Medicare Home Health Clinical Updates from CGS. Top 5 Reasons for Home Health Claim Denials

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Medicare Home Health

Clinical Updates

from CGS

Nebraska Association of Home & Community Health Agencies January 14, 2015

Top 5 Reasons for Home Health

Claim Denials

Denials by Medical Review

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 2

Top HH Medical Review Denial Reasons

Denial Reason  Code Denial Reason # Claims Denied  (Jan – Nov 2014) 5FFTF Missing/incomplete/untimely face‐ to‐face documentation  1,834 (42%)

5HMED  Medical necessity of services not 

supported 

1,547 (36%)

56900  No/untimely response to ADR  552 (13%)

5HPLN  Missing/incomplete/untimely plan 

of care 

216 (5%)

(2)

Essential Home Health Documentation

4 OASIS and Coding Use LCD for Guidance Reasonable and Medically Necessary Skilled Service Intermittent Skilled Nursing or

Therapies Homebound Documentation Technical Components: OASIS Submission,

Certification/Orders/ FTF

© 2014 Copyright, CGS Administrators, LLC. January 9, 2015

Home Health Coverage Resources

CMS “Medicare Benefit Policy Manual” (CMS Pub. 100-02) Ch. 7 Home Health

www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf CGS “Home Health Coverage Guidelines” webpage

www.cgsmedicare.com/hhh/coverage/Home_Health_Coverage_Guid elines.html

CGS “LCDs & Coverage”

Home Health Physical Therapy

http://www.cgsmedicare.com/hhh/coverage/index.html

•Click on “Active LCDs” on left side tool bar

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 5

Face-to-Face (5FFTF)

and

Physician Certification (5PCER)

Denial Reason #1 (5FFTF)

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Denial Reason #1: 5FFTF

Face-to-Face Documents

To be eligible for Medicare home health services, a patient must have Medicare Part A and/or Part B and:

1. Be confined to the home; 2. Need skilled services;

3. Be under the care of a physician;

4. Receive services under a plan of care established and reviewed by a physician; and

5. Have had a face-to-face encounter with a physician or allowed non-physician practitioner (NPP).

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 7

Denial Reason #1: 5FFTF

Face-to-Face Documents

Certifying physicians and acute/post-acute care facilities must provide, upon request, the medical record documentation that supports the certification of patient eligibility for the Medicare home health benefit to the home health agency, review entitles, and/or CMS.

42 CFR 424.22(c)

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 8

Denial Reason #1: 5FFTF

Face-to-Face Documents

Information from the HHA can be incorporated into the

certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient.

 Information from the HHA must be corroboratedby other medical record entries and align with the time period in which services were rendered.

 The certifying physician must review and sign off on anything incorporated into the patient’s medical record that is used to support the certification of patient eligibility.

(4)

Denial Reason #1: 5FFTF

Face-to-Face Documents

The certifying physician’s medical record must contain information that justifies the referralfor Medicare home health services. Including:

1. The need for the skilled services; and 2. Homebound status

AND must contain the actual clinical note for the face-to-face

encounter visit that demonstrates that the encounter: 3. Occurred within the required time frame; 4. Was related to the primary reason the patient

requires home health services; and 5. Was performed by an allowed provider type.

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 10

Denial Reason #1: 5FFTF

Face-to-Face Documents

The Recertification document must be:

1. Signed and dated by the physician who reviews the plan of care.

2. Indicate the continuing needfor skilled services 3. Estimate how much longer the skilled services

will be required.

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 11

Denial Reason #1: 5FFTF

Electronic Code of Federal Regulations: Title 42 CFR 424.22; Requirements for home health services

http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=&SID=c86654e32a4f36f15d70fab390124c29& n=pt42.3.424&r=PART&ty=HTML#se42.3.424_122

(5)

Denial Reason #1: 5FFTF

Performed By Whom?

Face-to-face encounter may be performed by:

Certifying physician (must be Medicare enrolled)

Non-physician practitioner (NPP) in collaboration with the certifying

physician

Physician who cared for the patient in an acute/post-acute facility

during a recent stay and has privileges in that facility

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 13

Denial Reason #1: 5FFTF

When?

