Hospice Widespread edits

(1)

Hospice Widespread edits

Befriend this foe

to prevent claim denials

Beth Noyce RN BSJMC HCS-D COS-C

Beth Noyce, RN, BSJMC, HCS D, COS C Clinical Educator & QA Specialist

and Dana Walling, RN, COS-C Director of Nursing, Branch Manager Applegate HomeCare and Hospice of Utah

What are widespread edits and

why should you care?

• Screen for claims

– With greatest risk of

inappropriate

payment

– In areas identified

as potential

problems through

data analysis

.

(2)

What are widespread edits and

why should you care?

• Examples include:

– Diagnosis in combination with other

factors

– Charges relating to utilization

– Level of care issues

– Length of stay or number of visits

What are widespread edits and

why should you care?

• Result from edit probes that

hi h d

i l

t

ft

th

prove a high denial rate after the

payer:

– Validates the hypothesis that such claims are being billed in error.

– Checks a sample of 100 claims that fit the edit description (from across all agencies).

Medicare Program Integrity Manual, Chapter 3 - Verifying Potential Errors and Taking Corrective Actions, 3.11.1.2 - "Probe" Reviews

(3)

What are widespread edits and

why should you care?

Widespread edits

• Widespread edits

automatically reroute claims

– at high risk of payment errors – for review before payment – to verify that care was y

appropriate.

What are widespread edits and

why should you care?

• Awareness of current

widespread edits can:

– Help agencies better understand CMS coverage;

– Help clinicians e p c c a s

(4)

What are widespread edits and

why should you care?

• Payers review edits quarterly.

– High denial rate = edit continues. – Payers must teach providers to

decrease inappropriate claims.

7

What are widespread edits and

why should you care?

• Claim denial

Claim denial

– Lower payment or no payment for services already provided. – Hundreds or

thousands in lost thousands in lost revenue with each denied claim.

(5)

Which claims are targets of

hospice widespread edits?

• Non-Cancer length of stay

– (NCLOS provider-specific)

• DC & readmit

• Provider exceeding hospice cap & no

review for past year

• 290.40, Vascular dementia, >240 days,

routine

Which claims are targets of

hospice widespread edits?

• LOS > 1 year; LOS > 730 days (> 2 years); • LOS > 999 days General inpatient services • Lymphoma 202xx-203xx primary dx & LOS

>180 days, routine

• Cardiomyopathy NEC 425.4 primary dx, y p y p y , LOS >181 days

(6)

Game Plan

• Hospice Edits

– Common reasons for denial

– Additional edit-specific criteria

– Documentation tips to avoid denial

Common reasons for denial

Documentation must support

6-month terminal prognosis

Medical records sho ld contain

• Medical records should contain

enough clinical factors and

descriptive notes to show:

– The illness is terminal, and – Progressing in a manner that a g g

physician would reasonably

conclude that the beneficiary's life expectancy is 6 months or less.

(7)

Documentation must support

6-month terminal prognosis

N NHPCO id t l

New NHPCO guidance tool:

http://www.nhpco.org/files/public/regulatory/Instructions_Pt_Face_to_Face_Encounter.pdf

Documentation must support

6-month terminal prognosis

• Missing, incomplete or

untimely Certification of

Terminal Illness (CTI)

– Seen as lack of

documentation by MD that

the patient still has a terminal

prognosis of 6 months or less

(8)

Documentation must support

6-month terminal prognosis

• Physician’s CTI must state

– The patient has a terminal

illness

– With a life expectancy of 6

months or less

– If the terminal illness runs its

normal course.

Documentation must support

6-month terminal prognosis

• The initial CTI must be

signed by:

– Hospice medical director or

the physician IDG group

member

and

– Attending physician, if the

patient has one.

(9)

Documentation must support

6-month terminal prognosis

• The CTI must be

renewed each

certification period.

Each must specify

– Each must specify

the dates of the

certification period.

Documentation must support

6-month terminal prognosis

• Recertification CTIs must

include:

– Statement by the hospice

physician

– Specifying why the

patient’s terminal prognosis

is still 6 months or less.

(10)

Documentation must support

6-month terminal prognosis

CTI (no more than 15 days before new cert)

• The physician must sign immediately

following the narrative.

• No check boxes or standard language

that is used for all patients.

• The narrative must be completed by

the certifying physician, not by other

hospice personnel.

Documentation must support

6-month terminal prognosis

Fi

i

k

l

h

• First-person narrative makes clear that the

CTI is in the physician’s own words.

(11)

Documentation must support

6-month terminal prognosis

CTI CTI

• An attestation statement under the physician signature must state that the signature means:

– The physician confirms that s/he composed the narrative p

– Based on review of the medical record or examination of the patient

• The physician must also sign the attestation statement.

