Hospice
Downloadable tip sheet on the Hospice Quality Reporting Program
Beth Says:
You are correct. Item-specific guidance for J0905 says "Generally, clinical documentation that the patient is currently taking pain medication is evidence that pain is an active problem for the patient." I agree that marking "no" at J0900 and marking "yes" at J0905 feels awkward. However, even if the assessing clinician did not document a formal pain screening, but a medication was documented as prescribed specifically for pain, the patient qualifies for a comprehensive pain assessment. Then, if the comprehensive pain assessment is documented the agency gets credit for that element of the comprehensive assessment at admission. If you find such documentation in the patient record, I recommend a QAPI project to determine whether pain screenings that occur are not being documented and/or formal pain screenings are being neglected.
Beth Says:
No. Please see page 9 of the HIS Guidance Manual: Examples for patient admission: Situation A: The patient signed an election statement on Monday with an effective date of Tuesday. The nurse went to the patient’s home on Tuesday afternoon and the patient expired before the nurse arrived, so the nurse completed a death visit. Instructions: In this situation, the hospice is not required to submit an HIS- Admission or HIS-Discharge. Although the patient signed the election statement and survived to the effective date of the election, the patient expired before the hospice visit could be made in the setting where the services were to be provided.
Beth Says:
Good question. For now, only the national comparison group is reported in the CASPER system's Hospice-Level Quality Measures Report. No date is promised for a state comparison group to appear, other than CMS' statement that Hospice Compare and the CASPERs that precede each public publishing date will include state comparisons. My best guess (and it's only a guess) is that state comparison groups will become available early summer or late spring to accommodate CMS' plan to launch Hospice Compare in late summer 2017.
Beth Says:
The hospice provider can take credit in the HIS for preference discussions only when a member of the hospice staff (paid or unpaid) also attempts the discussion with the patient during allowed time parameters. This is true regardless of whether a non-hospice provider discusses the patient's preferences with the patient at any time. The HIS measures whether the HOSPICE incorporates NQF best-practices into its patient care.
Beth Says:
Submit within 30 days of the event (admit or death) date.
Beth Says:
Yes. Within one day means by the end of the following day.
Beth Says:
No. The HIS Guidance Manual says: Item A0245 refers to the initial assessment the registered nurse must complete, as defined in the Medicare Hospice Conditions of Participation. Item A0245 is intended to reflect the date on which the initial nursing assessment (as defined in the Medicare Hospice Conditions of Participation) was initiated. However, any portions of the NQF items that must be completed within a specific time frame following the initial assessment only refer to a "clinician" performing such tasks, except in examples cited. For example, a hospice physician may perform the comprehensive pain assessment, or an LPN could instigate a bowel program by teaching the importance of diet and hydration in preventing constipation. Both would qualify as performing best-practice processes if completed in the allowed time parameters.
Beth Says:
The discharge HIS applies to all patients admitted to hospice services under the Medicare hospice benefit. See page 8 of the HIS Guidance Manual: 1.4 Applicable Facilities and Requirements for New Facilities All Medicare-certified hospice providers are required to submit HIS data on all patient admissions on or after July 1, 2014, onward. Reporting eligibility and requirements for new hospice providers is addressed by CMS through rulemaking. For more details on requirements for new facilities, see proposed and final rules published by CMS in the Federal Register: https://www.federalregister.gov/. 1.5 Applicable Patients A HIS-Admission and a HIS-Discharge record are submitted for all patient admissions to a Medicare-certified hospice program on or after July 1, 2014, regardless of the following: Payer source (Medicare, Medicaid, or private payer) Patient age Where the patient receives hospice services (home, nursing home, assisted living facility, freestanding hospice) Length of stay
Beth Says:
YA visit that began when the patient was alive is counted as one visit occurring on the day of death.
Beth Says:
The data updates at least monthly in the CASPER system and will update quarterly on Hospice Compare. Each time the data will include 12 months' worth of data. For instance, if the CASPER system were updated in April 2018, the reports would be based on all HIS data submitted by hospice agencies nationwide throughout the calendar year 2017. Three months later, the same 2017 HIS data would formulate the scores for Hospice Compare in July's update, while the CASPER system would "roll" forward to include quarters #2, #3, and #4 of 2017 along with quarter #1 of 2018. And so forth.
Beth Says:
Yes. The scores will reflect actual final_visits performed. CMS expects such instances to be rare, and expects hospice agencies to document accurately and promptly the family's refusal of all final_visits for each of those days, as well as all services offered, each time a service is offered and refused.
