Documentation for Hospice: Eligibility & Relatedness. TAPM/TXNMHO Hospice Palliative Essentials HOPE 2015 (9/18/2015)

Transcription

1 Documentation for Hospice: Eligibility & Relatedness TAPM/TXNMHO Hospice Palliative Essentials HOPE 2015 (9/18/2015)

2 Presenter Ronald J Crossno, MD FAAFP FAAHPM Chief Medical Officer, Kindred at Home (formerly Gentiva) ronald.crossno@gentiva.com Disclosures No relevant financial disclosures No discussion of off-label usages

3 Learning Objectives Define hospice eligibility as delineated within the Medicare Hospice Benefit Discuss prognostication and the hospice eligibility certification process Discuss updated thinking regarding the determination of hospice relatedness / unrelatedness

4 Certification Growing evidence that certification is important in the role of hospice and palliative care providers Physician specialty board certification Requires 1-year fellowship beyond primary board certification HMD Certification Board ( Requires experience and demonstration of knowledge via testing Helpful in differentiating your hospice from others HPNA-associated certification ( CHPN, ACHPN, CHPPN, CHPLN, CHPNA, CHPCA NASW ( CHP-SW

5 Disclaimer This presentation is not intended to suggest that anything other than the complete truth should ever be documented False documentation is not tolerated under any circumstances!

6 Disclaimer This presentation is not intended to suggest that anything other than the complete truth should ever be documented False documentation is not tolerated under any circumstances! Any suggested findings used in this presentation are to be documented only if actually present

7 Triad of Medical Practice Traditional medicine has three aspects Diagnosis Prognosis Therapeutics Modern medicine has emphasized two of these almost to the exclusion of the third Advances through the 20 th Century emphasized research concentrating on diagnosis and therapeutics Only recently has prognosis been a subject of dedicated research

8 Prognosis versus eligibility Determining prognosis is the practice of medicine Growing body of literature on prognostication Determining eligibility is different, not directly involving medical practice Compares findings to a predetermined list of criteria Since by statute, hospice eligibility is based on prognosis, eligibility criteria are just guidelines

9 Local Coverage Determinations (LCDs) From each Medicare Administrative Contractor (MAC) No national coverage determinations for hospice MAC creates its own guidelines Designed to aid in making payment decisions (i.e. determinations) Specific to each MAC & therefore are local coverage determinations State Medicaid programs & private insurers may use one of these or have their own guidelines

10 What are the guidelines? The three (3) hospice MACs have published the following hospice LCDs: CGS Administrators, LLC one (1) longer, single hospice LCD* National Government Services, Inc. one (1) longer, single hospice LCD* Palmetto, GBA seven (7) hospice LCDs, based on non-cancer categories * the CGS and NGS LCDs are very similar MACs & others have responsibility to ensure that payment is made only for services that are reasonable & necessary

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12 Where are the guidelines? Available for access online: Choose Local Coverage Determinations Select your geographic area (usually your state or choose all states ) Enter hospice as a keyword Click Search by type Updates occur with minimal notice, though usually changes just represent minor tweaks or corrections (last accessed 6/15/2015)

13 How strictly are LCDs enforced? Can one be hospice eligible without meeting an LCD? Yes CMS requires each MAC to include a statement to the effect that: Some patients may not meet these guidelines, yet still have a life expectancy of 6 months or less. Coverage for these patients may be approved if documentation of clinical factors supporting a less than 6-month life expectancy not included in these guidelines is provided.

14 Basis for Hospice Certification Hospice Medical Directors (HMDs) certify/recertify Medicare beneficiaries for hospice when the prognosis is for a life expectancy of six months or less, if the terminal illness runs its normal course (b)(1)

15 Duration of hospice care coverage Election Periods (a) an individual may elect to receive hospice care during one or more of the following election periods: (1) An initial 90-day period; (2) A subsequent 90-day period; or (3) An unlimited number of subsequent 60-day periods. Must still be certified as being eligible

16 Certification of terminal illness (a) Timing of certification (1) General rule. The hospice must obtain written certification of terminal illness for each of the periods listed in (2) Basic requirement. the hospice must obtain the written certification before it submits a claim for payment. (3) Exceptions. (i) If the hospice cannot obtain the written certification within 2 calendar days, after a period begins, it must obtain an oral certification with 2 calendar days (ii) Certifications may be completed no more than 15 calendar days prior to the effective date of election. (iii) Recertifications may be completed no more than 15 calendar days prior to the start of the subsequent benefit period.

