Determining Hospice Eligibility and Relatedness

Transcription

1 Determining Hospice Eligibility and Relatedness Jennifer Kennedy, MA, BSN, RN, CHC National Hospice and Palliative Care Organization September 2015

2 Learning objectives Review of federal hospice regulations Hospice physician role Attending physician role Interdisciplinary team role Assessment of Hospice of Central PA s: Determination of eligibility and relatedness process Identification of compliance risks and areas for improvement Identification of resources National Hospice and Palliative Care Organization,

3 418.3 Definitions The Regulation Terminally ill means that the individual has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course. National Hospice and Palliative Care Organization,

4 Palliative Goals of Care The person beginning hospice care, or his or her representative, needs to understand that his or her illness is no longer responding to medical interventions to cure or slow the progression of disease and then must choose to stop further curative attempts while palliative care continues and intensifies, as needed, for continued symptom management. (Italics added) Medicare Program; FY 2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements; and Updates on Payment Reform, 78 Federal Register 152 (7 August 2013), p National Hospice and Palliative Care Organization,

5 Terminal Prognosis National Hospice and Palliative Care Organization,

6 Determining Terminal Prognosis Life expectancy of 6 months or less. Is this someone at high risk of death? General indicators of poor prognosis. Disease-specific indicators of poor prognosis, including the local coverage determinations (LCD). National Hospice and Palliative Care Organization,

7 Would you be surprised if this patient died within the next 6 months? National Hospice and Palliative Care Organization,

8 General Indicators Performance status Global measure of patient s functional capacity Karnofsky Performance Status (KPS) Palliative Performance Scale (PPS) Decline in cognitive/physical function (KPS/PPS <50%) National Hospice and Palliative Care Organization,

9 General Indicators, cont. Recurrent serious infections Signs of severe malnutrition Disease-related weight loss >10% in last 6 months Albumin <2.5 gm/dl Prolonged loss of appetite, little oral intake Multiple non-healing pressure ulcer, stage 3-4 Multiple comorbidities (CHF, COPD, ESRD, etc.) National Hospice and Palliative Care Organization,

10 Clinical Case Mrs. Smith is a 95 year old woman who moved in with her daughter 1 year ago because she could no longer live alone. Her daughter calls the hospice today because, She s just stopped eating. Mrs. Smith does not see a physician but has been to the emergency room twice in the last 6 weeks because of confusion; once, she was admitted with a urinary tract infection. Since then, she has been weaker and spends most of her day in bed or the recliner. The admission nurse examines her and finds she is very thin and frail, cannot stand or walk without assistance, and has a stage 2 pressure ulcer on her sacrum and another on her left heel. National Hospice and Palliative Care Organization,

11 Documentation of Prognosis Paint the picture narrative is necessary! Remember Function, Cognition, Nutrition Use objective LCD data when it s available If the patient doesn t meet the LCD, describe why they are terminally ill anyway; often more than one diagnosis is contributing to the prognosis National Hospice and Palliative Care Organization,

12 Terminal Diagnosis and Related Diagnoses/ Conditions National Hospice and Palliative Care Organization,

13 Determining the Principal Diagnosis The principal diagnosis should reflect the condition to be chiefly responsible for the services provided. The principal diagnosis reported on the hospice claim form should be determined by the hospice as the diagnosis most contributory to the terminal prognosis. It is often not a single diagnosis that represents the terminal prognosis of the patient, but the combined effect of several conditions that makes the patient s condition terminal. 78 Federal Register 152 (7 August 2013), pp.48236, National Hospice and Palliative Care Organization,

14 Determining the Principal Diagnosis The principal diagnosis should be the condition determined by the certifying hospice physician(s) as the diagnosis most contributory to the terminal decline. Certifying physicians should use their best clinical judgment in determining the principal diagnosis and related conditions, based on the hospice comprehensive assessment and review of any and all other clinical documentation. 78 Federal Register 152 (7 August 2013), p.48240, National Hospice and Palliative Care Organization,

