The Sea of Change for Hospice. Objectives. Painting the Relatedness Picture

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1 AN OVERVIEW Painting the Relatedness Picture Strategies for Effective Hospice Operations Julia H Maroney RN MHSA Director, Clinical Operations Consulting Simione Healthcare Consultants Objectives Review key additional reporting requirements, diagnosis coding changes and Medicare Part D medication coverage issues affecting hospice providers. Review the relationship between the additional reporting requirements, diagnosis coding changes and Medicare Part D medication coverage issues and the impact of these changes on the determination of relatedness of conditions and medications provided under the hospice benefit. Describe specific clinical operational strategies that hospices can use for successful implementation of these requirements. 2 PROPERTY OF SIMIONE HEALTHCARE CONSULTANTS The Sea of Change for Hospice OIG ZPIC ADR 3 1

2 2014 was quite a year! 2015 looking to continue Significant number of challenges introduced in 2014 including: Medicare D prior authorizations Additional Data Reporting on Claims Most problematic for hospices medications Hospice Information Set (HIS) Diagnosis Coding Enforcement Return to Provider - Claims not coded correctly Notice of Election/NOTR 2015 CAHPS Coding clarifications Payment changes 4 PROPERTY OF SIMIONE HEALTHCARE CONSULTANTS Related or Unrelated? Common thread is the decision making regarding a patient s diagnosis, treatments and medications and whether they are Related or more importantly Unrelated to the patients terminal prognosis. 5 Diagnosis vs Prognosis? Significant area of concern for the Hospice industry and CMS. Requires broadened scope of thinking and practice changes for many hospices. Necessary for appropriate beneficiary care and reimbursement. NHPCO has been at the forefront of this discussion with CMS. Important that the hospice industry take initiative. 6 2

3 Medicare D and Relatedness Decisions Hospice is required to cover medications which are reasonable and necessary to manage the terminal illness and related conditions. Medicare D covers medications for patient if the hospice determines they not related to the terminal illness and related conditions. Hospice is required to provide documentation why meds are not covered under hospice. 7 Federal Requirements for Hospice Drug Coverage Federal regulations at 42 CFR (f) stipulate that the Medicare Hospice Benefit must cover ALL medications and biologicals used primarily for the relief of pain and symptom control for the terminal illness and related conditions (the term medications and biologicals is defined in section 1861(t) of the Social Security Act). This includes both prescription and over-the-counter drugs as defined in 1861(t) of the Act. There are drugs that are statutorily excluded from the Part D benefit and may or may not be covered by the Hospice, depending on organization policies: Drugs for the symptomatic relief of cough and cold Most prescription vitamins Nonprescription (i.e., OTC) drugs. 8 Medicare Part D Revised Guidance July 18, 2014 Revised Guidance: Service-Payment/Hospice/Downloads/2014-PartD- Hospice-Guidance-Revised-Memo.pdf Effective July 18, 2014 with full implementation by 10/1/

4 Medicare D Sponsor Prior Authorization Medicare Part D Prior Authorization (PA) required for unrelated medications for all patients with an active hospice election. CMS encourages Part D sponsors to limit PA process to FOUR classifications of medications for those drugs that are CLEARLY unrelated to the terminal illness and related conditions: Analgesics Antinauseants (Antiemetics) Laxatives Antianxiety Drugs (Anxiolytics) Hospices are still responsible for all other medications that are related to the terminal illness and related conditions. 10 Five Buckets for Consideration of Medication Coverage Determination Related and medically necessary: Covered by Hospice POC. Related but deemed medically unnecessary for the Hospice POC. Unrelated and will be submitted to Medicare Part D for processing. Unrelated but in one of the four identified categories and submitted to Medicare Part D for prior authorization. Unrelated and no longer medically necessary. 11 Patients and Formularies Hospice Provider Confusion formularies for medication coverage, taken as a never cover Hospices are required to cover medically necessary care related to the palliation and treatment of the terminal illness and related conditions. REMINDER: Formularies for medication, DME, supplies are meant to help control costs not limit care 12 4

5 Patients and Formularies Hospices can continue to use formularies as a GUIDE. Hospices are required to provide medications that are effective to meet the needs of the patient. CMS expects hospice providers to provide nonformulary medications if no formulary alternative is available when they are necessary to meet the patient s needs and desired outcomes. If a patient wishes to have a drug not on the formulary, and hospice physician/pharmacist has determined that drug on formulary is effective: Patient may get drug, but will have to pay out of pocket. Medicare D would not cover. ABN would be required if the hospice bills the patient Additional Data on Claims Required additional visit reporting on claims, location of service, and post mortem visits. Additionally medications being covered by the hospice are to be included on the claims. Decisions to cover or not cover Transferred through to claims Additional Data on Claims Requirements Effective April 1, 2014 General Inpatient Care Visits (GIP) NPI-Inpatient Facility Identification Post-Mortem Visits Injectable and Non-Injectable Drugs Infusion Pumps Injectable and Non-Injectable Drugs/Infusion Pumps are impacted by relatedness decision 15 5