17 Certification of terminal illness (b) Content of certification. Certification will be based on the physician s or medical director s clinical judgment regarding the normal course of the individual s illness. The certification must conform to the following requirements: (1) The certification must specify that the individual s prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course. (2) Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. Initially, the clinical information may be provided verbally, and must be documented in the medical record and included as part of the hospice s eligibility assessment.

18 Certification of terminal illness (c) Sources of certification. (1) For the initial 90-day period, the hospice must obtain written certification statements from -- (i) The medical director of the hospice or the physician member of the hospice interdisciplinary group; and (ii) The individual s attending physician, if the individual has an attending physician. The attending physician must meet the definition of physician specified in

19 To Summarize Certification Rules Initial benefit period Attending (if there is one) and hospice physician Subsequent benefit periods Hospice physician only Other requirements No earlier than 15 days before benefit period Must have oral or written certification within 2 days Cannot submit bill without written certifications If a patient leaves hospice for any reason, Days remaining in that benefit period are lost Readmission starts with the next numeric benefit period

20 Admission to hospice care (a) 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). (b) 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.

21 Hospice Certification Is a Process Hospice certification is more than just a signature! Each certification or recertification is a process composed of several components Each component must be present and labeled in order for the certification to be considered complete A hospice physician must complete every hospice certification for which the patient is terminal

22 Other certification requirements Must clearly state benefit period start & end dates Standard to go by: Terminally ill means that the individual has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course Other requirements Can only be done by a physician (MD or DO); no one else Attending must be chosen by the patient Written or verbal certification within 2d of start of care Cannot bill until both written certifications are obtained Cannot certify any earlier than 15 days before the BP starts

23 Condition of participation: Medical Director (b) Standard: Initial certification of terminal illness. The medical director or physician designee reviews the clinical information of 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;

24 Condition of participation: Medical Director (c) Standard: Recertification of terminal illness. Before the recertification period for each patient, the medical director or physician designee must review the patient s clinical information.

25 Initial & 2 nd benefit periods Must include a physician narrative, composed by a certifying physician Attending* or HMD may do initial HMD to do 2 nd BP *Many recommend not using the attending physician since he/she is often unfamiliar with the narrative documentation requirements. Must include a narrative attestation statement Signed/dated by the composing physician Must contain the actual certification Signed/dated by the same physician who composed the narrative

26 3 rd & subsequent benefit periods Must document a face-to-face (F2F) encounter Must include a F2F encounter attestation If done by NP or non-certifying physician, must state findings were giving to certifying physician Must include a physician narrative Same as for 1 st and 2 nd BP Must include a narrative attestation Same as for 1 st and 2 nd BP Signed/dated by the composing physician Must include the actual certification Signed/dated by physician who composed the narrative

27 Physician Narratives Regulations require a physician narrative for every certification Done by the hospice physician (or attending) The physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification and recertification forms, or as an addendum to the certification or recertification forms (b)(3) The narrative shall include a statement directly above the physician signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patient s medical record or, if applicable, his/her examination of the patient (b)(3)(iii) [emphasis added] The narrative must reflect the patient's individual clinical circumstances and cannot contain check boxes or standard language used for all patients (b)(3)(iv)

28 Face-to-face (F2F) encounters As of January 1, 2011, a hospice physician or hospice nurse practitioner must have a face-to-face encounter with each hospice patient, whose total stay across all hospices is anticipated to reach the 3 rd benefit period, no more than 30 days prior to the 3 rd benefit period recertification, and must have a face-to-face encounter with that patient no more than 30 calendar days prior to every recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care (4)

