Clinical Compliance

Coverage & Compliance Tips for Hospice Agencies

11/22/2023

Nancy Kendrick and I had the opportunity September 13-15 to attend the 2023 Home Health & Hospice Medicare Administrative Contractors (MAC) Collaborative Summit in Las Vegas. 

We gained many insights from this unique educational opportunity for home health and hospice providers who attended from every state and Medicare jurisdiction.

These key points from the summit can help your hospice agency reduce claim denials. 

Documenting a Patient’s Terminal Status: Common Errors 

•    Not submitting IDG meeting notes.
•    Medical records do not include comprehensive information from other staff members. 
•    Conflicting documentation by different disciplines, showing different level(s) of decline and no explanation included. 
•    No measurable signs or symptoms for comparison. 
•    Insufficient support of terminal status in documentation.

TIPS

Documentation is essential in ‘painting the picture,’ especially for patients that:
•    Have remained on the hospice benefit for a long period of time; or
•    Have chronic illnesses with a more general decline.

Documentation to support a terminal prognosis at the time of the hospice admission may include:
•    Changes in condition to initiate the hospice referral.
•    Diagnostic documentation to support terminal illness.
•    Physician assessments and documentation.
•    A date of diagnosis.
•    A course of the illness.
•    The patient’s desire for palliative care.
•    Records that show a trajectory of decline.

Documentation to support the terminal prognosis throughout the hospice election:
•    Changes in the patient’s weight.
•    Diagnostic lab results.
•    Changes in pain (type, location, frequency)
•    Changes in responsiveness.
•    Skin condition (turgor).
•    Changes in the level of dependence for ADLs.
•    Changes in anthropomorphic measurements (abdominal, girth, upper arm measurements.
•    Changes in vital signs (RR, BP, pulse).
•    Changes in strength.
•    Changes in lucidity.
•    Changes in intake/output.
•    Increasing ER visits or hospitalizations.

Documenting Weight and Mid-Upper Arm Circumference (MUAC) 
Weigh at least monthly, more often if possible. Take weights in a consistent manner.  
•    Time of day 
•    Consistent clothing
•    Relative to mealtimes
•    Show prior and current weights. 

Take Mid-Upper Arm Circumference (MUAC) on admit and weekly in a consistent manner.
•    Remove clothing from arm used.
•    Be consistent.
•    Measurements can be taken from: 
o    Upper arm
o    Girth
o    Leg 
•    Show prior and current measurements.
•    Explain how and where measurements are taken. 

Documenting Weight Using Non-Clinical Methods
Documenting the Level of Pain 
•    0-10 scale (preferred).
•    Consistent method of measuring pain. 
•    Use methods that the patient/caregiver understand.
o    Colors
o    Small, Medium, Big
o    Wong-Baker FACES Pain Rating Scale

Non-clinical Examples
•    Patient was holding her abdomen while I was talking to her.
•    Patient said they did not feel like going for a walk today.
•    Patient winced when I was helping him to the bathroom.

Documenting Responsiveness 
•    Does the patient react to your presence? 
•    Is the patient receptive to care? 
•    Does the patient seem frightened?
•    Does the patient remember you from the last visit? 

Non-Clinical Examples 
•    Patient did not remember the conversation we had about his daughter during our last visit. He typically enjoys sharing stories about her. 
•    Patient appeared to be scared when I tried to help her get dressed. 
•    I had to prompt the patient repeatedly to continue conversation. Usually very talkative. 
•    Is the patient unresponsive? 
•    Do they respond to touch? Smell? Light? Pain?
•    Do they fade in and out of alertness? 

Assessment Information to Support Terminal Prognosis

ADLs and Vital Signs 

Clinical – Respirations, blood pressure, pulse, temperature, etc.
•   Graphs easily illustrate change.

Non-Clinical
•   Patient was breathing harder than normal.
•   Patient was having difficulty talking d/t SOB.

Lucidity  

Clinical
o    Can the patient follow conversation?
o    Decisions – simple or complex
o    Current events

Non-Clinical
o    Patient could not remember daughter’s name.

Strength

Clinical
o    Hand squeeze
•   Has there been a change?
•   Can the patient raise his/her hands to do this?
o    Standing
•   Assisted or unassisted
•   Length of time
•   Safely

Non-Clinical
o    Patient could not open the jar of pickles for her lunch.
o    Patient needed assistance getting out of his chair. Normally, He can do this independently.

Election Statement Contents 
•    CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 20.2.1.1 
•    Identification of the hospice that will provide care to the beneficiary. 
•    Beneficiary/representative’s acknowledgment that they understand what hospice is. 
•    Beneficiary/representative’s acknowledgement that they have been provided information on the hospice’s coverage responsibility and that election includes information indicating:
•    That services unrelated to the terminal illness and relatd conditions are exceptional and unusual, and
•    The hospice should be providing virtually all care needed by the beneficiary who has elected hospice.
•    Effective date of the election
•    May be first day of hospice services or later date but may not be retroactive.
•    The beneficiary/representative may sign the election form before or on the effective date.
•    If the beneficiary/representative signs the election form on a date after the effective date of the election, dates billed prior to the date the election is signed are not covered.

Examples
Effective date is 06/01/23. The representative signs the election 06/04/23.  The hospice bills services for 06/01-06/30/23.
•    0601-06/03 would be non-covered for no valid election in place.
•    06/04-06/30 would be covered as the election is valid the date it is signed.

