Hot Regulatory Topics Judi Lund Person, MPH NHPCO

1. Hot Regulatory TopicsJudi Lund Person, MPHNHPCO

2. Eligibility

3. Eligibility for Admission Medicare Hospice Benefit § 418.20 Eligibility requirements. • In order to be eligible to elect hospice care under Medicare, an individual must be-- • (a) Entitled to Part A of Medicare; and • (b) Certified as being terminally ill in accordance with Sec. 418.22.

4. Compliance “Hot Spots” • Eligibility of hospice patients • Initial • Ongoing • Physician narrative • Certain non-cancer diagnosis • Dementia/ Alzheimer's • Debility unspecified • Level of care documentation • GIP

5. MAC Compliance “Hot Spots” • Eligibility of hospice patients • Ongoing • Physician narrative • Certain non-cancer diagnosis – evidencing 6 month or less prognosis • Dementia/ Alzheimer's • Debility unspecified • Level of care documentation • GIP – eligibility for all days billed at GIP

6. Opportunities to document eligibility • Certification • Verbal certification • Written certification • Physician narrative statement • Admission • Comprehensive assessment • Ongoing hospice service • Every note by the IDT • Update to the comprehensive assessment • Recertification • F2F encounter • Physician narrative statement

7. Eligibility assessment Definitely eligible Probably eligible Not eligible

8. Eligibility - 1st 90-day period • Demonstration of eligibility at admission • Information/ consultation between attending physician and hospice physician • Procurement of medical history and recent clinical documentation • For the clinical record • For use in the certification process • Attending physician and hospice physician certify patient based on their medical judgment of the disease progression

9. Eligibility - 1st 90-day period • Demonstration of eligibility at admission • Physician narrative should concisely describe why the patient is initially eligible for hospice • Comprehensive assessment documentation by IDG should evidence the details of the patient’s eligibility

10. Eligibility – Continued and at Recertification • Demonstration of eligibility at recertification • Physician narrative should concisely describe why the patient is continues to be eligible for hospice • Clinical note from face-to-face visit demonstrates eligibility (if 3rd of subsequent benefit period) • Update to the comprehensive assessment documentation by IDG should evidence the details of the patient’s continued eligibility

11. Certification/ Recertification NHPCO Certification/ recertification Process Maps available for purchase in NHPCO’s Marketplace

12. Although not the primary hospice diagnosis, the presence of disease such as the following…should be considered in determining hospice eligibility Co-morbidities • Chronic obstructive pulmonary disease • Congestive heart failure • Ischemic heart disease • Diabetes mellitus • Neurologic disease (CVA, ALS, MS, Parkinson’s) • Renal failure • Liver Disease • Neoplasia • Acquired immune deficiency syndrome • Dementia

13. Local Coverage Determination Policies (LCDs) GUIDELINES, not regulations: • Developed by each MAC (CGS, NGS, NHIC, Palmetto) • Outline guidelines for condition-specific determination of eligibility • Discuss documentation of secondary diagnoses and co morbid conditions to support terminal prognosis

14. Local Coverage Determination Policies (LCDs) • More emphasis on functional decline in the updated LCDs • Must have details to document the extent of decline • Need to consider the impact of disease on patient’s quality of life • Be familiar with the LCDs that are used in medical review for your region

15. Documentation Using LCDs • Documentation needs to address: • Impairments in function & structure • Activity limitations • Participation restrictions • Secondary diagnoses • Co-morbid conditions

16. Documentation Using LCDs • Address the patient’s activity level, self care, communication, and mobility • Give a historical perspective of what the patient’s ability was in the previous time period and then document current status • BUT REMEMBER… • Decline  eligibility • Decline  necessary or sufficient 67

17. Documentation Using LCDs • Use specifics to show the extent of the symptoms and limitations • Use the term “as evidenced by” to qualify the problems • Include symptoms such as wt loss, decubitus ulcers, & edema • Co-morbid conditions such as CHF, COPD and diabetes affect prognosis