29 Timing for Narratives & F2F Narratives / Certifications (all benefit periods) No earlier than 15 days prior to the start of the BP F2F (3 rd and later benefit periods) No earlier than 30 days before start of the BP to which it applies Must occur before (or on same day as) the narrative / certification For readmissions into 3 rd or later benefit periods, F2F must be done before the oral or written certification, unless: CMS has described exceptional circumstances for legitimate emergencies Missing the timing on a F2F and/or narrative can have significant financial impact

30 Traditional Clinical Documentation Intended to document what you see and what you do Audiences for this include: Oneself, for later review and comparison over time Other clinicians to understand this patient s care and progress Sometimes: outside reviewers

31 Today s Hospice Documentation Different documents are aimed at different audiences Traditional charting clinicians & sometimes others Eligibility documentation (e.g. narratives) payer reviewers! Use language appropriate for the audience For payers, this is the language of the LCD

32 * If documenting with one of these, explain why pt is still terminal! Four Ways to Document Eligibility Perfect Fit Meets an LCD guideline Close Fit + Support* Almost meets an LCD guideline + has significant comorbids Close Fit + Rapid Decline* Almost meets an LCD guideline + has rapid decline Clinical Judgment* There is not a guideline but does have a terminal prognosis

33 Clinical Judgment Let s do this first, since it is the easiest If no applicable LCD, then say so Don t fit square pegs into round holes Just document how pt is terminal Use prognostic language Upon review, it will hopefully be sent to a clinician since there is no applicable LCD for criteria comparison Unfortunately, some initial reviewers may deny these Be willing to appeal, with HMD involvement

34 Opportunities for Improvement Remainder of this section on certification will: Discuss commonly identified issues Provide suggestions for improvement Do so in the context of a specific guideline, when doing so makes sense

35 Eligibility Documentation Is Special Physician Narratives, Nursing Reviews of Decline, etc. Tell the story of the patient s prognosis Non-prognosis information is not needed in this documentation Should stand on its own, using language from the LCD Remember: primarily intended for external reviewers! Should always include the basic elements

36 Documentation Should Be Individualized Helpful to have a routine, but Don t be overly formulaic

37 Writing issues Legibility Dictate or use EHR (but more than standard language) References to see xyz F2F Narrative See my narrative See my dictation Watch the dates Cut n paste Don t do this!

38 Remember Case Managing Case-managing means being aware of the big picture Taught to document what is seen but Must also document what happened since the last visit Face to Face: patient perks up for the doctor such that this encounter may not represent the patient s overall condition Paroxysmal Nocturnal Dyspnea: patient has severe nighttime

39 Technical Issues Start & stop dates for the benefit period Signature & date for certifications Face-to-face done before the narrative Narrative/certification done by same HMD Proper documentation of who is the Attending Verbal / written certification by different physicians Okay to be different, but need explanation

40 Missing the Mark Inconsistent values PPS BMI FAST Constants that change Heights? Yes, heights! Resolving contradictions Sometimes things do change Inter-rater variability Inconsistencies need explanation

41 Documenting In-eligibility The day that hospice ineligibility is documented, is the last day that can be billed for care Discharge planning should start that day DC planning range is 2d to 30d, depending on state rules If eligibility is being questioned, consider documenting this with something along the lines of: More information is needed to confirm ongoing terminal prognosis (and then immediately start getting that information)

42 More Documentation Issues Let s turn now to some specific issues that are commonly seen These were all taken from real chart reviews Represent significant, yet easy opportunities for improvement

43 ADLs Activities of Daily Living Different organizations have different lists; be consistent These are not Instrumental Activities of Daily Living Non-ambulatory patients are dependent on others for ambulation If dependent in all ADLs (a.k.a. total care ) Best to say dependent in 6/6 ADLs Cannot self-feed Are considered to be incontinent of bowel and bladder

44 Cancer Usually straightforward, yet PPS should be < 70% Should have advanced disease with metastases Be wary with breast and prostate Always ask oneself if patient is progressing as expected If not, reconsider prognosis & whether testing is indicated Be especially vigilant when recertifying if no tissue diagnoses at admission

45 Cardiopulmonary Findings Dyspnea or angina at rest Remember to document symptoms at rest when present, not just worsen with exertion Don t forget conversational dyspnea / orthopnea / PND Intolerant of being off supplemental O 2 Hypoxemia Criteria are while on room air, at rest Use specific diagnoses Diastolic vs. Systolic heart failure Pulmonary fibrosis vs. COPD

46 Dementia Must document both parts of the criteria FAST 7 and Secondary condition, such as - 10% wt loss in 6 mo - Upper tract UTI - Aspiration pneumonia - Recurring infections - Stage III-IV decubiti or Significant comorbid condition, such as - AFTT, CHF, COPD, etc. What about FAST 6E?

