Face-to-face (F2F) encounters

Transcription

1 Documenting Eligibility: Face-to-Face & Narratives Mark A Fox, MD, FACP, FAAHPM, HMDC National Medical Director Kindred at Home 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 used onlyif such findings are actually present Objectives Discuss the recommendations for documentation of the regulatory face-to-face encounter. Describe the elements recommended for composing optimal narratives. Become familiar with hospice eligibility Understand what reviewers are looking for in your narratives Mark A Fox MD 1

2 Face-to-face (F2F) encounters 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. The face-toface encounter must occur prior to, but no more than 30 calendar days prior to, the 3 rd benefit period recertification, and every benefit period recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care (a)(4) Who may do the hospice F2F? Hospice physician Must be employed or contracted by the hospice Volunteers considered employed Hospice nurse practitioner Must be employedby the hospice May notbe contracted May notbe: Physician Assistant, Nurse Clinician, RN, etc. F2F attestation Different attestation from the narrative attestation Hospice physician or hospice nurse practitioner: must attest in writing that he or she had a face-toface encounter with the patient, including the date of that visit (b)(4) If hospice nurse practitioner or non-certifying hospice physician, F2F attestation: shall state that the clinical findings of that visit were provided to the certifying physician for use in determining continued eligibility for hospice care (b)(4) Date the attestation is signed does not necessarily have to be the same date as the actual F2F visit Mark A Fox MD 2

3 What goes in the F2F documentation? Should be thorough and complete clinical data, with emphasis on findings pertinent to eligibility History & physical findings Not necessarily decision-making or management Specific items Same key elements as for narratives: Age / Diagnoses / Functional-Nutritional-Cognitive impairments / Disease-specific findings / Serial changes over time But, this is not the certification narrative, so no need to document conclusions about eligibility Additional F2F documentation cautions By regulation only a physician (MD/DO) can certify hospice eligibility This is not the place to do that and doing so may cause inconsistencies in the record For NPs, there may also be scope of practice issues by writing prognostic or certification statements If clearly not eligible, the clinician doing the F2F should immediatelycall the patient s interdisciplinary team leader to discuss potential discharge planning CMS does not allow hospice billing for patients documented as having a prognosis greater than six months F2F example The pt is 89 y/o male with hospice diagnosis of Alzheimer s Disease. The pt is a FAST 7D, PPS-30% unchanged since last cert period. The pt is eating 25% of 3 saucer size meals, down from 50%. The pt had aspiration pneumonia and required cipro 2 weeks ago. Pt prior MAC and is now 20 cm. Pt is sleeping 20/24 hrs previously 16/24. PEarousable, confused, dentures are ill fitting, cheekbones and clavicles prominent, clothes ill fitting, lungs-coarse rhonchi noted in left lower lung field, heart-murmur now noted, abd-soft, decreased bowel sounds, Ext-muscle wasting, contractures now noted of hands, Sacrum-stage 3 draining serosanguinous fluid but clean based. I attest that I had a face-to-face encounter with <name> on <date>, and that the clinical findings of that encounter have been provided to the certifying physician for use in determining whether this patient's prognosis is for a life expectancy of six months or less if the disease runs the normal course. Mark A Fox MD 3

4 Documenting eligibility / ineligibility Potential pitfalls during F2F visits Presentation may be different than usual for the patient Patients may perk up for F2F by authority figure / stranger Access to chart findings may not be available Documentation cautions Obtain input from IDG members Review the clinical record If unsure, avoid making definitive statements regarding prognosis, rather use a statement like: Will discuss findings & eligibility at next IDG meeting Are F2F encounters billable? F2F visits are not separately billable CMS states that as a component of the certification process, F2F is an administrative function included in the hospice per diem CMS also stated that if non-administrative physician-level professional services are also provided at the time of the F2F, the professional component could be billed For additional billable visit Documentation must support the claim as reasonable and necessary, and sufficient to justify the code billed NPs may only bill if designated as the attending physician (states may have further restrictions on this) How to document F2F + billable visit? F2F documentation goes in the standard place Complete the attestation Documentation may be as simple as see my progress note of xx/yy/zzzz Billable visit Document on a progress note: Dictated note, EMR note, hand-written Format should follow standard physician-documentation format (history / exam / diagnosis & decision-making) Additionally, would optimally include attention to the patient s prognosis REMEMBER this is not the certification narrative! Mark A Fox MD 4