For initial certifications only

Recertifications do not require a face-to-face encounter

Certifying physician must document FTF took place within

90 days prior to start of care (SOC), or

30 days after SOC

Reminder:

FTF must be related to primary reason for home health admission

Exceptionalcircumstance: Patient death beforeFTF can be

performed

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 14

Denial Reason #1: 5FFTF

Face-to-Face

The physician who cared for the patient in an acute or post-acute facility may choose to use documentation from the patient’s medical record, (such as a discharge summary) to inform the certifying physician of the clinical findings from the face-to-face encounter.

IF

The compiled documentation is reflective of the clinical findings of the face-to-face encounter

AND

Serves as that physician’s communication to the certifying physician

(6)

Denial Reason #1: 5FFTF

Face-to-Face Signatures

The document from the acute or post acute facility record

Must be signed and dated by the certifying physician,

Must indicate the certifying physician received the information from the physician who performed the face-to-face encounter, and Must show the certifying physician is using that documentation as

his/her documentation of the face-to-face encounter

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 16

Denial Reason #1: 5FFTF

Documentation

Physician certification documentation requirements:

The patient needs intermittent SN care, PT, and/or SLP services The patient is confined to the home

A plan of care has been established and will be periodically reviewed

by a physician

Services will be furnished while the individual was or is under the care of a physician

A face-to-face encounter

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 17

Denial Reason #1: 5FFTF

Documentation

The face-to-face encounter:

occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care was related to the primary reason the patient requires home health

services, and

was performed by a physician or allowed non-physician practitioner

Must be a separate and distinct section of, or an addendum to, the certification and

(7)

Denial Reason #1: 5FFTF

Documentation

Does the documentation clearly answer “why home health and why now?”

Reminder: Good documentation should address:

Objective clinical evidence of patient’s individual need for care Progress or lack of progress

Medical condition Functional losses

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 19

Denial Reason #1: 5FFTF

Readmission

If the patient is discharged, then readmitted, the same FTF document can be used if:

The timeframestill meets requirements, AND

There is not a 60 day or greater gap between episodes

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 20

Denial Reason #1: 5FFTF

Electronic Code of Federal Regulations: Title 42 CFR 424.22; Requirements for home health services

http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=&SID=c86654e32a4f36f15d70fab390124c29& n=pt42.3.424&r=PART&ty=HTML#se42.3.424_122

(8)

Denial Reason #1: 5FFTF

Face-to-Face Regulations

Medicare Benefit Policy Manual (CMS Pub. 100-02) Ch. 7, §30.5.1.1

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 22

Examples

of FTF Documentation

“Don’ts”

Insufficient documentation – Miscellaneous

Diagnoses/clinical findings on FTF not related to home care ordered Altered documentation without acceptablenotations for changes

 FTF signedby Non Physician Practitioner (NPP) only

No date of FTF encounter

Not clearly titled as face-to-face encounter

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 23

FTF Documentation:

Important Reminders

FTF is requirement for Medicare payment

Missing/incomplete documentation results in entire claim being denied

As the billing entity, the home health agency’s (HHA’s)

responsibilitiesinclude:

Facilitating and coordinating between patient and physician to ensure FTF occurs timely

Ensuring all FTF requirements are met Ensuring physician’s documentation is complete 

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FTF Documentation

“The FTF encounter is an additional certification content requirement, and we (CMS) expect the HHA to coordinate with the

physician and patient to ensure compliance.” (CMS FAQ # 34)

http://cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/HomeHealthPPS/Downloads/Home-Health-Questions-Answers.pdf

(revised May 9, 2014)

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 25

Medical Necessity (5HMED)

Denial Reason #2

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 26

Denial Reason #2 5HMED

Medical Necessity

All services (even skilled) must be reasonable and medically necessary related to the patient’s condition

Observation and assessment Teaching

Therapy

•Refer to Physical Therapy (PT) Local Coverage Determinations (LCD)

•http://www.cgsmedicare.com/hhh/coverage/index.html

(10)

Denial Reason #2 5HMED

Medical Necessity

Does the documentation clearly answer “why home health and why now?”