47 Adult Failure to Thrive Should not use as principal, terminal diagnosis BUT Still excellent for documenting eligibility as a secondary diagnosis Document to the secondary condition Remember the criteria: Function: PPS of 40% or less Nutrition: BMI < 22kg/m 2 Evidence of ongoing decline Unexplained or multiple causes

48 Decline Great word! But try to document decline without ever using the word!! Use actual values Tie these values to actual dates e.g. BMI was 21 on Jan 1 st and now is 19 Confirm the prior values / dates

49 Losing Track of Time Very common documentation issue in LLOS pts Patient was eligible at admission With comorbid / secondary condition With rapid decline Then, 6+ months later, the supporting condition or rapid decline is no longer operative Don t get overtaken by stability Must consider basis for prognosis at every recertification!

50 Example #1: Narrative for BP yo male on hospice for Parkinsons Disease. He is either in bed or in a Broda chair. He is frail and dependent for all ADL s. He is incontinent of bowel and bladder. His speech is barely loud enough to hear and is generally unintelligible. He has a hx of aspiration pneumonia. Wound on coccyx has healed and doing skin prep to area. Pt requires lateral supports bilaterally in Broda chair. Pt is incontinent of bowel & bladder. Based on the clinical finding of the Face to Face

51 Example #1: Narrative for BP 11 (good) 85 yo male on hospice for Parkinsons Disease. He is either in bed or in a Broda chair. He is frail and dependent for all ADL s. He is incontinent of bowel and bladder. His speech is barely loud enough to hear and is generally unintelligible. He has a hx of aspiration pneumonia. Wound on coccyx has healed and doing skin prep to area. Pt requires lateral supports bilaterally in Broda chair. Pt is incontinent of bowel & bladder. Based on the clinical finding of the Face to Face

52 Example #1: Narrative for BP 11 (bad) 85 yo male on hospice for Parkinsons Disease. He is either in bed or in a Broda chair. He is frail and dependent for all ADL s. He is incontinent of bowel and bladder. His speech is barely loud enough to hear and is generally unintelligible. He has a hx of aspiration pneumonia. Wound on coccyx has healed and doing skin prep to area. Pt requires lateral supports bilaterally in Broda chair. Pt is incontinent of bowel & bladder. Based on the clinical finding of the Face to Face

53 Example #2 of an optimal narrative This 99 yo NH resident has end-stage dementia from Alzheimer s disease with a FAST of 7C, reflecting her nonverbal, non-ambulatory status. Her care was complicated by a hip fracture requiring pinning 3 weeks ago. During that hospitalization, she had an episode of aspiration pneumonia, and continues to frequently choke at meals. Her PPS of 40% reflects her dependence in 5/6 ADLs and sleeping >20h/d, up from 12h/d six months ago. Her BMI is 22.2, though she is having more trouble feeding herself. Considering this data, she clearly meets dementia guidelines (FAST 7, recent aspiration pneumonia, ongoing decline) so that she is unlikely to survive another 6 months.

54 Some Helpful Literature References Manfredonia JF, Policzer JS. Chapter 3 Clinical Care, Eligibility and Certification of Terminal Illness. The Hospice Medical Director Manual, Second Edition. AAHPM. 2012: Mitchell SL, Kiely DK, Hamel MB, Park PS, Morris JN, Fries BE. Estimating Prognosis for Nursing Home Residents with Advanced Dementia. JAMA. 2004;291(22): Mitchell SL, Miller, SC, Teno JM. Prediction of

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56 Relatedness What is driving this issue from the CMS standpoint? Money!!!!! Multi-millions spent on Part D for hospice patients opioids, etc., etc., etc.

