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The HOPE of Wisconsin Annual Conference November 12, 2013

The HOPE of Wisconsin Annual Conference November 12, 2013. Medical Directors’ Workshop James W. Cope, MD. Agenda. CERT Hospice Growth Audits Wage Index Final Rule for FY 2014 Additional Data Reporting Face-to-Face Encounter NGS LCD / Terminal Prognosis. CERT.

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The HOPE of Wisconsin Annual Conference November 12, 2013

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  1. The HOPE of Wisconsin Annual ConferenceNovember 12, 2013 Medical Directors’ Workshop James W. Cope, MD

  2. Agenda • CERT • Hospice Growth • Audits • Wage Index Final Rule for FY 2014 • Additional Data Reporting • Face-to-Face Encounter • NGS LCD / Terminal Prognosis

  3. CERT • Comprehensive Error Rate Testing • Began 2003 (prior > OIG) • Random Sample ~ 50,000 FFS claims • ~ 75 RNs + coders • 2 Medical Directors • Result • Error Rates • Projected $$ in Error • Most recent = 8.5% = $29.6 Billion

  4. CERT • Hospice Error Rate ~ 10% • Projected Error Amount ~ $300M • Main Issues • Certification / Recertification • Terminal Prognosis

  5. Trends in Utilization • Beneficiaries • 513,000 in 2000 • > 1.3 million in 2012 • Expenditures • $2.9 B in 2000 • $14.7 B in 2012 CMS expects ~ 8% increase / year CMS 2014 Wage Index Final Rule 8.7.2013

  6. Diagnosis Trends • Top 5 Diagnoses 2002 • Lung cancer, CHF, Debility, COPD, Alzheimer’s • Top 5 Diagnoses 2012 • Debility, Lung cancer, Failure to Thrive, CHF, COPD (Debility + FTT = 19% of beneficiaries)

  7. Audits • Office of Inspector General • June 2012 – Part D paid for Rx instead of the hospice • May 2013 – GIP • 2013 work plan • Hospice Marketing Practices & Financial Relationships with Nursing Facilities

  8. Audits • MACs • ask your Mac • CERT • Ongoing / Random • Recovery Audit contractors • No hospice activity yet • ZPICs (fraud fighters) • Dept of Justice

  9. 2014 Hospice Final RuleAugust 7, 2013 • Diagnosis Reporting • Hospice Quality Reporting Program • Data Collection • Payment Reform

  10. Diagnosis Reporting • Must apply ICD-9-CM Coding Guidelines • Principle Diagnosis and all additional diagnoses related to the terminal condition • May not use nonspecific, symptom dxs & certain dementia dxs • Debility & FTT (RTP after 10/1/14)

  11. Diagnosis ReportingDementia • May not use codes from “Mental, Behavioral & Neurodevelopmental Disorders” • 290, 294 • Nonspecific • Manifestations of other more specified conditions • May use codes from “Diseases of the Nervous System & Sense Organs” • 331s > Alzheimer’s, Front-temporal dementia, Pick’s, Lewy Body dementia

  12. Diagnosis Reporting • Principle Diagnosis • Select the condition most contributory to the terminal prognosis • *** Eligibility for the Medicare Hospice benefit is based on prognosis, not diagnosis !

  13. Local Coverage Determination • Determining Terminal Prognosis • Effective 12/7/2007 • Can be used to evaluate any beneficiary • No diagnosis codes

  14. Plan of Care • Initial assessment within 48 hrs • Comprehensive assessment within 5 days • Updated no less than q 15 days • Plan of Care • Formulated by IDG • Specify care needed for terminal illness & related conditions • Review, & revise as needed, no less than q 15 days

  15. Related To ? ‘‘hospices are required to provide virtually all the care that is needed by terminally ill patients.’’ Hospice Final Rule 12/16/1983, page 56010

  16. Related To ? “…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.” (78 FR 48236)

  17. Payment Reform & Data Collection • MedPAC, OIG & GAO call for more data • Needed to better align costs & reimbursements • Costs > U-shape curve • Costs highest at start & end of stay

  18. Data Collection • CR 8358 (7/26/2013) • Additional Data Required • Visit data for hospice staff providing GIP in SNFs or Hospitals • Nurse, Aide, PT, OT, SLP, SW (incl calls) • Post-mortem visits on day of death • PM modifier • Eff 1/1/2014; enforced 4/1/2014

  19. Data Collection • Prescription Drugs • Infusion Pumps • NPI for any facility where beneficiary is receiving care, if not the billing hospice

  20. Face-to-Face Encounter • Hospice physician or Hospice NP • Prior to 3rd benefit period • No more than 30 days prior to benefit period* • Attestation • F2F visit = Administrative (i.e., not billable)

  21. References • Social Security Act §1861 dd • 42 CFR 418 • Hospice Wage Index Final Rule 2014 • CMS Benefit Policy Manual Pub.100-2, Ch. 9 • CMS Claims Processing Manual Pub 100-4, Ch. 11

  22. Thank You

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