Beth Says:
Yes. the HIS Guidance Manual states concerning A1400. Payor Information: Response J, Self-pay should be selected if the patient has any amount of personal funds available to contribute to healthcare expenses (services, supplies, medications, etc.) during the hospice episode of care.
Beth Says:
I recommend starting HIS submission right away. The 2017 hospice final rule states: . . . beginning with the FY 2018 payment determination and for each subsequent payment determination, we finalized our policy that a new hospice be responsible for HQRP quality data submission beginning on the date of the CCN notification letter; we retained our prior policy that hospices not be subject to the APU reduction if the CCN notification letter was dated after November 1 of the year involved. For example, if a provider receives their CCN notification letter and the date in the letterhead is November 5, 2016, that provider will begin submitting HIS data for patient admissions occurring after November 5, 2016. However, since the CCN notification letter was dated after November 1st, they would not be evaluated for, or subject to any payment penalties for, the relevant FY APU update (which in this instance is the FY 2018 APU, which is associated with patient admissions occurring 1/1/16 – 12/31/16). This policy allows CMS to receive HIS data on all patient admissions on or after the date a hospice receives their CCN notification letter, while at the same time allowing hospices flexibility and time to establish the necessary accounts for data submission before they are subject to the potential APU reduction for a given reporting year. Currently, new hospices may experience a lag between Medicare certification and receipt of their actual CCN Number. Since hospices cannot submit data to the QIES ASAP system without a valid CCN Number, CMS proposed that new hospices begin collecting HIS quality data beginning on the date noted on the CCN notification letter. We believe this policy will provide sufficient time for new hospices to establish appropriate collection and reporting mechanisms to submit the required quality data to CMS. Requiring quality data reporting beginning on the date listed in the letterhead of the CCN notification letter aligns CMS policy for requirements for new providers with the functionality of the HIS data submission system (QIES ASAP).
Beth Says:
The HIS captures up to 9 visits per day per discipline. CMS does not prescribe the number of visits needed, except to say that the plan of care, which includes ordered services and disciplines, must meet patient and family needs specific to their circumstances. The IDG, including the physician, must adapt the plan of care to address the patient's and family's changing needs at the end of life.
Beth Says:
CMS specifies no difference for routine home care patient visits whether the patient is at home or in an inpatient hospice facility. Count all visits by each discipline provided by the hospice staff, paid or unpaid.
Beth Says:
No. These disciplines are also counted on the last 3 days of life. They're just counted in O0510 rather than in O0530.
Beth Says:
Regulatory rules don't specify that the physician must perform a face-to-face encounter to verify a change to the terminal diagnosis. Rather, that if the terminal illness changes, the physician need not create a new CTI, but must document the change and update it on the next CTI that is due. Even the initial terminal illness documented on the CTI does not require a face-to-face encounter by the physician. But CMS does state that clinical documentation in the patient record must support the terminal illness that the physician specifies.
Beth Says:
If a nurse doesn't consider co-morbidities to be related to the terminal illness, the nurse must discuss this with the physician. In order for any condition to be considered unrelated, the hospice physician must document why it is unrelated to the terminal illness and does not affect the patient's 6-month prognosis. The 2015 & 2016 Hospice Final Rules state that the terminal prognosis, rather than exclusively the terminal illness disease process must be considered when determining which services the hospice agency will include in its hospice claim. Both say that CMS has always intended that the hospice agencies provide (pay for) virtually all services that the terminally ill patient needs.
Beth says:
Coding benefit periods with both ICD-9 and ICD-10 diagnosis codes is a good idea for hospice agencies prior to October 1, 2015, when ICD-10 becomes required. I highly recommend dual coding as well as ICD-10 claim submission testing to ensure the ICD-10 claims will be accepted successfully by payers. Here's why:
- Painting the most vivid picture possible of a hospice patient's condition through accurate ICD-10 may prevent unnecessary scrutiy by regulatory entities and payers. ICD-10 provides opportunities to filter claims for specific characteristics that may or may not support a beneficiary's qualification for hospice services. Dual coding before ICD-10 is required will help hospice coders identify in advance additional information to show hospice patient accuity that is possible in ICD-10, but not in ICD-9.
- Since hospice providers must bill by calendar months, hospice claims will clearly bear ICD-9 codes through September 30, 2015, and ICD-10 codes beginning October 1, 2015. Hospice providers must be sure that claims include diagnosis codes only from the correct code set for the month the services were provided to the beneficiary. If hospice providers wait until the last minute to get familiar with and apply ICD-10 diagnosis coding to hospice claims, hospice coders will be more likely to use ICD-10 codes that could potentially prompt increased scrutiny or rejected claims.