57 CMS Statements on Relatedness It is our [CMS ] 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 need(s) would be unrelated to the terminal prognosis. [emphasis added] FY 2014 Hospice Wage Index and Payment Rate Update

58 Role of the Hospice Physician Based on CMS statements, the hospice physician is designated to make relatedness determinations This is still subject to post hoc review, as is the case for eligibility determinations IOW HMDs must justify the decisions in hospice documentation How is the hospice physician expected to do this?

59 NHPCO Terminal Prognosis Process Flow Developed by NHPCO Relatedness Working Group Presented to CMS with no negative feedback This has been essentially the same as what Gentiva has been teaching since late 2013.

60 NHPCO Terminal Prognosis Process Flow 1. Identify the Principal (terminal) Hospice Diagnosis Use ICD coding principles (Lots of resources but not covered here) Identify all the diagnoses and choose the primary one Have to follow the rules regarding what can / cannot be a Principal Diagnosis (e.g. not Debility, unspecified or Dementia in CCE )

61 Step 1 examples Some are straightforward, stand-on-their own Stage IV Lung Cancer Others are not straightforward, needing a combination of diagnoses to explain Alzheimers Disease with dementia Late effects of stroke, with vascular dementia Hypertensive renal disease with ESRD Key point The terminal illness increasingly requires a combination of diagnoses to describe, but

62 NHPCO Terminal Prognosis Process Flow 2. Are there other diagnoses caused by or exacerbated by Principal Hospice Diagnosis? This is where the other diagnoses are considered to determine what is related. In this step, is there pathophysiologic causation or exacerbation between the considered diagnosis and the Principal Hospice Diagnosis?

63 Step 2 examples Diabetes Caused by Pancreatic Cancer, after resection CHF Exacerbated by the patient s ESRD

64 NHPCO Terminal Prognosis Process Flow 3. Are there additional Diagnoses or Symptoms that contribute to the 6 month or less prognosis? Whether or not pathophysiologically related, does the additional diagnosis (or symptom) contribute, in an appreciable fashion, to the terminal prognosis?

65 Step 3 examples CHF Has AD with dementia that worsens the pt s prognosis Lung Cancer Has COPD that worsens the pt s prognosis Breast Cancer Has brittle, unstable Diabetes that worsens the pt s prognosis

66 NHPCO Terminal Prognosis Process Flow 4. Are there additional Diagnoses, Conditions, or Symptoms caused or exacerbated by treatment of the Related Conditions? These are the side effect conditions

67 Step 4 examples Diabetes caused by steroids treating end-stage COPD Constipation caused by opioid therapy for breast cancer Depression that is worsened in a bipolar patient dying of end-stage heart failure Dyspnea in a patient with CHF and COPD Worsened pain from arthritis in someone now immobile with dementia

68 NHPCO Terminal Prognosis Process Flow Remember, the default is related Only if no to all above steps is the diagnosis unrelated Hospice physician must document for each unrelated diagnoses with a reason why each is unrelated (e.g. explaining how they do not fall into any of the just discussed categories) Diagnoses are related / unrelated Treatments & medications are covered / not covered

69 Additional resources on relatedness NHPCO online resources (videos, flow sheet Determining Terminal Prognosis. NHPCO tool): New CMS statements on relatedness CMS statements in proposed CCJR rules where a beneficiary s underlying chronic condition would be affected by their LEJR procedure, or where the beneficiary s LEJR or post-lejr care must be managed differently as a

70 Reminder: Disclaimer This presentation is not intended to suggest that anything other than the complete truth should ever be documented False documentation is not tolerated under any circumstances! Any suggested findings used in this presentation are to be documented only if actually present

71 Summary Discussed basis for hospice certification Discussed the role of prognostication, eligibility determination and LCDs in certifying for hospice care Reviewed a number of documentation recommendations Discussed relatedness in the context of hospice care and optimal documentation

72 Time for Questions!

73 Example 3: BP 1 84 yo Dx d Alzheimers 4/2012 with decline as evidenced by weakness, falls with hip fx 2011, now sleeping >20hrs per day with inadequate po intake & progressive malnutrition. Given functional state & rapid decline, prognosis < 6 months.