6 CR Injectable/Non-Injectable Drugs Reporting Injectable and Non-Injectable Prescription Drugs billed through the hospice: Injectable prescription drugs are reported on a line item basis per fill using appropriate revenue code and the applicable HCPCS code. Non-Injectable Prescription Drugs are reported on a line item basis per fill using the appropriate revenue code the applicable National Drug Code (NDC). Hospices must report the infusion medication on a line-item basis for each fill using revenue code 0294 along with the appropriate HCPCS code. Over the Counter medications are not required to be reported on the claim. Only applies to medications for which hospice is financially responsible. 16 Diagnosis Coding and Relatedness Threads The primary and secondary diagnoses are determined following ICD9 (ICD10) coding guidelines (using debility, AFTT, and Dementia correctly) These codes appear on the claim 17 Diagnosis Coding Clarifications Included in 2014 Wage Index Final Rule: Clarification of Existing ICD 9 CM Coding Rules Key Points: Need to include related diagnoses on claims No longer can use Debility/Adult Failure to Thrive as primary diagnosis Claims RTP d as of 10/1/14 Dementia Diagnoses-only specific codes using ICD-9 CM coding conventions Additional coding information found in CMS Change Request 8877 August 2014 : Hospice Manual Update for Diagnosis Reporting and Filing Hospice Notice of Election (NOE) and Termination or Revocation of Election. 18 6

7 Diagnosis Coding Clarifications 2015 Wage Index Proposed/Final Rule: Reiterated coding requirements Announced edits that will be implemented by CMS from Medicare Code Editor (MCE) Definitions of Terminal Illness and Related Conditions were introduced in the proposed rule but not finalized. CMS took notes and we can expect this to resurface again. 19 Diagnosis Coding Requirements Wage Index for 2016 Clarified that hospices are to be coding ALL diagnoses following coding guidelines Not JUST those diagnoses related to the terminal prognosis 20 PROPERTY OF SIMIONE HEALTHCARE CONSULTANTS How are Hospices Doing with these Requirements? Every day hospices are dealing with the decisions to cover or not cover items for a patient. Overall observing that there is a lack of documentation to support these decisions in the record. Not clear in the record how decision was made No documentation in record signed/dated by hospice MD or Medical Director Systems don t assist with requirement 21 7

8 Difference Between Diagnosis vs Prognosis? What is the difference between Diagnosis and Prognosis? Diagnosis (example definition): The identification of a specific diseases by the examination of symptoms and signs and by other investigations. Prognosis (example definition): A forecasting of the probable course and outcome of a disease, especially of the chances of recovery. Questions to Ask: Does this diagnosis or condition contribute to or influence the patient s terminal prognosis? What conditions should the hospice provider reasonably be expected to include in the Interdisciplinary Plan of Care? 22 Diagnosis vs Prognosis? The focus on terminal prognosis is not new for CMS but is a change of focus for many providers. Why is this important to CMS? To ensure appropriate coverage of services under the Medicare Hospice Benefit. Impacts other payers as well. To ensure appropriate Medicare spending allocation for Hospice beneficiaries (i.e. Medicare Hospice Benefit vs Medicare A, B, or D). Will also have survey and audit implications. 23 Decision-making and Documentation In the December 16, 1983 Hospice final rule (48 FR through 56011), regarding what is related versus unrelated to the terminal illness, we stated:... we believe that the unique physical condition of each terminally ill individual makes it necessary for these decisions to be made on a case-by-case basis. It is our general view that hospices are required to provide virtually all the care that is needed by terminally ill patients. Therefore, unless there is clear evidence that a condition is unrelated to the terminal prognosis, all services would be considered related. It is also the responsibility of the hospice physician to document why a patient s medical needs would be unrelated to the terminal prognosis. 24 8

9 Lack of Documentation - Risky Lack of documentation in the patients record to support why a decision was made to not cover a medication, treatment (wound care), or service (outpatient/inpatient care); could leave hospice vulnerable for payment of these services. Ask How could you demonstrate your noncoverage decisions? 25 Regulations The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from, the patient's attending physician (if any). In reaching a decision to certify that the patient is terminally ill, the hospice medical director must consider at least the following information: (1) Diagnosis of the terminal condition of the patient. (2) Other health conditions, whether related or unrelated to the terminal condition. (3) Current clinically relevant information supporting all diagnoses. 26 Confusion Diagnosis/Prognosis Diagnosis Coding the Primary diagnosis following the ICD 9 Coding guidelines, and related conditions Prognosis - It is often not a single diagnosis that represents the terminal prognosis of the patient, but the combined effect of several conditions that makes the patient s condition terminal. * CMS 2015 Wage Index The combined effect of everything that is wrong with the patient 27 9