15 What is contributory? The relationship between diagnoses may change over time How does a patient with ESRD on dialysis with End-stage heart failure look when referred 5 months before death? How does the same patient look when referred 5 weeks before death? Or 5 days before death? National Hospice and Palliative Care Organization,

16 Most Contributory Diagnosis LCDs: not the only diagnoses that can or should be used to enroll patients in hospice care Look up diagnoses in the coding manual! This may be difficult for some providers to accept as they may not understand how malnutrition, anemia, or depression, for example, could be reported as a principal hospice diagnosis. 78 Federal Register 152 (7 August 2013), pp National Hospice and Palliative Care Organization,

17 Determining the Terminal Diagnosis We are clarifying that the certifying physician would select the condition he or she feels is most contributory to the terminal prognosis. this principal diagnosis, along with the other related diagnoses, would be included on the hospice claim. Having all related conditions reported on the hospice claim form will ensure that hospices are aware of and provide all of the expert care, including services, drugs, supplies, and DME, that a Medicare hospice beneficiary requires as he or she approaches end-of-life. 78 Federal Register 152 (7 August 2013), p National Hospice and Palliative Care Organization,

18 Determining the Terminal Diagnosis Malnutrition, dysphagia, and decreased functional status and muscle weakness.... There are ICD-9-CM codes for all of the clinical presentations listed above. eligibility should always have been based on the terminal prognosis of the patient, and this prognosis would typically involve more than one diagnosis. 78 Federal Register 152 (7 August 2013), p National Hospice and Palliative Care Organization,

19 Related Conditions The principal diagnosis should be the condition determined by the certifying hospice physician(s) as the diagnosis most contributory to the terminal decline. Certifying physicians should use their best clinical judgment in determining the principal diagnosis and related conditions, based on the hospice comprehensive assessment and review of any and all other clinical documentation. 78 Federal Register 152 (7 August 2013), p.48240, National Hospice and Palliative Care Organization,

20 Co-morbidities The presence of diseases, the severity of which is likely to contribute to a life expectancy of six months or less, should be considered in determining hospice eligibility. Chronic obstructive pulmonary disease Congestive heart failure Ischemic heart disease Diabetes mellitus Neurologic disease (CVA, ALS, MS, Parkinson s) Renal failure Liver Disease Neoplasia Acquired immune deficiency syndrome Dementia Clinically pertinent related to terminal prognosis National Hospice and Palliative Care Organization,

21 Related Conditions unless there is clear evidence that a condition is unrelated to the terminal prognosis; all services would be considered related. It is also the responsibility of the hospice physician to document why a patient s medical needs would be unrelated to the terminal prognosis. all of a patient s coexisting or additional diagnoses related to the terminal illness or related conditions should be reported on the hospice claim. 78 Federal Register 152 (7 August 2013), pp , National Hospice and Palliative Care Organization,

22 Related Conditions this determination of what is related versus unrelated to the terminal prognosis remains within the clinical expertise and judgment of the hospice medical director in collaboration with the IDG. necessary for these decisions to be made on a case-by-case basis 78 Federal Register 152 (7 August 2013), p National Hospice and Palliative Care Organization,

23 Definitions Term Primary diagnosis Secondary diagnosis Unrelated diagnosis Definition The principal diagnosis determined as the diagnosis most contributory to the terminal prognosis. Related to either the terminal prognosis or the primary diagnosis Condition UNrelated to the terminal prognosis OR the primary diagnosis OR a secondary diagnosis National Hospice and Palliative Care Organization,

24 Determining Relatedness National Hospice and Palliative Care Organization,

25 Why all the Fuss? CMS discussion about relatedness Virtually all care at EOL is related Diagnoses on claim form FY 2014 Hospice Wage Index Rule FY 2015 Hospice Wage Index Rule Abt data related to $ leakage in to Medicare Parts A, B, D Proposed definitions for terminally ill and related conditions Virtually all care at EOL is related Diagnoses on claim form $ leakage in to Medicare Parts A, B, D Virtually all care at EOL is related Co-morbidities Diagnoses on claim form FY 2016 Hospice Wage Index Rule National Hospice and Palliative Care Organization,