74 Taken on its own, does this narrative explain why this patient is eligible for 1. Yes 2. No 3. Unsure hospice?

75 What does this narrative lack? Example 3: BP 1 84 yo Dx d Alzheimers 4/2012 with decline as evidenced by weakness, falls with hip fx 2011, now sleeping >20hrs per day with inadequate po intake & progressive malnutrition. Given functional state & rapid decline, prognosis < 6 months.

76 Examples 4a & 4b BP 15: 73 yo female w/ Alzheimers Dementia w/ progressive wgt loss despite adequate po intake. Contractures all 4 extremities w/ no wounds. Patient declining clinically w/ poor prognosis < 6 months to live. DNR & Palliative care only. BP 16: 74 yo female with end stage Alzheimers Dementia. Patient eating all meals but continues to decline w/ wgt loss & worsening flexure

77 Taken on their own, do these narratives explain why this patient is 1. Yes 2. No 3. Unsure eligible for hospice?

78 BP 16: 74 yo female with end stage Alzheimers Dementia. Patient eating all meals but continues to decline w/ wgt loss & worsening flexure contractures. No wounds. Receiving excellent Personal Care Examples 4a & 4b BP 15: 73 yo female w/ Alzheimers Dementia w/ progressive wgt loss despite adequate po intake. Contractures all 4 extremities w/ no wounds. Patient declining clinically w/ poor prognosis < 6 months to live. DNR & Palliative care only.

79 Example 5: BP 11 This is a 90-year-old lady who has been admitted to hospice services with severe Alzheimers dementia, & she has significant comorbidities of heart failure, & delusions & paranoia that are associated with her dementia. On the FAST score, she is 7E, & she is 30% on the PPS score. She continues to suffer from diffuse musculoskeletal pain, and she requires transdermal fentanyl patch to help control the pain. Her appetite is poor & she has continued to lose weight, although this has been blunted by the efforts of the nursing home staff to feed her. With their assistance & encouragement, she is consuming up to 5% of all the meals presented to her. Her weight is 197 pounds, & her BMI is Her mid arm circumference is 29cm. The patient is now sleeping at least 20 hours out of a 24-hour day & her speech has become mumbled & unclear. She requires 100% assistance with all her activities of daily living & she is nonambulatory. The patient will become upset & aggressive & agitated with her activities of daily, such as bathing and dressing. She has also developed flexion contractures of her left hand & left elbow. The patient continues to decline consistent with her terminal diagnosis, & she remains appropriate for continued hospice care.

80 Taken on its own, does this narrative explain why this patient is eligible for 1. Yes 2. No 3. Unsure hospice?

81 Example 5: BP 11 This is a 90-year-old lady who has been admitted to hospice services with severe Alzheimers dementia, & she has significant comorbidities of heart failure, & delusions & paranoia that are associated with her dementia. On the FAST score, she is 7E, & she is 30% on the PPS score. She continues to suffer from diffuse musculoskeletal pain, and she requires transdermal fentanyl patch to help control the pain. Her appetite is poor & she has continued to lose weight, although this has been blunted by the efforts of the nursing home staff to feed her. With their assistance & encouragement, she is consuming up to 75% of all the meals presented to her. Her weight is 197 pounds, & her BMI is Her mid arm circumference is 29cm. The patient is now sleeping at least 20 hours out of a 24-hour day & her speech has become mumbled & unclear. She requires 100% assistance with all her activities of daily living & she is nonambulatory. The patient will become upset & aggressive & agitated with her activities of daily, such as bathing and dressing. She has also developed flexion contractures of her left hand & left elbow. The patient continues to decline consistent with her terminal diagnosis, & she remains appropriate for continued hospice care.