Home Health
Beth Says:
When an unexpected discharge occurs, the clinician qualified to complete the OASIS who most recently visited the patient must create a discharge OASIS from that visit. If no subsequent visit occurred, the recert responses would be copied to the DC OASIS and other DC OASIS data extrapolated according to the findings during that assessment visit. If the clinician who most recently visited the patient is no longer with the company, the clinical supervisor must complete the DC OASIS items as accurately as possible from the information documented on the recertification comprehensive assessment, and document clearly why the supervisor is completing the DC OASIS assessment instead of the clinician who last visited the patient.
Beth Says:
When an unexpected discharge occurs, the clinician qualified to complete the OASIS who most recently visited the patient must create a discharge OASIS from that visit. If no subsequent visit occurred, the recert responses would be copied to the DC OASIS and other DC OASIS data extrapolated according to the findings during that assessment visit. If the clinician who most recently visited the patient is no longer with the company, the clinical supervisor must complete the DC OASIS items as accurately as possible from the information documented on the recertification comprehensive assessment, and document clearly why the supervisor is completing the DC OASIS assessment instead of the clinician who last visited the patient.
Beth Says:
Yes, the OASIS compliance workshop will help you prepare for your OASIS certification. We'll still address the important information and updates, and since home health is looking at new COPs instead of a new OASIS data set imposed next year, I'll teach OASIS accuracy in context of the OASIS as a tool to help achieve COP compliance, and how responses and risk adjustment can affect star ratings.
Pre-Claim Review FAQs from CGS
CGS Says:
During the pause of the Home Health Pre-Claim Review (PCR) demonstration, no new requests will be reviewed or accepted on or after April 1, 2017 for the duration of the pause of the demonstration.
CGS Says:
Yes. During the pause of the PCR demonstration, if you received a UTN we encourage you to include the UTN on the final claim.
CGS Says:
That is correct. For any pending PCR submissions there is no need to follow up. For home health follow_up that have not received a UTN, you can submit the claim for payment and it will be processed under normal claim processing rules.
CGS Says:
You do not need to submit resubmissions PCR requests while the PCR demonstration is paused. PCR resubmissions will not be reviewed by CGS and a UTN would not be assigned for you to submit on the final claim.
CGS Says:
No new requests or resubmissions will be reviewed or accepted on or after April 1, 2017, for the duration of the pause of this demonstration.
CGS Says:
During the pause, home health claims can be submitted for payment and will be processed under normal claim processing rules.
CGS Says:
We encourage you to include the UTN on the final claim when it has been processed through the PCR, and a UTN was provided. The claim will be processed under normal claim processing rules.
CGS Says:
For claims that have received a UTN, we encourage you to include the UTN on the final claim. During the pause, home health claims can be submitted and will be processed under normal claim processing rules.
CGS Says:
If a claim was submitted without a UTN, where a valid UTN was issued, a reopening should be requested. Providers should submit the reopening with the type of bill 32Q.
Earning Documentation Credentials
Beth says:
The AHCC/BMSC web page at DecisionHealth.com explains criteria for obtaining credentials in ICD-10 diagnosis coding, HCS-D, and OASIS-C1/ICD-10 accuracy, HCS-O, and plans to offer a hospice-specific documentation credential, HCS-O in the near future. As an AHCC board member, I am assisting with the hospice credential development, and also worked on the committee with NCCA to accredit the HCS-D and the HCS-O credential tests.
OASIS Answers also offers an OASIS documentation credential.
AHIMA offers ICD-10 coding credentials that are not specific to home health and hospice.
ICD-10 Diagnosis Coding
Beth Says:
The rules haven't changed, but the emphasis has.
When only one specific aspect of a neurological disease, such as treating ataxic gait (R26.0) for a patient with Parkinson's Disease (G20), or urinary catheter care (Z46.6) for Multiple Sclerosis (G35), is the focus of care, list that as primary, and the disease lower on the list. It's relevant, but not the focus of care in such instances. But if more than one aspect are the focus of care, list the neurological disease primary, and include, lower on the list, the problems addressed in the POC that aren't integral to care for every patient with that condition.
The big emphasis difference comes from (in my opinion) case-mix changes for ICD-10 that don't pay more for neurological conditions if they happen to be primary vs. secondary.
Just as with ICD-9, list the ICD-10 diagnoses in order of clinical importance to the home health or hospice plan of care.
* Content taught requires application by the learner to achieve favorable results. Diagnosis coding requires practice. Nothing on this website is intended to promise that participants will gain expertise by merely participating in a course.