Reminder: Good documentation should address:

Objective clinical evidence of patient’s individual need for care Progress or lack of progress

Medical condition Functional losses Treatment goals Discharge planning

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 28

Denial Reason #2 5HMED

Medical Necessity

Covers all disciplines

Nursing Physical therapy Occupational therapy Speech language pathology

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 29

Denial Reason #2 5HMED

Medical Necessity

Full denials OR

Partial denials, resulting in Low Utilization Payment Adjustment (LUPA) or therapy downcodes

Additional information

http://www.cgsmedicare.com/hhh/coverage/HH_Coverage_Guideline s/1E.html

(11)

Denial Reason #2 5HMED

Medical Necessity -

“Do’s”

Identify skilled service, andreason skilled service is necessary for beneficiary in objective terms

“Wound care completed per POC to left great toe. No s/s of infection, but patient remains at risk due to diabetic status.”

“Range of motion (ROM) is tolerated to lower extremities. Unsafe to teach caregiver ROM due to displaced fracture.”

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 31

Denial Reason #2 5HMED

Medical Necessity –

“Do’s”

Demonstrate medical necessity of skilled observation and assessment by documenting complexity of beneficiary’s condition and co-morbidities affective outcomes.

“Lungs sound coarse throughout. Patient finished antibiotic therapy today for pneumonia, and seeing pulmonologist tomorrow for follow up to due to COPD and emphysema.”

“Stasis wound on LLE continues to show 50% granulation and moderate serous drainage. Instructed patient on need to elevate legs and exercises related to peripheral vascular disease.”

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 32

Denial Reason #2 5HMED

Medical Necessity

– “Don’ts”

Skilled nursing fables:

“As long as you document teaching, it is a billable visit.”

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Denial Reason #2 5HMED

Medical Necessity –

“Don’ts”

Medicare Benefit Policy Manual (CMS Pub. 100-02) Ch. 7, §40.1 and §40.2 lists requirements in order for a service to be covered by Medicare as “skilled.” The service must:

Require the skills of a nurse or qualified therapist

•Service is NOTskilled because it is performed by a nurse or qualified therapist

•Service does NOTbecome unskilled because it is taught

Be reasonable and necessary to treat patient’s illness or injury •Patient’s condition warrants the skilled care

•MUST BE evident in documentation

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 34

No Response to Additional

Development Request (ADR)

(56900)

Denial Reason #3

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 35

Plan of Care (5HPLN)

Denial Reason #4

(13)

Denial Reason #4: 5HPLN

Plan of Care

Medicare Benefit Policy Manual (Pub. 100-02) Ch. 7, §20.1.1,

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdfstates:

… payment can be made only if a physician certifies the need for services and establishes

a plan of care.

January 9, 2015

37 © 2014 Copyright, CGS Administrators, LLC.

Denial Reason #4: 5HPLN

Plan of Care

Plan of care must be reviewed, signed and dated by physician who established the plan of care at least every 60 days, and prior to submitting the claim to Medicare. It is not acceptable for HHAs to wait until the end of a 60-day episode to obtain a completed certification.

Orders must include

Patient’s name

Disciplinesbeing provided, including frequency, duration and

modality

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 38

Denial Reason #4: 5HPLN

Plan of Care

Common denial reasons include:

Dates: Verbal order, date of physician signature Incomplete orders/POC

Timeliness: must be SIGNEDand DATED by physician prior to billing

Missing dates: “Received date” NOT accepted

CGS: “Physician Orders, Plan of Care and Certification” webpage

www.cgsmedicare.com/hhh/coverage/HH_Coverage_Guidelines/1 B.html

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Denial Reason #4: 5HPLN

Plan of Care

Certification must be obtained when POC is established, or soon after; and must be complete, signed and dated by the physician who established the POC prior to submitting the claim.

Required contents: CMS Medicare Benefit Policy Manual (Pub. 100-02) Ch. 7, § 30.2.1

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 40

Homebound Status (5HHBD)

Denial Reason #5

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Denial Reason #5: 5HHBD

Homebound Criteria

Medicare Benefit Policy Manual (CMS Pub. 100-02) Ch. 7, §30.1.1 defines “confined to home” (homebound)

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf

CGS Homebound Webpage

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Denial Reason #5: 5HHBD

Homebound Criteria

MLN Matters article MM8444, “Home Health – Clarification to Benefit Policy Manual Language on Confined to the Home Definition, http://www.cms.gov/Outreach-and-Education/Medicare-

Learning-Network-MLN/MLNMattersArticles/Downloads/MM8444.pdf Clarifies definitionof patient being “confined to home” Reflects definition in Social Security Act (Section 1835(a))

Removes vague terms to ensure clear and specific definition

Not a change in homebound definition

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 43

Denial Reason #5: 5HHBD

Homebound Criteria

Two criteria are used to determine homebound status

Criteria-One:

The patient must either:

Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence.