26 NHPCO Relatedness Workgroup A subcommittee of the NHPCO Regulatory Committee. Formed in 2013 in response to FY 2014 proposed Hospice Wage Index Rule. The group s mission was to develop resources for the NHPCO membership that will assist in determining related diagnoses, treatments, medications, supplies, and equipment for a patient. National Hospice and Palliative Care Organization,

27 Determining Relatedness Hospice physician reviews all available information Hospice physician confers with attending physician and IDT Determination made Relatedness is not determined by the CFO based on cost to hospice provider. It is determined patient by patient, case by case related to the palliative plan of care. National Hospice and Palliative Care Organization,

28 Role of the Nurse Provision of clinical information to the hospice physician. Comprehensive assessment History and physical Discharge summary from hospital Clinical information from attending physician National Hospice and Palliative Care Organization,

29 Role of the Other IDT Members Social worker, dietician, chaplain, Continuous provision of information to the hospice physician. Updated to the comprehensive assessment National Hospice and Palliative Care Organization,

30 Role of the Hospice Physician Determining the diagnoses is within the scope of practice of medicine Formal diagnoses for the record vs. nursing diagnoses Hospice physician can determine new diagnoses that are present but have not been previously designated formally Example: Dementia is documented in the record, but does not state the etiology of the dementia National Hospice and Palliative Care Organization, NHPCO, 2014

31 The Determination Process Is the condition being considered a diagnosis or a symptom (or both)? Diagnoses will need a determination of whether they are related or unrelated Symptoms are almost automatically related (Coding guidelines state these do not need to be listed if they are a normal part of the diagnosis) What if they are both diagnosis and symptom? (Example: Depression) National Hospice and Palliative Care Organization,

32 The Determination Process Is there active pain or an active symptom? Should be considered related Is there a likelihood of pain or another symptom? Should be considered related Questions about: Arthritis pain, Migraine prophylaxis, etc. National Hospice and Palliative Care Organization,

33 The Determination Process Is the diagnosis caused by or causing the terminal condition? Some obvious examples include: HIV AIDS Ischemic heart disease Congestive heart failure Cerebral atherosclerosis Vascular dementia How far do you drill down? Diabetes mellitus Diabetic nephropathy ESRD HTN Hypertensive nephropathy ESRD DMT2 National Hospice and Palliative Care Organization,

34 The Determination Process Is the diagnosis in question stable? If not requiring management Does not need to listed Example: Remote prostate cancer If requiring management, does the treatment interact or potentially interact with the terminal illness? Determined case by case National Hospice and Palliative Care Organization,

35 Other Considerations All determinations must be done with consideration of the patient s prognosis If not eligible all the above is moot (Discharge (or do not admit) the patient) If any DX (or TX for a DX) contributes to the terminal prognosis it is related Is a TX under consideration still beneficial within the patient s expected prognosis? May still be related, but should be discontinued National Hospice and Palliative Care Organization,

36 Common Denominator All the above determinations require medical judgment The hospice physician must complete the documentation Must have hospice physicians who can make such decisions Must have adequate information on the patient s status National Hospice and Palliative Care Organization,

37 Relatedness Flow Chart Determining relatedness is a continuous process by the hospice physician which takes into account the changes in the patient's condition. National Hospice and Palliative Care Organization,

38 National Hospice and Palliative Care Organization,

39 Case Study #1 Mona is 84 and has a 5 year history of dementia. She is now nonverbal and has lost the ability to walk. She now weighs 99 Lbs, down from 105 lbs 4 months ago. She was recently hospitalized for pneumonia and had developed diarrhea, C diff positive. She will be coming home on medications for C diff. Is the C diff related to the patient s prognosis? Yes. The pneumonia is related to the dementia and is contributing to the terminal prognosis. The treatment of the pneumonia resulted in C Diff. National Hospice and Palliative Care Organization,