Documentation must support

6-month terminal prognosis

• Even if all other documentation is in order

to support the beneficiary’s eligibility,

overlooking a detail can get a claim denied

(12)

Edit-specific criteria

Documentation must support

6-month terminal prognosis

• Documentation is

essential in

“painting the

picture” of each

p ctu e o eac

patient’s decline.

Documentation must show

medical necessity

• Clinical documentation must

reflect diagnoses and

ordered treatments to support why the patient needs hospice care now. • Qualifying criteria for one

diagnosis does not always match those of another.

(13)

Documentation must

show medical necessity

• Decline documentation is key to illustrating support of the patient’s 6-month life expectancy.

25

Edit-specific Criteria

Documentation must support

6-month terminal prognosis

L

l C

• Local Coverage

Determinations (LCD)

help determine whether

the payer will agree that

the patient meets

p

qualifying criteria.

– LCDs are published on MAC or RHHI web sites.

(14)

Check your MAC/RHHI for LCDs

A w/ J15 w/ J6 w/ J14 27 w/ J11 Former New A NGS NHIC B Cahaba CGS C Palmetto Palmetto D NGS TBD Documentation tips

Documentation tools can help

• A tool to help clinicians track decline along

LCD

it i

ifi

d

i l i k

(15)

Documentation Tips

Argue the case on paper (or EMR)

to avoid claim denials

• For hospice care to

be covered, the

medical record must

clearly show hospice

eligibility throughout

the time hospice care

is provided.

Documentation Tips

Argue the case on paper (or EMR)

to avoid claim denials

• Denial can result from documentation that:

– Excludes adequate decline specifics – Focuses primarily on custodial care

(16)

Documentation Tips

Argue the case on paper (or EMR)

to avoid claim denials

• When the condition does not run the

normal course of decline and remains

temporarily unchanged:

•The medical record’s documentation

Documentation Tips

Argue the case on paper (or EMR)

to avoid claim denials

•The medical record s documentation

must explain why the beneficiary still

(17)

Documentation Tips

Argue the case on paper (or EMR)

to avoid claim denials

• Avoid vague

statements

such as “slow

d

li

”

d

decline” and

“disease

progressing.”

Documentation Tips

(18)

Documentation Tips

Tools to guide documentation

• http://geriatrics.uthscsa.edu/tools/Hospice_elegibility_card__Ross_and_Sanchez_Reilly_2008.pdf

Documentation Tips

(19)

Tools to guide documentation

(20)

Tools to guide documentation

Documentation Tips

Argue the case on paper (or EMR)

to avoid claim denials

Al

d

t

if it

ill b

dit d

• Always document as if it will be audited.

• Objective, specific documentation, shows

precisely why the patient qualifies for

hospice care.

(21)

Common denial reasons

Missing, Incomplete, Untimely

Election Statements

• Documentation

must show the

required election

statement was

i

d b f

signed before

providing hospice

care.

Missing, Incomplete, Untimely

Election Statements

• The election statement must include:

– Hospice agency

– Patient acknowledgement of understanding

• Hospice care

• Which other Medicare services are waived

– Date the election is effective – Dated signature

(22)

Denials involving level of care

• Claims found lacking can lead to • Claims found lacking can lead to

– Reduced level of care,

OR

– Complete denial

• Due to

– Missing, incomplete or untimely certifications

AND/OR

– Missing, incomplete, untimely election statements.

Denials involving level of care

• Claims can be

decreased or denied

when the record does

not support the patient’s

need for provided

– general inpatient – general inpatient OR

(23)

Denials involving level of care

• General inpatient care documentation

t l

l

h

must clearly show:

– Procedures necessary for pain control or acute or chronic symptom management that cannot feasibly be provided in other settings.

OR

– Skilled nursing care needed when home support has broken down, eliminating the feasibility of furnishing needed care at home.

Denials involving level of care

• General inpatient services

– Provided to meet the patient’s skilled p needs that can’t be met at home.

VS.

• Inpatient respite care

– Provided to meet a caregiver’s need

f b k f i i

for a break from care-giving responsibilities.

(24)

Denials involving level of care

General Inpatient (GIP)

VS

VS.

Respite

Provider-specific edits becoming

more widespread, too

(25)

How can my agency

decrease its risk of

denials?

How can my agency decrease

its risk of denials?

• Provide and

document only

care that is

medically

necessary for the

diagnoses and

program type listed

on the claim.

(26)

How can my agency decrease

its risk of denials?

P

id

l

th t

t

• Provide only care that meets

hospice program requirements.

51

How can my agency decrease

its risk of denials?

C

d

t

• Conduct

agency

self-audits to find

and correct

problems

before CMS

finds them.

(27)

How can my agency decrease its

risk of denials?

• Use recertification as an opportunity to

k

make sure

– Beneficiary still qualifies; and

– Documentation clearly supports continuing care.

VS.

