Did you get your PEPPER yet?
How does your hospice compare? If you haven't checked since April 10, take a break and find out.
Hot Hospice PEPPERs at PEPPERresources.org posted April 10, 2017. Check it out to see if your scores differ greatly from others in your state, region, and the nation. Of course, if they do, your hospice is at greater risk of scrutiny by Medicare's program integrity contractors and the Office of Inspector General (OIG).
Claims with one diagnosis
Hospice claims with just one diagnosis coded fell from 37.3% in 2015 to 14.3% at the end of 2016, say Q4Hospice PEPPERs. That's more than a 50% improvement, a great indicator of the industry's increasing regulatory compliance.
It also spotlights more readily those hospices clinging tightly to the one-diagnosis mindset. Targeting those agencies to scrutinize for potential non-compliance will be child's play for CMS and the OIG.
Why anyone is still doing this? How likely is a terminal patient to have only one problem? Probably not very likely. In addition to the terminal illness, a hospice patient could certainly qualify for coding Palliative Care (Z51.5).
My guess is that agencies listing only one diagnosis are protesting CMS' clarification that hospices must provide and pay for "virtually all needs" of hospice patients, and that any diagnoses related to the terminal prognosis must be listed, even though the hospice won't be covering them. I don't recommend noncompliance as a form of protest. Too expensive when it catches up with you.
Live discharges are a hot PEPPER topic for hospice as well. Of all discharges in Q4 of 2016, including those due to death, hospices discharged 7.3% because the beneficiaries were no longer terminally ill, and 4.7% of beneficiaries revoked the hospice benefit. Based on prior CMS and OIG statements, I think we'll see increased scrutiny for the live discharges with the longest lengths of stay. Live discharge for beneficiaries not terminally averaged 218.8 days of hospice care before their live discharges.
Long length of stay
Along similar lines, I expect the CMS/OIG examination microscope to focus on "Long Length of Stay" beneficiary episodes – those that occur past 180 days of hospice service – whether still receiving services or already discharged. The PEPPER with this information shows that nationally, beneficiary episodes with such late episodes occur, on average, for beneficiaries with 392.3 days of hospice care under their belts. At just 12.9% of all episodes, this characteristic narrows the scrutiny field.
And watch out for CMS and OIG interest in episodes that meet both criteria.
There's more, but why give it away all at once?
Go get your PEPPER and see where you stand.
If you don't like what you find, let me know if I can help.