OR

Have a condition such that leaving his or her home is medically contraindicated.

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 44

Denial Reason #5: 5HHBD

Homebound Criteria

Two criteria are used to determine homebound status (cont)

Criteria-Two:

There must exist a normal inability to leave home

AND

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Denial Reason #5: 5HHBD

Homebound Criteria

The patient may be considered homebound (confined to the home) if absences from the home are:

infrequent;

for periods of relatively short duration; for the need to receive health care treatment; for religious services;

to attend adult daycare programs; or for other unique or infrequent events

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 46

Denial Reason #5: 5HHBD

Homebound Criteria

Documentation must support homebound status throughout Beware of vague descriptions: “taxing effort”, “unable to leave home”

Utilize objective, measurable language

“After ambulating 20 feet, patient has increased dyspnea and complains of back pain.”

“Patient has unsteady gait, and must sit to rest after 20 feet of ambulation.”

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 47

Denial Reason #5: 5HHBD

Homebound Criteria

Does the documentation clearly answer “whyhome health and

why now?”

Reminder: Good documentation should address:

Objectiveclinical evidence of patient’s individual need for care

Progress or lack of progress Medical condition Functional losses

(17)

Denial Reason #5: 5HHBD

Homebound Criteria

“The patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relative short duration, or are attributable to the need to receive health care treatment.”

Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7, §30.1.1)

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 49

Denial Reason #5: 5HHBD

Homebound Criteria

The patient may have more than one home

Vacation home Home of caregiver Seasonal home

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CGS Home Health Denial Fact Sheets

-NEW!

Available from Home Health Quick Resource Tools webpage

http://www.cgsmedicare.com/hhh/education/materials/HH_QRT.ht ml 5HHBD – Homebound Status http://www.cgsmedicare.com/hhh/education/materials/pdf/hh_5hhbd_ factsheet.pdf 5FFTF – Face-to-Face Encounter http://www.cgsmedicare.com/hhh/education/materials/pdf/HH_5FFTF _FactSheet.pdf

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CGS Home Health Denial Fact Sheets –

NEW!

5HMED – Medical Necessity

http://www.cgsmedicare.com/hhh/education/materials/pdf/HH_5HME D_FactSheet.pdf

5HNOA – No OASIS

http://www.cgsmedicare.com/hhh/education/materials/pdf/hh_5hnoa_ factsheet.pdf

5HPLN/5HORD – Missing Plan of Care or Orders

http://www.cgsmedicare.com/hhh/education/materials/pdf/HH_5HPL N-5HORD_FactSheet.pdf

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 52

Are We On the Same Page??

Providestaff with the requirements; Information is Power!! Guide decisions and empowerclinicians with coverage

criteria.

Education on coverage and documentation standards.

Oversight of documentation.

Ensure technical pieces are covered.

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 53

Questions?

CGS Provider Contact Center 1-877-299-4500 (Option 1)

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Thank You!

Please complete the Event Evaluation Attendance Form Post-Test

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 55

Medicare Hospice

Clinical Updates

from CGS

Nebraska Association of Home & Community Health Agencies January 14, 2015

Top Hospice Medical Review Denial Reasons

Top 5  Denial Reason  Codes Denial Reason Claims Denied by  These Codes  (Jan ‐Nov ‘14) 5PTER Six‐month prognosis not supported 2,581 (62%) 5PPOC POC does not meet requirements 579 (14%) 5PCER Missing/incomplete/untimely

certification/recertification

477 (12%)

(20)

Medical Review Hierarchy

58 Physician visits Physician visits Level of care Terminal status Plan of Care (POC) including review 

of the POC  every 15 days Certifications including face‐to‐face (FTF)

Election Statement

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 58

CR 8877

Overview of Changes

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 59

CR 8877

“Hospice Manual Update for Diagnosis Reporting and Filing Hospice Notice of Election (NOE) and Termination or Revocation of Election”

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3032CP.pdf

 Effective for dates of service on/after October 1, 2014  Prohibits use of “Symptoms, Signs, and Ill-defined Conditions”

(21)

CR 8877: Diagnoses

Codes prohibited as principal diagnosis 799.3 and 780.79 (Debility)