How can my agency decrease its

risk of denials?

• Be sure ALL hospice

physician signatures

are legible or

verifiable

–Implement signature

Implement signature

logs or use EMR

electronic signatures.

(28)

How can my agency decrease

its risk of denials?

• Implement PI projects

• Implement PI projects,

including coaching and

education, to improve

documentation and

otherwise ensure

compliance.

55

Coach and educate!

• Coach clinicians to argue anew the case

for hospice eligibility with each recert.

• Avoid recerts that show no decline.

(29)

Coach and educate!

• After coaching: supports eligibility

How can my agency decrease

its risk of denials?

• Respond to ADRs promptly

• Respond to ADRs promptly.

– Many claims are denied because

providers don’t respond on time.

– ADRs come with resources for

help.

p

• Meet deadlines and follow instructions.

(30)

How is the change to new MACs

affecting widespread edits?

• CMS requires that incoming

Medicare Administrative Contractors

(MACs) consolidate edits that were

used by fiscal intermediaries (RHHIs)

h

di

if

to ensure that edits are uniform

throughout each MAC’s jurisdiction.

59

How is the change to new MACs

affecting widespread edits?

• CMS says MACs must choose

which existing edits to

incorporate, and:

– Consider impact on providers,

– Coordinate changes with CMS,

(31)

How is the change to new MACs

affecting widespread edits?

• Currently, information on

MAC/RHHI

b it

i

i i

l

MAC/RHHI web sites is minimal.

• CMS says MACs must educate:

– Clearly communicate changes to

providers “early and often in bulletins, special newsletters, and/or training

seminars/workshops.”

Medicare Administrative Contractor Workload Implementation Handbook

Widespread Edits

• Speak up!

–Ask your MAC to

make widespread edit

information more

accessible to

providers

providers.

–Remind them to

focus on education!

(32)

Palmetto

3 March 2011 Hospice Coalition Q & A

• No new medical reviews established for

N

C

L

th f St

(NCLOS)

Non-Cancer Length of Stay (NCLOS)

rates only.

• Edits / probes planned for 2011 include:

– Providers exceeding Hospice Cap, – Average Length of StayAverage Length of Stay,

– Non-Cancer Length of Stay rates – New providers.

Palmetto

March 3, 2011 Hospice Coalition

• The J11 Hospice LCDs (11004 – HHH) remain the same as those under Title 18 (00380-RHHI) the same as those under Title 18 (00380 RHHI) and are listed below.

– HIV Disease – Liver Disease

– Neurological Conditions – Renal Care

Al h i ' Di &R l t d Di d

– Alzheimer's Disease &Related Disorders – Cardiopulmonary Conditions

– Adult Failure To Thrive Syndrome

(33)

Palmetto

• Top Ten Hospice denials in March 2011 Medicare

advisory: y

– Documentation Submitted Does Not Support Prognosis of

Six Months or Less

– Physician Narrative Statement Not Present or Not Valid – No Plan of Care

– Lack of Response to Medical Record Request – No Certification for Dates Billed

– No Valid Election Statement Submitted – Initial Certification Not Timely

– Subsequent Certification Not Timely – Continuous Care Hours Not Documented – Initial Certification Not Signed

NHIC

(34)

NHIC

NGS

(35)

How will the change to new MACs

affect future widespread edits?

• Stay current with MAC/RHHI

newsletters and bulletins.

– Widespread edit information is

not easy to find on any web

site. Be persistent!

P bli h d

h

i

– Published when announcing

probe results or new

widespread edits.

References

• Medicare Program Integrity Manual, Chapter 3

-Verifying Potential Errors and Taking Corrective

A i 3 11 1 2 "P b " R i

Actions, 3.11.1.2 - "Probe" Reviews

• Medicare Benefit Policy Manual, (CMS Pub. 100-02), Ch. 7, §§30.2 and 40.2.

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

• http://www.cms.hhs.gov/Manuals/IOM/list.asp Medicare Administrative Contractor Workload • Medicare Administrative Contractor Workload

Implementation Handbook, 2/12/08

• http://geriatrics.uthscsa.edu/tools/Hospice_elegibility_car d__Ross_and_Sanchez_Reilly_2008.pdf

(36)

References

• http://www.palmettogba.com/Palmetto/Providers. nsf/files/03222010 Hospice Coalition Question_ p _ _ s.pdf/$FIle/03222010_Hospice_Coalition_Questi ons.pdf • http://www.palmettogba.com/palmetto/providers. nsf/DocsCat/Providers~Regional%20Home%20 Health%20Hospice%20Intermediary%20%28RH HI%29~Resources~Medical%20Review~7GM2 DG1566?open&navmenu=|| DG1566?open&navmenu=|| • http://www.medicarenhic.com/RHHI/RHHI_index .shtml • http://www.cgsmedicare.com/hhh/index.html