Are You Ready to Respond to ADR’s?

1. Are You Ready to Respond to ADR’s? Meeting documentation challenges and tougher expectations By Karla Lykken RN Director of Medical Review Gentiva Health Services

2. Learning Objectives • Applying current standards for determining and documenting hospice eligibility • Applying measurable data to support and document patient decline • Identifying changes and documenting to support a higher level of care • Developing and documenting a plan for live discharges

3. Palmetto Top Denial Reasons (October – December 2013) • Not hospice appropriate 30% • No Plan of Care submitted 29.8% • Requested records not submitted 10.9% • Physician Narrative Statement not present 10.5% • F2F Encounter Requirements not met 10.5% • No valid election submitted 2.6% • No certification present 2.3%

4. Eligibility • Educating your team(s) on Local Coverage Determinations (LCD’s) • Educating your team(s) to document towards the clinical elements that meet LCD • Do not try to “make” the patient meet LCD • Documenting all clinical factors that indicate the patient has a limited life expectancy

5. Local Coverage Determinations • How well does your team know the LCD’s? • How well does your team apply some of the key measurable components of LCD’s? - PPS or Karnofsky Scale - Weights, BMI’s, MAC’s - FAST - NYHA Classification

6. Other measurable data • How well does your team apply other measurable data to help “paint the picture”? - Edema – location, +1, + 2, pitting - Abdominal girth on cardiac and liver patients - Blood sugars on diabetic patients - Level of effort, 1 or 2 people to perform a task, ADL etc.

7. Other measurable data • Symptom Assessments Scales • Trends in vital signs • Orders for medication adjustments/changes • Increasing calls to the office or after hours • Increasing need for unscheduled visits • Increasing need for DME, supplies etc.

8. Maximizing data • How is the patient’s PPS or Karnofsky score validated? • Does your program utilize other scales of scoring such as FAST, NYHA, Norton Pressure Score etc? • Does your program utilize some of these scales only if they relate to the patient’s diagnosis? • Does the patient also have a related diagnosis of Adult Failure to Thrive? • Are baseline weights, BMI’s and Mid-arm circumferences always obtained and then monitored for ongoing comparisons?

9. Get specific! • If the patient weighs 87lbs with a BMI of 16.8kg/m² - is documenting that enough? • If it’s noted the patient has a FAST of 7C and a PPS of 30% is that enough? • If you were paying for care out of your pocket based on someone else’s documentation what would you expect to see written?

10. Get specific! • Are check marks enough? • Does your team document their assessments as if they are picking and choosing body systems cafeteria style? • Is the hospice diagnosis the only one that “counts” when completing assessments?

11. Get specific! • How will the related/non-related diagnoses be documented? • Has a process been developed to assure the hospice Medical Director and the nursing staff know what medications, supplies, and DME are determined related/non-related? • How and where will that be documented?

12. Changes in level of care • How well does your team understand the differences in the four levels of hospice care? • Does the team use and document correct terminology when discussing levels of care? -General Inpatient hospice care in the hospital -General Inpatient hospice care in a LTCF -Unrelated hospitalization • Does the team’s documentation clearly reflect the current level of care?

13. Changes in level of care • Why the need for a higher level of care? • What should be reflected in the current Plan of Care? • Is it enough for us to say the patient “still requires GIP” or “still requires CC”? • Does the documentation tell the story why the higher level of care was needed and why it was reasonable to continue or discontinue it? • Could an outside reviewer connect the dots?

14. Live discharges • Lots of discussion little documentation! • Do your live discharge medical records have “discharge planning discussed” written all over it but no documentation regarding exactly what was discussed? • Would an outside reviewer be able to tell what the discharge plan entailed or that it was “just discussed”?

15. Live discharges Live discharges from a higher level of care • Should reflect the patient’s clinical and social/environmental needs that lead to admission (to the higher level of care) and current clinical and social/environmental status supporting discharge to routine home care • Should clearly document the actions taken to implement discharge

16. Live discharges from hospice service When to document when discussion has turned to reality? • Eligibility and the plan for the next two weeks should be discussed in each IDG • Stay focused on the clinical factors that still indicate the patient may be eligible • Document measurable data without making a judgment such as weight up 5lbs, FAST 7C has been the same the last 12 months etc

17. Life discharge from hospice services • It’s okay to document “eligibility discussed” – just don’t make a statement indicating the patient is “ineligible” if that is still under discussion. • Remember only the hospice Medical Director can make that determination. • The end of the benefit period is not the determining factor for the date of discharge. • If the pt is determined ineligible for example on 09/30/13 and the benefit period ends 10/02/13, and the discharge date is planned for 10/14/13, you cannot re-certify and bill the patient for 10/03/13-10/14/13.

18. Tips for working ADR’s • First and foremost always remember it is not an option not to respond – even if you think you won’t get paid. • Stick to the clinical facts! • If possible always write a clinical summary. • Whatever is presented as evidence in the summary must be present in the medical record! • Carefully review the medical record – the patient may initially look ineligible but upon a thorough review may clearly look eligible!

19. Tips for working ADR’s • Don’t fret over inconsistencies – review the record – what does the documentation for the dates under review support? • Don’t try to make the patient meet LCD – focus on all contributing clinical factors • As much as we like it to be “pretty” remember the evidence doesn’t necessarily have to be “pretty” but it sure has to be there!

20. Tips for working ADR’s Keep in mind some of the common focal points for ADR’s -Non cancer patients with a long length of stay -Timing of certifications and re-certifications -Timing of Face-To-Face Visits -Physician’s Narratives (are they based on the F2F if applicable and timely) -Frequently adjusting claims for missing visit notes -Patients discharging for hospitalizations related to their hospice diagnosis then coming back on service once discharged from the hospital

21. Tips for working ADR’s • Expect a new focus on documentation regarding related/unrelated diagnoses -if related we must provide documented evidence hospice provided those related medications, equipment, supplies etc -if unrelated the hospice MD must document why the diagnosis is unrelated

22. Appeal! Appeal! Appeal! • Always take advantage of an opportunity to appeal! • A denial doesn’t necessarily mean the patient isn’t eligible • Remember a denial due to the documentation not supporting eligibility is very subjective! • The denial means we just may have to collect a bit more data and argue a bit harder

23. Remember WE are the EXPERTS! • As a hospice provider it is our responsibility to provide ongoing monitoring, applying our knowledge of disease process, case managing the total care of the patient, and implementing plans of care whether it be for continued care or safe and timely discharge. Always remember WE are the end of life EXPERTS!

24. Questions?