783.7 (Adult failure to thrive) Multiple dementia codes

See CR 8877 Attachment A for complete list

Claims with prohibited codes will be returned to provider (RTPd)

with reason code 30727

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 61

CR 8877 Resources

Change Request 8877, http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3032CP.pdf

Medicare Learning Network (MLN) Matters Article MM8877,

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8877.pdf

January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 62

CR 8877

CGS HHH Medicare Bulletins,

http://www.cgsmedicare.com/hhh/pubs/mb_hhh/index.html

CGS ListServ messages

‘Recent News’ webpage,

http://www.cgsmedicare.com/hhh/pubs/news/index.html

Join/Update Listserv,

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Six Months or Less

Terminal Prognosis (5PTER)

Hospice Denial Reason #1

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Denial Reason #1: 5PTER

Six Months or Less Terminal Prognosis

Results in full denial

Medical necessity is alwaysbased on the patient’s condition

•Is it the patient or the documentation

•Make the reviewer see the patient

Documentation is expected to show significant changes in the beneficiary’s condition and the plan of care

For more helpful guidance on hospice documentation:

http://www.cgsmedicare.com/hhh/coverage/coverage_guidelines/ho spice_documentation.html

65 January 9, 2015 © 2014 Copyright, CGS Administrators, LLC.

Denial Reason #1: 5PTER

Six Months or Less Terminal Prognosis

Documentation must “paint the picture”, especially for long-term hospice patients, or those with chronic illness and general decline

Use quantifiable values and measurements to show changes in:

Weight

•Document patient’s weight at least monthly and more often if possible

Measurements

•Arm/girth/leg measurements starting at admission

(23)

Denial Reason #1: 5PTER

Six Months or Less Terminal Prognosis

Use quantifiable values and measurements to show changes in:

PainLevelof pain

•Expressed in the waypatient/family memberunderstands

•Document any extenuatingcircumstances

Responsiveness

•Does the patient react to your presence?

•Does the patient remember you from last visit?

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Denial Reason #1: 5PTER

Six Months or Less Terminal Prognosis

Use quantifiable values and measurements to show changes in:

Levels of Activities of Daily Living (ADL) dependence What can they do SAFELY?

Are they impulsive?

Vital signs

Respiration rate, blood pressure, pulse, temperature Grapheasily shows change

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Denial Reason #1: 5PTER

Six Months or Less Terminal Prognosis

Strength

Ask the patient to squeeze your hands Is the patient able to stand?

How long?

Lucidity

Can the patient carry on a lucidconversation? Can the patient make decisions?

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Denial Reason #1: 5PTER

Six Months or Less Terminal Prognosis

Intake/output

Make sure the serving size is appropriate

Is there a system in place to measure output that is workablefor the patient/family?

Skin condition Broken skin?

Stagewounds whenever possible Redness?

Itching?

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Denial Reason #1: 5PTER

Six Months or Less Terminal Prognosis

Pitfalls in terminal prognosis documentation:

Paradigm shiftfor medical professionals •Have been trained to showimprovement – not decline

Amount and detail dependent upon situation •Chronic, deteriorating condition vs. rapid progression

71 January 9, 2015 © 2014 Copyright, CGS Administrators, LLC.

Denial Reason #1: 5PTER

Six Months or Less Terminal Prognosis

Failing to show “big picture”

Send in relevant documentation outsideof period requested Should be able to identify person from the documentationwithout

seeing the name

Obtain history and physical information

 May come from more than one source  Recent hospital stay?

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Denial Reason #1: 5PTER

Six Months or Less Terminal Prognosis

Use functional scale, as appropriate (don’t round numbers)

 Karnofsky Performance Scale (KPS) • 30%, 40%, 50%, etc.

 Palliative Performance Scale (PPS) • 30%, 40%, 50%, etc.

 Functional Assessment Staging (FAST)  New York Heart Association (NYHA)

• Must be stated by physician

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Denial Reason #1: 5PTER

Six Months or Less Terminal Prognosis

Don’t forget documentation from the interdisciplinary group (IDG) meetings

 Information from other staff members  May havedifferent perspectives

 Different staff members see patient at different timesand in different circumstances

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Denial Reason #1: 5PTER

Six Months or Less Terminal Prognosis

Refer to Local Coverage Determination (LCD) for guidance Use observations and data,not conclusions

Clinical indicators of decline

• Weight loss, infections, changes in mobility, etc.