5 Physician narratives Regulations require a physician narrative for each certification Done by the hospice physician (or attending for initial BP) 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) Physician narratives (2) 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) 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) What is a narrative? Definition: Narrative(nar-uh-tiv) noun a story or account of events, experience or the like [ Should be primarily in sentence format Should paint the picture of the patient s prognosis, preferably in language understandable by a lay person with some knowledge of eligibility guidelines What is not a narrative? A simple list of findings Fragments or phrases that are jotted down Stories take into account its audience Source: accumulating case law and external reviewer opinions Mark A Fox MD 5

6 Traditional clinical documentation Intended to document what you see and what you do Audiences for this include: Yourself, for later review and comparison over time Other clinicians to understand this patient s care and progress Sometimes: outside reviewers 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 Assumptions Other clinicians can make inferences from what you re implying, but Some external reviewers may lack training to make assumptions Others (e.g. ICD coders) are not allowed to make assumptions Only explicit statements should be used For example, if someone is taking insulin Weknow he has diabetes, but Reviewers cannot assume that Mark A Fox MD 6

7 WHAT DO THE PAYER REVIEWERS GO BY? Eligibility guidelines No national coverage determination for hospice Each Medicare AdministrativeContractor (MAC) has its own guideline(s) Designed to aid in making payment decisions (i.e. determinations) Each jurisdiction s MAC develops: local coverage determinations (LCD) State Medicaid programs & commercial insurers may use one of these or have their own guidelines What are the LCD guidelines? The following three (3) hospice MACs have published their own 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 Mark A Fox MD 7

8 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 08/08/2017) Must a patient meet an LCD? No! Not necessarily Palmetto has no LCDs covering cancer CMS requires each MAC include a statement that says something 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. Mark A Fox MD 8

9 The 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 * If documenting with one of these, explainwhy then patient is still terminal! #4 Clinical judgment Let s do this first, since it is the easiest If no applicable LCD, then HMD should say so Don t try to fit a square peg into a round hole Then document how it is that the patient has a clinical prognosis for a life expectancy of six months or less Use prognostic language If questions upon external review, the chart will likely be sent to a clinician since there is no applicable LCD for direct criteria comparison It is still possible some initial reviewers may deny these Be willing to appeal, with HMD involvement Opportunities for Improvement Remainder of this discussion will: Discuss commonly identified issues Provide suggestions for improvement Do so in the context of a specific guideline, when doing so makes sense Mark A Fox MD 9

10 Eligibility documentation is special Physician narratives, nursing reviews of decline, etc. Tell the story of the patient s prognosis Non-prognosis diagnoses are not needed in the narrative Should stand on its own, using language from the LCD Remember: primarily intended for external reviewers! Should always include the basic elements Pt s age, terminal diagnosis, and related comorbid diagnoses Functional/Nutritional/Cognitive impairment documentation PPS / BMI / MAC / ± FAST (if for Alzheimers Dementia) Disease-specific findings (from the applicable LCD) Document trajectory of the terminal illness Physicians should use a prognostic statement Documentation should be individualized Helpful to have a routine, but Don t be overly formulaic the quadratic equation Legibility Dictate or use EHR References see xyz F2F Narra ve See my narrative See my dictation Watch the dates Cut n paste Don t do this! If it is not written, it was not done. Writing issues Innovation and Excellence in Advanced Illness at End of Life 41 st Annual Hospice & Palliative Care Conference September 2017 Asheville, NC Mark A Fox MD 10

11 Always think big picture 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 dyspnea while trying to sleep, but this never gets documented because of only documenting what I see Infections in a facility: patient treated by facility nurse, but never put in hospice record Technical issues Start & stop dates for the benefit period Signature & date for certifications Face-to-face done before the narrative Narrative and certification done the same day by the same HMD Proper documentation of who is the Attending Verbal / written certification by different physicians Okay to be different, but need a written explanation of why Missing the mark Inconsistent values PPS BMI FAST Constants that change Heights? Yes, heights! Resolving contradictions Sometimes things do change Inter-rater variability - MACs All need explanation Mark A Fox MD 11