40 Case Study #2 Arthur is 77 and is diagnosed with advanced Alzheimer s disease, debility, AFFT, and hyperlipidemia. He is a resident of a long term care facility and was recently referred to hospice after a 13% weight loss in 6 months. Which diagnosis is not related to the terminal prognosis? The patient s hyperlipidemia is irrelevant to his terminal Alzheimer s disease, in the face of no oral intake, and it therefore has no bearing on his prognosis. National Hospice and Palliative Care Organization,

41 NHPCO Resources co.org/regulator y-compliancehospices/determ ining-terminalprognosis National Hospice and Palliative Care Organization,

42 Coverage per the Regulations Requirements for coverage. To be covered, hospice services must be reasonable and necessary for the palliation or management of the terminal illness as well as related conditions Covered services. (f) Medical appliances and supplies, including drugs and biologicals. Only drugs which are used primarily for the relief of pain and symptom control related to the individual's terminal illness are covered. National Hospice and Palliative Care Organization,

43 Buckets of Relatedness RELATED and HELPFUL RELATED BUT NOT HELPFUL RELATED BUT NOT ON FORMULARY UNRELATED & HELPFUL PART D ELIGIBLE UNRELATED, BUT NO LONGER HELPFUL National Hospice and Palliative Care Organization,

44 Related vs. Unrelated, unless there is clear evidence that a condition is unrelated to the terminal prognosis; all services would be considered related. It is also the responsibility of the hospice physician to document why a patient s medical needs would be unrelated to the terminal prognosis. 78 Federal Register 152 (7 August 2013), p National Hospice and Palliative Care Organization,

45 Documenting Un-relatedness It is the hospice physician s responsibility to document what is unrelated Where should that occur? In the certification narrative? Not the best place In a progress note? May be hard to locate In the med profile? Include non-med treatments? Stand-alone document? EMR vs. Paper documentation concerns National Hospice and Palliative Care Organization,

46 Documenting Unrelatedness cont What does the hospice physician document? CMS has providing varying guidance on this Recent CMS Open Door Forum call: should be a brief narrative that is reasonable in explaining why the condition is unrelated National Hospice and Palliative Care Organization,

47 Examples of Unrelatedness Two examples are repeatedly offered for unrelatedness Neither has been validated by CMS 1. Glaucoma is pathophysiologically unrelated to the patient s lung cancer, and does not contribute to the terminal prognosis. 2. Hypothyroidism is physiologically unrelated to the patient s COPD, and since it is well managed, it does not contribute to a worsened prognosis. National Hospice and Palliative Care Organization,

48 Reasonable and Necessary The Medicare Hospice Benefit requires the hospice to cover all reasonable and necessary palliative care related to the terminal prognosis and related conditions. Section 1862(a)(1)(C) of the Social Security Act (the Act) forbids payment for any items or services which are not reasonable and necessary for the palliation and management of the terminal illness. Services which are not needed... would not be reasonable and necessary. 78 Federal Register 152 (7 August 2013), p.48236, National Hospice and Palliative Care Organization,

49 All Diagnoses on the Claim Form For service dates of October 1, 2015 and forward, all diagnoses (related & unrelated) must be entered on the hospice claim form An unrelated diagnosis on the claims form does not necessarily equal hospice responsibility If a hospice physician determines that a diagnosis does not medically contribute to the terminal prognosis, he/she documents why it does not medically contribute to the terminal prognosis in the clinical record National Hospice and Palliative Care Organization,

50 Medications National Hospice and Palliative Care Organization,

51 51 If medication is deemed related Hospice covers the cost Care (services, treatment, etc. ) Medications DME & supplies Documentation should appear in the clinical record that it is related Physician narrative Plan of care Medication profile 51 National Hospice and Palliative Care Organization, 2015

52 Related and NOT in Plan of Care Not effective not supported by the evidence or truly necessary May be harmful for reasons not usually thought of by patients and families not free from harm Duplicate medications Not on hospice formulary or preferred med list And pt/family decline an equivalent medication that would be covered National Hospice and Palliative Care Organization,