10 Hospice Diagnosis Coding Requirements Medicare Claims Processing manual chapter 11 - Processing hospice claims. Hospices are to be coding diagnoses on claims following the ICD-9 CM Guidelines Require reporting of all additional or co-existing diagnoses HIPAA Requirement to adhere to the ICD-9 diagnosis and procedure codes. 28 Steps for Diagnosis Coding on Claims 1. Patient Information gathering a) H & P b) Labs c) Assessments 2. Medical Decision-making/Documentation a) Diagnoses impact prognosis b) Medications (treatments, services) 3. Diagnosis Coding, Medicare D, Claims Data 29 Considerations for Medical Decision-Making How does the physician get the information needed to make a decision if the patient is terminal? Sources: History & physical Hospital discharge information Labs & other test results Clinical findings on initial & comprehensive assessments Face to face findings 30 10

11 What About The LCD s? Local Coverage Determinations (LCDs) are a guide to determine prognosis for patients with specific disease related criteria: Pulse Ox < 88% COPD FAST Scales NYH Scales PPS Expect future updates. Hospice Diagnosis = What s causing prognosis of six months or less 31 Sample Medical Decision Making Referral received for a hospice patient. Referred from hospital following inpt stay for pneumonia/sepsis. COPD, CAD, HTN, Afib, Pacemaker Hist. Stroke, Obesity, DM II x 20 years, using insulin, arthritis, hist. non healing ulcers to lower extremities. Smoker 65 years. Nursing Assessment reports PPS 40%, lack of sensation lower legs and fingers, two ulcers to legs requiring wound care, Pulse ox RA 82%, NYH scale IV, O2 at 4L cont./bipap at night. Mild dementia, extremely HOH. Reports back pain inhibiting mobility/impacting sleep. Meds Prednisone, Insulin, Advair, Digoxin, Coumadin, Lasix, Tramadol. 32 Sample Diagnosis Prognosis - Medication Medical Decision Primary COPD Secondary (related/co-morbidities contributing to prognosis) CAD A Fib HTN Diabetes (length of time, impact to clinical prognosis) Open non-healing wounds Arthritis Dementia without behavior disturbance Decision to cover all diagnoses; all medications as physician determined all were contributing to terminal prognosis for patient

12 34 Decision-Making For Relatedness Must be the Hospice Physician Not the NP role Cannot be a nursing decision Is not a management decision Not dictated by pre-coverage decisions or formularies Individual decision based on the patient s unique clinical presentation and medical assessment of prognosis 35 Unrelated Conditions Unrelated conditions, treatments and medications Defined with reason by Medical Director/Hospice MD. This is not a nursing or management decision. Be clearly documented and distinguishable component in the record. Signed and dated by Medical Director/Hospice MD. Documentation started on admission and updated as new diagnoses, medications and treatments are added or patient condition changes. Integrate this discussion into operations

13 Recommended Strategies Documentation of decision making must be present in the clinical record and signed by the Medical Director/Hospice Physician. Lists terminal diagnosis and related conditions as well as unrelated diagnosis and medications. Many hospices using Physician Narrative or orders for this information but it is the hospice s discretion where this documentation is located. IDG discussion and comprehensive assessment may be used but the physician must document his/her rationale for related/unrelated. 37 Recommended Strategies POC should be reviewed at each IDG to ensure all conditions/medications/etc. are addressed. Work with PBM and electronic medical record (EMR) vendor regarding medication listing both for cert/re-cert and ongoing with changes. Need to ensure that MD has reviewed and approved related/unrelated medications and treatments. Treat each Hospice POC individually. Need to evaluate on patient by patient basis 38 How Are You Doing? Review how your hospice documents the decisions to cover or not cover diagnoses, medications, treatments and inpatient stays. Is your MD documenting clearly in record? Signed and dated clear statements? Do you need more than what is in the system? What about changes, added meds, ER visits, hospital stays? Does your documentation support why your hospice didn t cover something? Documented by MD? Does the documentation reflect all conditions contributing to the patient s prognosis? 39 13

14 Consider Changes to Patient Status Hospices need to look at documentation for notrelated decisions. Falls Inpatient stays Look at internal processes for decision making and documentation. How do you decide/document changes in meds, treatment when not related? 40 Questions? 41 SIMIONE.COM Simione Healthcare Consultants provides solutions for your core home care and hospice challenges organizational, financial, sales & marketing, technology, and mergers & acquisitions. Over 1000 organizations use our practical insight and tools to reduce costs, mitigate risk and improve efficiencies to steward the way they conduct business. Julia H Maroney RN MHSA jmaroney@simione.com 42 PROPERTY OF SIMIONE HEALTHCARE CONSULTANTS 14