12 Documenting ineligibility The day that hospice ineligibility is documented, is the last day that can be billed for care Discharge planning should start that day Discharge planning range is 1d 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) Eligibility will be discussed with the IDT at our next meeting (needs to be addressed at the next meeting) Documenting ineligibility (2) If you are the HMD composing a narrative and do not find documentation to support eligibility STOP!!! There is no need to compose a narrative on an ineligible patient Either get the missing information you need, or Start discharge planning 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 Mark A Fox MD 12

13 ADLs Activities of Daily Living Different organizations have different lists; be consistent Ambulation, Eating, Dressing, Transferring, Bathing, Toileting Non-ambulatory patients are dependent on others (or devices) for mobility If dependent in all ADLs (a.k.a. total care ) Cannot self-feed Are considered to be incontinent of bowel and bladder ~ FAST 6e Cancer LCD guideline Usually straightforward, yet PPS should be < 70% Should have advanced disease with metastases Be wary with breast /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 Cardiopulmonary LCDs Cardiac NYHA Class IV (symptoms at rest) despite optimal management Optimally treated with medication Angina at rest of declines invasive therapy Pulmonary Symptoms at rest despite optimal management Infections or frequent visits to the ER, office, hospital Presence of resting room air hypoxemia or hypercapnia Additional findings, secondary conditions or comorbids help support eligibility (but are not enough alone) e.g. Ejection fraction < 20% on echo, arrhythmias, syncope e.g. COPD + heart failure Mark A Fox MD 13

14 Cardiopulmonary Findings Dyspnea or angina at rest Remember to document symptoms at rest when the same symptoms 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 Alzheimers LCD guideline (1) FAST 7 + at least 1 significant secondary/comorbid condition in last 6-12 months Secondary conditions include delirium, serious infections, decubitus ulcers > stage III, 10% weight loss, or < 2.5 Comorbid conditions include CHF, COPD, CKD, cirrhosis, malignancies, recurrent infections 41 Alzheimers LCD guideline (2) LCD says: FAST 7+ and at least 1 significant secondary/comorbid condition in last 6-12 months Using the close fit rationale, a few patients who are FAST 6E may be eligible for care This should not be routine or common in a program FAST 6E + rapid decline + at least 1 significant secondary/comorbid condition in last 6-12 months, or FAST 6E + more than 1 significant secondary/comorbid condition in last 6-12 months No longer eligible if no rapid decline or >6-12 months since last significant secondary/comorbid condition 41 st Annual Hospice & Palliative Care Conference September 2017 Asheville, 42 NC Mark A Fox MD 14

15 Dementia findings Must document both parts of the criteria FAST 7 (caution if ambulatory) 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. Stroke / Coma guidelines Coma Not just being comatose, but unlikely to survive 6 months (e.g. no further life-sustaining treatment) Stroke PPS of 40% or less Lack of intake sufficient to sustain life and no lifesustaining interventions, or Secondary or comorbid conditions indicating a likely prognosis of < 6 months Renal guidelines Stopping or declining to start dialysis Other criteria Creatinine, GFR Renal labs important, but less so than other findings Comorbid or secondary conditions Albumin <2.5 is strong predictor If on service and not declining, must recheck labs to monitor ongoing eligibility Mark A Fox MD 15

16 Liver failure guidelines Labs are important Albumin 2.5 and Protime INR 1.5 Long list of other findings Hepatorenal syndrome, Ascites, etc. Important to consider etiology Progressive (e.g. primary biliary cirrhosis) Potentially reversible (e.g. alcoholic who stops drinking) Adult Failure to Thrive LCD 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 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 Open the record! Consider a flow-sheet Mark A Fox MD 16

17 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! Remember the bottom line Is the prognosis for this patient, today, a life expectancy of 6 months or less if the terminal illness runs its normal course? If the answer is no the patient is not eligible for hospice care. If the answer is yes certify the patient and document why. Paint a picture of the prognosis Every narrative/certification is an opportunity to paint the picture of the patient s prognosis If the patient meets an applicable LCD, explain this If the patient does not meet an LCD, but is still terminal, explain this If you lack the information needed to adequately document a terminal prognosis: DO NOT CERTIFY THE PATIENT Either Get missing information & then certify, or Do not admit or discharge the patient Mark A Fox MD 17

