Hospice Widespread edits

Transcription

1 Hospice Widespread edits Befriend this foe to prevent claim denials Beth Noyce, RN, BSJMC, HCS-D D, COS-C 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. 1

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 prove a high h 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, "Probe" Reviews 2

3 What are widespread edits and why should you care? Widespread edits automatically reroute claims at high risk of payment errors for review before payment to verify that care was appropriate. What are widespread edits and why should you care? Awareness of current widespread edits can: Help agencies better understand CMS coverage; Help epclinicians ca document accurately. 6 3

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 Lower payment or no payment for services already provided. Hundreds or thousands in lost revenue with each denied claim. 8 4

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 , 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 y NEC primary dx, LOS >181 days OBS primary dx, LOS > 240 days 5

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 should contain enough clinical factors and descriptive notes to show: The illness is terminal, and Progressing g in a manner that a physician would reasonably conclude that the beneficiary's life expectancy is 6 months or less. 6

7 Common reasons for denial Documentation must support 6-month terminal prognosis New NHPCO guidance tool: Common reasons for denial 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 7

8 Common reasons for denial 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. Common reasons for denial 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. 8

9 Common reasons for denial Documentation must support 6-month terminal prognosis The CTI must be renewed each certification period. Each must specify the dates of the certification period. Common reasons for denial 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. 9

10 Common reasons for denial 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. Common reasons for denial Documentation must support 6-month terminal prognosis Fi i k l h h First-person narrative makes clear that the CTI is in the physician s own words. 10

11 Common reasons for denial Documentation must support 6-month terminal prognosis CTI An attestation statement under the physician signature must state that the signature means: The physician confirms that s/he composed the narrative Based on review of the medical record or examination of the patient The physician must also sign the attestation statement. Common reasons for denial 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 Excerpt of actual denial letter: 11

12 Edit-specific criteria Documentation must support 6-month terminal prognosis Documentation is essential in painting the picture of each patient s decline. Edit-specific criteria 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 Common reasons for denial 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 Local Coverage Determinations (LCD) help determine whether the payer will agree that the patient meets qualifying criteria. LCDs are published on MAC or RHHI web sites. 13

14 Check your MAC/RHHI for LCDs A w/ J14 w/ J6 w/ J15 Former New w/ J11 A NGS NHIC B Cahaba CGS C Palmetto Palmetto D NGS TBD 27 Documentation tips Documentation tools can help A tool to help clinicians track decline along LCD criteria i specifics reduces denial risk. 14

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: Denial can result from documentation that: Excludes adequate decline specifics Focuses primarily on custodial care 15

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: Documentation Tips Argue the case on paper (or EMR) to avoid claim denials The medical record s documentation must explain why the beneficiary still has a six-month prognosis. 16

17 Documentation Tips Argue the case on paper (or EMR) to avoid claim denials Avoid vague statements such as slow decline and disease progressing. Documentation Tips Tools to guide documentation Ross_and_Sanchez_Reilly_2008.pdf 17

18 Documentation Tips Tools to guide documentation Ross_and_Sanchez_Reilly_2008.pdf Documentation Tips Tools to guide documentation Ross_and_Sanchez_Reilly_2008.pdf 18

19 Edit-specific criteria Tools to guide documentation Ross_and_Sanchez_Reilly_2008.pdf Edit-specific criteria Tools to guide documentation Ross_and_Sanchez_Reilly_2008.pdf 19

20 Edit-specific criteria Tools to guide documentation Ross_and_Sanchez_Reilly_2008.pdf 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. 20

21 Common denial reasons Missing, Incomplete, Untimely Election Statements Documentation must show the required election statement was signed before providing hospice care. Common denial reasons 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 42CFR

22 Common denial reasons Denials involving level of care 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. Common denial reasons 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 OR continuous care 22

23 Denials involving level of care General inpatient care documentation must clearly l 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 needs that can t be met at home. VS. Inpatient respite care Provided to meet a caregiver s need for a break from care-giving i responsibilities. 23

24 Denials involving level of care General Inpatient (GIP) Respite VS. Provider-specific edits becoming more widespread, too Palmetto-specific 24

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? Provide only care that t meets hospice program requirements. 51 How can my agency decrease its risk of denials? Conduct agency selfaudits 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 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 logs or use EMR electronic signatures. 27

28 How can my agency decrease its risk of denials? 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. 28

29 Coach and educate! After coaching: supports eligibility How can my agency decrease its risk of denials? Respond to ADRs promptly. Many claims are denied because providers don t respond on time. ADRs come with resources for help. Meet deadlines and follow instructions. Call for help if needed

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) 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, Medicare Administrative Contractor Workload Implementation Handbook 60 30

31 How is the change to new MACs affecting widespread edits? Currently, information on MAC/RHHI web sites is minimal. i 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. Remind them to focus on education! 31

32 Palmetto 3 March 2011 Hospice Coalition Q & A No new medical reviews established for Non-Cancer Length of Stay (NCLOS) rates only. Edits / probes planned for 2011 include: Providers exceeding Hospice Cap, Average 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) and are listed below. HIV Disease Liver Disease Neurological Conditions Renal Care Alzheimer's Disease &Related Disorders Cardiopulmonary Conditions Adult Failure To Thrive Syndrome March 3, 2011 Hospice Coalition Q & A 21 32

33 Palmetto Top Ten Hospice denials in March 2011 Medicare advisory: 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 April

34 NHIC NGS Common claim denial reasons

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! Published when announcing probe results or new widespread edits. References Medicare Program Integrity Manual, Chapter 3 - Verifying Potential Errors and Taking Corrective Actions, "Probe" " Reviews Medicare Benefit Policy Manual, (CMS Pub ), Ch. 7, 30.2 and (CMS) Medicare Benefit Policy Manual, (CMS Pub ), Ch. 9 Medicare Administrative Contractor Workload Implementation Handbook, 2/12/08 d Ross_and_Sanchez_Reilly_2008.pdf 35

36 References nsf/files/ _ Hospice _ Coalition_ Question s.pdf/$file/ _hospice_coalition_questi ons.pdf nsf/docscat/providers~regional%20home%20 Health%20Hospice%20Intermediary%20%28RH HI%29~Resources~Medical%20Review~7GM2 DG1566?open&navmenu= Questions? Thank you for attending! 36