Effective 10/01/2020:
•    Information on individual cost-sharing for hospice services.
•    Notification of the beneficiary/representative’s right to receive an election statement addendum for anything not covered by the hospice.
•    Information on the BFCC-QIO including the right to immediate advocacy and BFCC-QIO contact information.
•    Signature of the beneficiary/representative
•    Signature of the beneficiary/representative’s designated attending physician (if any).
•    The beneficiary/representative’s acknowledgement that the physician is their choice.

Model Election Statement
Here is a best practice example:  https://www.cms.gov/files/document/model-hospice-election-statement-modified-july-2020.pdf

Transfers
•    Transfers do not constitute revocation or discharge; an election continues as long as the beneficiary:
•    Remains in the care of hospice.
•    Does not revoke the benefit.
•    Is not discharged by a hospice.
•    The receiving hospice must file a new Notice of Election.
•    Benefit periods remain the same.
•    If the beneficiary is in the 3rd or subsequent benefit period, a face-to-face encounter is required.
•    If the receiving provider can verify the encounter was performed, the new hospice does not need to do an encounter.

When General Inpatient Care (GIP) Is Necessary

•    The beneficiary’s medical condition warrants a short-term inpatient stay for pain control or symptom management that cannot be provided in other settings.
•    Medication adjustment, observation, treatment is needed to stabilize the patient.
•    It is not appropriate to use GIP when caregiver support has broken down unless coverage requirements for GIP level are met.
•    The patient’s intensity of care cannot be managed in any other setting.
•    Services must conform with the written plan of care.
•    Services may only be provided in Medicare participating facilities.
•    Hospital
•    Skilled nursing facility (SNF)
•    Hospice inpatient facility

Documenting the Need for GIP Care
•    Upon transfer to GIP level of care, documentation should include both:
•    A precipitating event (onset of uncontrolled symptoms or pain)
•    The interventions tried in the home that have been unsuccessful at controlling the symptoms.
•    Pain management requiring skilled nursing.
•    Aggressive treatment for pain control .
•    Complicated technical delivery of medication.
•    Can include teaching caregiver delivery.
•    Frequent evaluation.
•    Frequent medication adjustment.
•    PRN medication
•    Symptom changes
•    Sudden deterioration
•    Uncontrolled nausea/vomiting
•    Uncontrolled delirium, agitation
•    The point of care should reflect the change in the level of care, the beneficiary’s response, and the collaboration with the facility staff.

Potential Issues with GIP Documentation
•    Long stays
•    Inappropriate use
•    No discharge planning.
•    Documentation not supporting GIP level of care.
•    GIP level of care for caregiver breakdown when medical symptoms/care do not support GIP.
•    A patient in the dying process does not make the patient eligible.
•    Discharge planning days are not covered.
•    An inpatient unit is not an automatic step down from the hospital.
•    Location does not determine level of care.

Inappropriate Use of GIP Care General Inpatient Care
•    For routine admission and care plan formation
•    Ongoing assessment of managed symptoms
•    No available caregiver for in-home care
•    Caregiver relief
•    General fall risk and/or supervision need.

Documenting GIP Care

Examples of Inappropriate Documentation
•    “Patient in general inpatient unit for end-of-life care.”
•    “Patient is comfortable. No chest pain, no dyspnea, no fever, good appetite. No signs and symptoms of disease present.”

Helpful Tips for GIP

Document at least daily:
•    Pain ratings
•    Vital signs
•    Weights
•    Intake and output
•    Descriptions and other objective data
•    Body language if unable to communicate.

Include Quantitative Data
•    A discharge plan should be documented daily for all GIP patients.
•    Discharge and disposition planning begins before admission.
•    Medicare does not pay for additional days for discharge plan.
•    How crisis remains ongoing
•    Completed interventions to resolve crisis.
•    Patient’s response

Respite Care

Examples of appropriate use of respite care:
•    Caregiver feels if he/she had relief of caregiving responsibilities for a short time, the caregiver could resume or continue caring for the beneficiary at home again. Caregiver is temporarily unable to provide care to beneficiary because of personal illness.
•    Caregiver needs to go out of town overnight.

Examples in which respite care is not appropriate:
•    The beneficiary did not have a caregiver providing care in the home on a regular basis.
•    The beneficiary was already in 24-hour care at a care facility and the desire for respite care is not related to a patient caregiver need.
•    The plan of care clearly states this is a permanent placement to a residential facility.
•    The respite care was not provided in a participating hospice inpatient unit, or a participating SNF or NF that additionally meets the special hospice standards.

Documenting the Change in Level of Care
•    Document current level of care and new level of care
•    Date when level of care changed.
•    Location where care is being provided.

Access additional information through Medicare University at https://www.ngsmedicare.com/documents/20124/121705/2320_091421_hospice_terminal_patient_508.pdf/36e61a9e-b407-ef74-07a0-bd80025c7f11?t=1631904955351

 How does your agency rate in relation to the above regulatory requirements? What areas cause you concern? Corcoran Consulting Group can help you develop and instill the processes and discipline to improve compliance, and patient satisfaction measures. This discipline will lead to increased revenue, and a competitive advantage. Call us at 203.691.1319, or contact us at info@corcoranconsultants.com, or visit corcoranconsultants.com. 
  
Maryanna Arsenault is a Corcoran Consulting Group consultant. She is an ACHC-Certified Consultant Home Health, Hospice, Private Duty.