82 Example 6: BP 6 Pt is a 65 yo LAF with ES Alzheimers. FAST 7B with history of cachexia, TIA, CVA, Hypothyroid, OSA, IBS, frequent falls, depression. Pt had a face to face encounter on 9/23/14 in her home. Pt with PPS 40%, down from 50% 2 months ago, and is total care for all ADLs, and needs 1:1 feeder support. Pt sleeps hrs/day, increased from 14/day. Pt is 59 tall, wt now 107.8#; MAC 22 with BMI Pt now has to be lead around, with decreased verbalization, with PICA and licks floor. Pt now with increasing

83 Taken on its own, does this narrative explain why this patient is eligible for 1. Yes 2. No 3. Unsure hospice?

84 Example 6: BP 6 Pt is a 65 yo LAF with ES Alzheimers. FAST 7B with history of cachexia, TIA, CVA, Hypothyroid, OSA, IBS, frequent falls, depression. Pt had a face to face encounter on 9/23/14 in her home. Pt with PPS 40%, down from 50% 2 months ago, and is total care for all ADLs, and needs 1:1 feeder support. Pt sleeps hrs/day, increased from 14/day. Pt is 59 tall, wt now 107.8#; MAC 22 with BMI Pt now has to be lead around, with decreased verbalization, with PICA and licks floor. Pt now with increasing dependent edema with recent elopement being

85 Example 7: BP 6 This 93 year-old Caucasian female continues under hospice care for cerebral atherosclerotic dementia. PPS is at 40% unchanged over 2 months. The patient does require assistance with all ADLs with the exception of feeding and she sleeps more than 14 hours in a 24-hour period. Height is at 62 inches. The patient has continued to lose weight from 152 pounds 2 months ago to 151 pounds currently. BMI is at 22 currently. The patient s weighed as much as 168 pounds 8 months ago. The patient does manifest dysphagia and choking. CNP notes dependence for all ADLs, incontinent of bowel and bladder. CNP notes the patient sleeps more than 18 hours in a 24-hour period. Failed swallow study noted and the patient is on pureed diet with nectar-thickened liquids and requires mechanical life for transfers, bed-to-chair existence. RN notes significant dysphagia, remains high aspiration risk, recent antibiotic for UTI, associated mental status changes as the patient has hospice diagnosis of cerebral atherosclerotic dementia with very significant aspiration risk and as the patient has shown decline in sleep pattern and weight loss as well as a continued aspiration risk and as further decline is anticipated, the patient remains appropriate for hospice care.

86 Example 7: BP 6 the problems States weight from 168 to 151 over 8 months But record shows 15# of that happened >6 months ago Cerebroatherosclerotic dementia Vascular Dementia can be used, but document more carefully Use FAST or not? Still need secondary condition Dysphagia and choking Very significant aspiration risk is not sufficient

87 Example 8: BP 4 This 63-year-old Caucasian male continues under hospice care for metastatic liver CA (mets to bone). PPS unchanged at 50% over the last 2 months. The patient requires assistance with all ADLs with the exception of feeding and transfers. He sleeps more than 14 hours in a 24-hour period. Height is at 63 inches, current weight is unchanged at 151 pounds, BMI of 26, it has been static over the last 2 months. The patient has lost from 154 pounds 5 months ago with BMI of 27 at that point. Complicating the patient s hospice diagnosis of metastatic CA and accelerating negative prognosis are diagnoses of hepatitis, DVT, and PE. CNP notes, he uses a walker, but is unsteady. Intermittently incontinent of bowel and bladder. Choking and coughing episodes with mashed, pureed foods. Patient has increased oral secretions, one-word responses only, although not always relevant to question asked. RN notes add, excessive oral secretion, expressive aphasia, mets to bone. As patient has PPS less than 70% and disease with distant mets to bone and declines further disease-directed therapy and has a prognosis consistent with 6 months and as the patient has shown continued decline over his interval of hospice care and as further decline is anticipated, he remains appropriate for hospice care.

88 Example 8: BP 4 the concerns Never mentions life-long cerebral palsy with resultant neuromuscular and neurocognitive deficits All functional findings are long-standing Cancer stated as metastatic to bone Initial diagnostic staging exam was not completed d/t cognitive issues Metastatic disease attributed to CT of pelvis/spine showing sclerosis in the sacral area possibly consistent with metastatic disease further evaluation with bone scan recommended As a result