! / d i /l /001 FOLLOW our social media! @PartACGS @PartBCGS HHHCGS ATTEND our events! Part A - https://wwwcgsmedicarecom/medicare_ dynamic/wrkshp/pr/parta_reportasp Part B - https://wwwcgsmedicarecom/medicare_ dynamic/wrkshp/pr/partb_reportasp HHH - https://wwwcgsmedicarecom/medicare_ dynamic/wrkshp/pr/hhh_reportasp claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is
Questions? CGS Provider Contact Center: 18772994500 Option 1: Customer Service Option 2: Electronic Data Interchange (EDI) Option 3: Provider Enrollment Option 4: Overpayment Recovery (OPR) Twitter: http://wwwtwittercom/hhhcgs Facebook: http://wwwfacebookcom/hhhcgs claims submission lies with the provider of services Current Medicare regulations can be found on the CMS Web site, wwwcmsgov Reproduction of this material for profit is