53 If medication is deemed unrelated CMS expects that another health care professional would come to the same conclusion after reviewing the same data Subject to MAC and auditor review Subject to Part D plan sponsor review Audits directed to start again with 2014 Part D claims Documentation should appear in the clinical record that it is NOT related Consistent, accessible location We expect drugs covered under Part D for hospice beneficiaries will be extremely rare. National Hospice and Palliative 53 Care Organization, 2015

54 Payment Responsibility Medications that WERE for the treatment of the terminal illness and/or related conditions prior to hospice admission will be discontinued as determined by the hospice IDG and discussed with patient/family because medications are no longer effective and/or causing additional negative symptoms. NOT covered under the MHB (not reasonable or necessary for the palliation of pain and/or symptom management). If beneficiary still chooses to have these medications, costs would be a beneficiary liability (not MHB or Part D) National Hospice and Palliative Care Organization,

55 Payment Responsibility If a beneficiary requests a drug for his/her terminal illness or related conditions that is NOT on the hospice formulary and the beneficiary refuses to try a formulary equivalent first or is determined by the hospice to be unreasonable or unnecessary for the palliation of pain and/or symptom management the beneficiary may opt to assume financial responsibility for the drug No payment for the drug will be available under Part D. National Hospice and Palliative Care Organization,

56 Dementia Medication Dementia medications (Aricept, Namenda, Exelon, Razadyne ) are less helpful and more harmful in advanced disease. Side effects: weight loss, bad dreams, sleep disturbances, bradycardia, and increased restlessness. NOT indicated or covered with FAST 7 without clear and ongoing benefit in managing identifiable and distressing behaviors. May be covered with FAST 6; discuss goals/outcomes with hospice physician or pharmacist. Two week tapering supply COVERED if med discontinued and an additional supply is needed. National Hospice and Palliative Care Organization,

57 Medical directors: Decisions Diagnoses Related or unrelated to the terminal prognosis Case-by-case Consistent reasoning that staff can understand and communicate Medications Related, reasonable, and necessary Clinically useful Covered by hospice or insurance National Hospice and Palliative Care Organization,

58 Medical Directors: Diagnoses The principal diagnosis should be the condition determined by the certifying hospice physician(s) as the diagnosis most contributory to the terminal decline. Certifying physicians should use their best clinical judgment in determining the principal diagnosis and related conditions, based on the hospice comprehensive assessment and review of any and all other clinical documentation. 78 Federal Register 152 (7 August 2013), p.48240, National Hospice and Palliative Care Organization,

59 Medical Directors: Documentation It is the responsibility of the hospice physician to document why a patient s medical needs would be unrelated to the terminal prognosis. Hypothyroidism and early dementia dx/meds not related to prognosis or to the POC for palliation/management of metastatic lung cancer. National Hospice and Palliative Care Organization,

60 Medical Directors: Documentation Must have a place and a process to determine and document Relatedness of diagnoses Medication: related, reasonable, necessary, covered Timely and accessible to the IDG Useful Wording must designate reasons for coverage decisions Defensibility National Hospice and Palliative Care Organization,

61 Make Good Choices Patient/family/community trust Do no harm! Financial consequences to the patient Financial consequences to the hospice Potential legal and/or compliance consequences Incur the wrath of Medicare National Hospice and Palliative Care Organization,

62 Hospice Risk Area Failure to identify and claim responsibility for a diagnosis and condition that contributes to the terminal prognosis. Increases risk for audit and financial penalty. Increases risk for Medicare decertification. National Hospice and Palliative Care Organization,

63 National Hospice and Palliative Care Organization,

64 References Subpart B Eligibility, Election and Duration of Benefits vol3/pdf/cfr-2011-title42-vol3-part418-subpartb.pdf Medicare Benefit Policy Manual Chapter 9 - Coverage of Hospice Services Under Hospital Insurance Guidance/Guidance/Manuals/Downloads/bp102c09.pdf Link to NHPCO Regulatory Alerts for Wage Index Rules ( ) National Hospice and Palliative Care Organization,