Review terminal admittingdiagnosis Reassessment is ongoing

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Denial Reason #1: 5PTER

Six Months or Less Terminal Prognosis

Local Coverage Determination (LCD) information from CMS website

www.cgsmedicare.com/hhh/coverage/Coverage_Guidelines/LCD.html

Click on “Hospice Determining Terminal Status”

The LCD is intended to provide guidanceto both the medical community and CMS contractors

76 January 9, 2015 © 2014 Copyright, CGS Administrators, LLC.

Denial Reason #1: 5PTER

Six Months or Less Terminal Prognosis

Terminal diagnosis documentation opportunities

 Admission

 Course of care (everyvisit)  IDG meetings

Changein level of care or plan of care  Recertification

77 January 9, 2015 © 2014 Copyright, CGS Administrators, LLC.

Plan of Care (5PPOC)

Hospice Denial Reason #2

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Denial Reason #2: 5PPOC

Plan of Care

Plan of care (POC) must be reviewed and updated by the hospice provider’s interdisciplinary group (IDG)

•At intervals specified in POC, butat least every 15 days

Send allPOCs that pertain to claim’s dates of service with documentation

•POC may be dated prior to dates of service being reviewed Submit sign-in sheet that shows who attended Must participate:

•Nurse

•Social worker

•Physician

•Spiritual care

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Denial Reason #2: 5PPOC

Plan of Care

CGS webpage “Hospice Plan of Care”

www.cgsmedicare.com/hhh/coverage/Coverage_Guidelines/Plan_ of_Care.html

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Certifications (5PCER)

Hospice Denial Reason #3

(28)

Denial Reason #3: 5PCER

Certifications

Everycertification/recertification must include:

Statement that the individual’s medical prognosis is that their life expectancy is 6 months or less if the terminal illness runs its normal course

The specific dates of the benefit period • Example: January 1, 2014 through March 2, 2014

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Denial Reason #3: 5PCER

Certifications

Physician(s) signature(s) and date

Physician signature mustbe hand signed and hand dated or validateddated electronic signature

The signature(s) must be legibleor verified

If narrative is an addendum, physician(s) must sign addendum also

Onlythe initial certification must be signed by the attending physician

(if there is one) ANDthe hospice medical directoror IDG physician

Attestation statement that indicates who composednarrative

Example: “I certify that Icomposedthis narrative”

Nurse practitioners CANNOTsign the certification or recertification

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Denial Reason #3: 5PCER

Certifications

Hospice certification requirements:

Timeline

–No later than 2 calendar days after the start of the benefit period

»By the end of the third day of the benefit period

–May be up to 15 days before start of care •Can be verbal certification

–Hospice staff must make an appropriate entry in the patient’s medical record as soon as they receive the verbal certification

(29)

Denial Reason #3: 5PCER

Certifications

CGS “Signature Guidelines for Home Health & Hospice Medical Review” quick resource tool

www.cgsmedicare.com/hhh/medreview/sig_guidelines.pdf

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Denial Reason #3: 5PCER

Certifications

Physician must include a narrative of clinical findings that supports a life expectancy of 6 months or less as part of the (re)certification, or as an addendum to the certification and recertification forms

May be based on review of clinical records and/or assessment Shows supportedprogression of decline

If the narrative exists as an addendum, the physician must sign both the certification and the addendum

86 January 9, 2015 © 2014 Copyright, CGS Administrators, LLC.

Denial Reason #3: 5PCER

Certifications

Attestation statement follows the narrative

Confirms compositionof the narrative

Based on assessment of patient and/or Review of medical records

Must reflect individualclinical circumstances

Cannotcontain check boxes or standard language used for all patients

(30)

5FFTF - Face-to-Face

Prior to the third benefit period, and with each subsequent recertification, beneficiaries must have a documented face-to-face encounter with a hospice physician, or nurse practitioner

Note: All prior hospice elections/benefit periods are counted

88 January 9, 2015 © 2014 Copyright, CGS Administrators, LLC.

5FFTF - Face-to-Face

Face-to-face encounter can be up to 30 days prior to the recertification date

ANDmust occur priorto certifying physician composition of narrative and signing of certification

 Recertification window remains 15 days prior, orby 2ndday after benefit period begins

89 January 9, 2015 © 2014 Copyright, CGS Administrators, LLC.

5FFTF - Face-to-Face

Documentation must include:

Physician/NP attestationthat FTF occurred FTF documentation clearly titled

If FTF is performed by NP, attestation must indicate clinical findings were communicated to certifying physician

Date and legible signature of physician/NP who performed encounter

(31)

No Response to Additional

Development Request (ADR)

(56900)

Hospice Denial Reason #4

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Levels of Care (5PRLM)

Hospice Denial Reason #5

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Denial Reason #5: 5PRLM

Levels of Care

Routine

General Inpatient Care (GIP)

Respite Care

(32)

Denial Reason #5: 5PRLM

Levels of Care

“General inpatient care may be required for procedures necessary for pain control or acute or chronic symptom management that cannot feasibly be provided in other

settings.”

Medicare Benefit Policy Manual(CMS Publication 100-02), Ch. 9,

Section 41.1.5

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Denial Reason #5: 5PRLM

Levels of Care

GIP is short term care for management of s/s that can not be controlled in another setting

Documentation should show what other measures have been tried priorto GIP

Documentation must substantiate higher level of care for all days billed at GIP level of care

Payment may be made for a portionof GIP days depending upon supporting documentation

95 January 9, 2015 © 2014 Copyright, CGS Administrators, LLC.

Denial Reason #5: 5PRLM

Levels of Care

General inpatient care documentation requirements:

Precipitating crisis

Interventions tried at home that were unsuccessful Supportive data that crisis is ongoing

Interventionsattempted to resolve crisis Patient’s response

Quantitativedata

(33)

Denial Reason #5: 5PRLM

Levels of Care

Symptom changes:

Sudden deterioration requiring skills of nurseUncontrollednausea/vomiting

Unmanageablerespiratory distress New or increased delirium, agitation

97 January 9, 2015 © 2014 Copyright, CGS Administrators, LLC.

Denial Reason #5: 5PRLM

Levels of Care

Pain requiring skills of nurse:

Frequentevaluation

Frequentmedication adjustment Aggressivetreatment to control pain Transfusions

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Denial Reason #5: 5PRLM

Levels of Care

Discharge planning beginsbefore admission

Medicare does not pay for additional days of GIP for discharge planning

(34)

Denial Reason #5: 5PRLM

Levels of Care

Respite Care

Caregiver relief, up to five consecutive days per respite period Can be more than one respite stay per billing period

Based on need for caregiver to have respite from demands of caring for hospice patient

100 January 9, 2015 © 2014 Copyright, CGS Administrators, LLC.

Medical Review Standards

CMS Medicare Benefit Policy Manual (CMS Publication 100-02)

Chapter 9 - Hospice

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c09.pdf

CGS “Hospice Coverage Guidelines” webpage

www.cgsmedicare.com/hhh/coverage/Hospice_Coverage_Guidelin es.html

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Medical Review Standards

Hospice Local Coverage Determination: “Determining Terminal Status”

www.cgsmedicare.com/hhh/coverage/Coverage_Guidelines/LCD.html

(35)

CGS Hospice Denial Fact Sheets -

NEW!

Available from Hospice Quick Resource Tools webpage,

http://www.cgsmedicare.com/hhh/education/materials/Hospice_Q RT.html 5FFTF – Face-to-Face Encounter, http://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_5 FFTF_factsheet.pdf 5PCER – Certification/Recertification, http://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_5 PCER_factsheet.pdf

5PPOC – Plan of Care

http://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_5 PPOC_factsheet.pdf

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CGS Hospice Denial Fact Sheets -

NEW!

5PNOE – Election Statement,

http://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_5 PNOE_factsheet.pdf

5PRLM – Reduced Level of Care,

http://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_5 PRLM_factsheet.pdf

5PTER – Six-month Terminal Prognosis,

http://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_5 PTER_factsheet.pdf

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Other Resources

CGS Hospice Quick Resource Tools

www.cgsmedicare.com/hhh/education/materials/Hospice_QR T.html

CGS Frequently Asked Questions

(36)

On the Same Page??

Provide staff with the rules - Information is Power!!

Guidedecisions and empower clinicians with coverage criteria

Educationon coverage and documentation standards

Oversight of documentation

Ensure the technical pieces are covered

106 January 9, 2015 © 2014 Copyright, CGS Administrators, LLC. 106

Questions?

CGS Provider Contact Center 877-299-4500 (Option 1)

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