18. The physician narrative • Components of a comprehensive and adequate physician narrative should include: • Explanation of the clinical findings that supports a life expectancy of 6 months or less • Reference to specific LCDs as appropriate • Reference to prognostic indicators or symptom management sales as appropriate

19. The physician narrative • Components of a comprehensive and adequate physician narrative should include: • Reference to functional status • PPS - Validated in palliative care • ECOG - Cancer • Karnofsky - Cancer • FAST - Dementia • Being specific is the most important thing: don’t say that the patient has lost weight – state that there has been a 15 pound weight loss in the past 2 months and 45 pounds in the last 6

20. The physician narrative • Components of a comprehensive and adequate physician narrative should include: • Evidence of a decrease in anthropomorphic measurements • Recent hospitalizations • Information about other significant complications in addition to the LCD specific criteria appropriate for that particular diagnosis • Statement should be concise, but adequate • Statement should contain prognostic indicators

21. Quality Reporting

22. CY2013 Quality Reporting Measures for quality reporting: • NQF #0209 Pain Measure • Structural Measure

23. CY2013 Quality Reporting NQF #0209: Comfortable Dying (NHPCO) Percentage of patients who were uncomfortable because of pain at the initial assessment (after admission to hospice services) whose pain was brought to a comfortable level within 48 hours.

24. CY2013 Quality Reporting Structural Measure: Participation in a QAPI program that includes at least 3 quality indicators related to patient care

25. CY2013 Quality Reporting QAPI Structural Measure Submission = • Indication if hospice has a QAPI program that includes at least three indicators related to patient care; and • Measures are used during reporting period • Description of all quality indicators related to patient care.

26. CY2013 Quality Reporting QAPI Structural Measure No results are submitted -- only the patient care measure descriptions

27. Hospice Quality Reporting • The data collection period is January 1 – December 26 of each year • Reporting is mandatory • Data due April 1 of each year • 2013 measures remain the same as 2012

28. Miss the deadlines? • Mandatory reporting • Measures required – no choice in what measures should be reported • Miss the 2013 reporting deadlines? • Deadlines HAVE NOT been extended • 2% cut in hospital market basket increase (hospice reimbursement rate “inflation adjustment”) in FY2014

29. CMS Resources 29 • CMS Hospice Quality Reporting web page • Information posted on CMS web site as it becomes available https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/index.html • Download PowerPoint presentations and hospice quality questions and answers: • http://www.cms.gov/Hospice-Quality-Reporting/ • Help Desk: help.hospicequality@rti.org • or by phone at 1.800.647.9670.

30. NHPCO Resources 30 Basic Information and Materials • www.nhpco.org/outcomemeasures • www.nhpco.org/qualityreporting Questions – send email to: • research@nhpco.org

31. The Future of Hospice Quality Reporting

32. Payment Year FY2015 • NQF #0209: Percentage of patients who report being uncomfortable because of pain on the initial assessment (after admission to hospice services) who report pain was brought to a comfortable level within 48 hours • Structural measure: Participation in a Quality Assessment and Performance Improvement (QAPI) program that includes at least three quality indicators related to patient care. Hospices would report whether or not they have a QAPI program with at least three indicators related to patient care.

33. Data Collection Period • Calendar year – January 1, 2013 through December 26, 2013 • Hospices submit data in the fiscal year prior to the payment determination. • For FY2015 and beyond: Data submission deadline of April 1of each year.