18 Painting the picture: key elements (1) Use sentence format State patient s age State patient s terminal diagnosis State the related medical conditions Describe how these impact prognosis; include description of their severity Painting the picture: key elements (2) Functional impairments PPS, ADL dependence, etc. Nutritional impairments Weight, BMI, MAC, albumin, etc. Cognitive impairments FAST for dementia, presence & severity of delirium, etc. Painting the picture: key elements (3) Disease specific and/or disabling symptoms Dyspnea at rest, NYHA Class, refractory angina, etc. Refer to applicable Local Coverage Determination Burden of disease Onset / duration / response to therapy / location of care / time-to-task completion / degree of frailty / asleep 12h/day Describe these serially, documenting trajectory of disease with absolute values over a time period Mark A Fox MD 18

19 Other key narrative elements Reference the basis for the narrative: Review of clinical records (explain any apparent inconsistencies) Physician or NP F2F assessment (not necessarily but considered a best practice) Make explicit statement of prognosis Her prognosis is days or weeks, at most He is unlikely to survive the next six months Best practice not to rely solely on pre-printed statements and attestations: Your own words are much more effective Common narrative problems Not legible Lacks sentences Never addresses prognosis Lacks previously discussed elements Failure to include Benefit Period dates Using the word decline instead of documenting how the patient declined Trying to use anlcd that does not apply to the patient The word Appropriate Intent of the narrative is to explain how it is that a patient has a terminal prognosis, thus making them eligible for hospice What makes a patient appropriate(or not) for hospice care could include additional considerations that may be unrelated to prognosis Mark A Fox MD 19

20 This is a lot to remember Which is why you should: Always refer to the applicable LCD (if there is one) Use a consistent prompt for the key elements Proofread your narrative to ensure it paints the picture of a terminal prognosis Dictate narratives Use the electronic health record in a manner that permits you to follow these requirements & best practices Narrative Coaching Patient name, age, hospice diagnosis, and location of care. Describe related medical conditions/diagnoses which provide impact to the terminal prognosis Functional CHANGES PPS, Dependence on ADL s, fall, with comparison data over the past 2-6 months Nutrition CHANGES BMI, weight, MAC, % food intake, any change in diet consistency, any dysphagia/choking, or cueing with swallowing, with a comparison data over the past 2-6 months Skin breakdown, decubitus ulcers/wounds, non-healing or worsening over time Infections and response to treatment and dates, Cognition CHANGES Change in speech and memory FAST - only if patient has the diagnosis of dementia Disease Burden CHANGES Change of sleep, location of care Response to treatment, (infection with dates) Task completion longer to eat, walking bed to chair, bathing, and skin breakdown Symptom Burden CHANGES over the past 2-6 months Increase and progression: Pain, Nausea/Vomiting, Dyspnea, Anxiety Increase in medication requirements to control symptoms over past 2-6 months Review of F2F (if applicable) and date. Summarize Based on these findings, it is my clinical judgment that this patient s prognosis is for a life expectancy of six months or less if the disease runs its normal course, as evidence by.. Questions Mark A Fox MD 20

21 Resources 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 6-Month Survival of Nursing Home Resident with Advanced Dementia Using ADEPT vs. Hospice Eligibility Guidelines. JAMA. 2010;304(17): Narrative Examples and Grading Fail BP 4 84 year old female with Alzheimers Dementia, as per face to face evaluation. Episodes of forgetful where the patient does not recognize her son & daughter in law which began over the past 2 month. The patient with worsening of arthritic diffuse pain requiring Norco or tramadol. The patient with episodes of pocketing food in mouth. Fail Mark A Fox MD 21

22 BP 2 The patient is a 92-year-old male who is admitted to hospice because of cardiopulmonary disease. Since his admission to hospice his PPS has remained stable at 50. His weight has gone from 171 pounds to 137 pounds. He has a very poor appetite with some choking episodes. He needs help with all ADLs except feeding. He gets short of breath with minimal exertion. He has generalized weakness. The patient s comorbidities include severe peripheral vascular disease, hypertension, CHF, CAD, and COPD PASS BP y/o male with TBI with progressive debility, sleeping most of the day/night, requires total assist with all ADLs & Hoyer lift transfers. Increased episodes of coughing & choking while eating. Recent wound to sacrum and increased O2 use for SOB at rest Fail BP 1 (admission) PASS Mark A Fox MD 22