34. Payment Year FY2015 • No additional measures • Creation of a hospice patient-level data item set • Target date for implementation: CY2014 • Data items included in standardized data set to support possible measures

35. Patient level data collection • Mandatory data collection process being designed to collect data on individual hospice patients – demographics, diagnoses, symptoms • Used to collect data for future quality reporting • Expect to see a form and process in 2014 or 2015

36. Standardized Data Item Set CMS developing standardized assessment instrument • Many items standardized and used by other providers • Some items developed specifically for hospice • Developed to collect information for hospice-appropriate quality measures • Pilot testing with 9 hospices summer/fall 2012 • Propose to implement hospice patient-level data item set as early as CY 2014

37. Payment Determinations beyond FY2015 • Possible measures – implemented in future rulemaking • 1617 Opioid with bowel regimen • 1634 Pain screening • 1637 Pain assessment • 1638 Dyspnea treatment • 1639 Dyspnea screening • 0208 Family Evaluation of Hospice Care

38. Experience of Care Survey • Similar to FEHC • CAHPS survey being developed now

39. Value Based Purchasing • Value based purchasing – pilot testing • Utilize already implemented measures • Implement pilot by January 1, 2016

40. Part D and Hospice

41. Part D and Hospice • OIG report issued in 2012 • Some Medicare hospice beneficiaries receiving hospice care also had drugs paid for under Part D • Scope of the problem: • 198,543 hospice beneficiaries • 677,022 prescription drugs through Part D • Drugs should have been covered by the hospice? • Part D paid pharmacies $33,638,137 • Beneficiaries paid $3,835,557 in copayments • Expect additional scrutiny for Part D payments

42. Recent Analysis • Analgesics only • 2010 information • 773,168 Medicare hospice beneficiaries enrolled in Part D • 112,555 (14.6%) received 334,387 analgesic prescriptions through Part D during hospice enrollment • Gross costs -- $13,000,430 • Examples of drugs: Fentanyl, oxycodone, morphine, hydrocodone, hydromorphone….

43. Recent Analysis • Location of patients? • 63% in nursing facilities and assisted living • 35% at home • Which hospices? • 96.7% of hospices billed some analgesics to Part D • Which pharmacies? • 40.9% of pharmacies

44. CMS Draft 2014 Call Letter • Questions about eliminating Part D payments for Medicare hospice patients • Comments submitted March 1 2013 • Proposing January 2014: • Part D sponsor who receives report that a beneficiary has elected the Medicare Hospice benefit • Sponsor place beneficiary-level prior authorization requirement for four categories of prescription drugs • Four categories: • Analgesics • antinauseants (antiemetics) • Laxatives • antianxiety

45. Multiple Diagnoses on Claim Form

46. Multiple diagnoses on claim form • Requirement is not new • Clarification in FY 2013 Final Hospice Wage Index Rule • Analyses by CMS hospice contractor, showed that 77.2% of hospice claims from 2010 only reported a principal diagnosis • CMS believes that hospice claims which only report a principal diagnosis are not providing an accurate description of the patients’ conditions

47. Multiple diagnoses on claim form • Providers should code and report coexisting or additional diagnoses to more fully describe the Medicare patients they are treating • CMS’ Hospice Claims Processing manual requires that hospice claims include other diagnoses “as required by ICD-9-CM Coding Guidelines” (IOM 100-04, chapter 11, section 30.1, available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c11.pdf)

48. Multiple diagnoses on claim form • CMS clarifies that all of a patient’s coexisting or additional diagnoses s should be reported on the hospice claim • paper UB-04 claim allows for up to 17 additional diagnoses • electronic claim allows for 24 additional diagnoses • Hospices should not report diagnoses which are unrelated to the terminal illness on their claims

49. Mixed messages from CMS • CMS is asking for all coexisting diagnoses and comorbidities • Often significant and used to make the case in the narrative for 6 month life expectancy • Example: • Patient with heart failure • Significant COPD and Parkinson’s disease • COPD and Parkinson’s contributing to decline • “Unrelated” to the heart failure • Previously instructed not to include these very significant but unrelated diagnoses on claim form

50. The issues • Diagnoses definition inconsistency by CMS • Related • Co-morbid • Secondary • Many EMR software solutions do not allow more that one diagnosis (5010 allows 25 spaces) • Payment for non-related dx; concern of providers