Recertification of the Hospice Terminal Illness. Compliance Tip Sheet. Version 2, Revised March Contents of Tip Sheet

Transcription

1 Cmpliance Tip Sheet Natinal Hspice and Palliative Care Organizatin Recertificatin f the Hspice Terminal Illness Cmpliance Tip Sheet Versin 2, Revised March 2012 Cntents f Tip Sheet Recertificatin prcess and requirements fr a patient entering the secnd 90-day benefit perid Recertificatin prcess and requirements fr a patient entering the first 60-day benefit perid and subsequent 60-day benefit perids Medicare recertificatin regulatins Recertificatin resurces INTRODUCTION The hspice regulatins fr certificatin and recertificatin are included in the Medicare regulatins at 42 CFR The Centers fr Medicare and Medicaid Services (CMS) made updates t the hspice certificatin and recertificatin regulatins between 2005 and 2011 that radically change hw a hspice prvider cmpletes these prcesses. The regulatry language appears later in this tip sheet. I. RECERTIFICATION OF TERMINAL ILLNESS FOR PATIENT ENTERING THE SECOND (2 nd ) 90-DAY BENEFIT PERIOD (b) CURRENT HOSPICE PATIENT WHO IS ELIGIBLE FOR HOSPICE SERVICES Wh cmpletes the recertificatin? The hspice medical directr r hspice physician Only the hspice medical directr r hspice physician is required t sign the recertificatin fr a new admissin t the secnd 90-day benefit perid unless therwise specified by state hspice licensure regulatins If state law requires an attending physician t sign the recertificatin, the hspice medical directr/ hspice physician shuld cmpse the brief narrative statement NOTES: N ne ther than a medical dctr r dctr f stepathy can certify r re-certify a terminal illness. A nurse practitiner (NP) may nt recertify hspice terminal illness. Page 1 f 12

2 The recertificatin prcess Timing f the recertificatin Required cmpnents f the recertificatin Hspice medical directr / hspice physician signs the certificate f terminal illness frm The hspice medical directr / hspice physician cmpses the brief narrative statement and signs the attestatin fr the statement If the hspice cannt btain the written certificatin within 2 calendar days, after a benefit perid begins, it must btain an ral certificatin within 2 calendar days and the written certificatin befre it submits a claim fr payment. Fr subsequent benefit perids, recertificatins may be cmpleted up t 15 days befre the next benefit perid begins. Recertificatin frm See NHPCO sample recertificatin frms Physician narrative statement Physician narrative attestatin (placed abve the physician signature) Billing cnsideratins Dcuments that must be cmpleted befre billing: Written / signed certificatin frm Physician narrative statement Narrative attestatin Hspices must use ccurrence span cde 77 t identify days f care that are nt cvered by Medicare due t untimely physician recertificatin. This is particularly imprtant when the nn-cvered days fall at the beginning f a billing perid If these requirements are nt met, n payment is made fr the days prir t the certificatin. Instead, payment begins with the day f certificatin, i.e., the date verbal certificatin (r written certificatin if that is dne first) is btained. If the physician frgets t date the certificatin, a ntarized statement r sme ther acceptable dcumentatin can be btained t verify when the certificatin was btained (c) CURRENT HOSPICE PATIENT WHO IS NO LONGER ELIGIBLE FOR HOSPICE SERVICES If the patient is n lnger eligible fr hspice services, the hspice initiates the discharge prcess. Hspice prviders must prvide a minimum f 2 days ntice prir t discharge. If state regulatins are mre stringent fr the discharge ntice, the prvider wuld adhere t the stricter requirement. (d) NEW ADMISSION TO THE SECOND (2 nd ) BENEFIT PERIOD If the patient is nt assessed as eligible fr hspice services, the hspice prvider des nt admit the patient. This is a recertificatin f terminal illness since it is the secnd benefit perid, even thugh it is a new admissin fr yur hspice. Wh cmpletes the recertificatin? The hspice medical directr r hspice physician Only the hspice medical directr r hspice physician is required t sign the recertificatin fr a new admissin t the Page 2 f 12

3 secnd 90-day benefit perid unless therwise specified by state hspice licensure regulatins. If state law requires an attending physician t sign the recertificatin, the hspice medical directr/ hspice physician shuld cmpse the brief narrative statement. NOTES: N ne ther than a medical dctr r dctr f stepathy can certify r re-certify a terminal illness. A nurse practitiner (NP) may nt recertify hspice terminal illness. The recertificatin prcess Hspice prvider checks the Medicare Cmmn Wrking file (CWF) fr previus hspice services. Hspice medical directr / hspice physician signs the certificate f terminal illness frm. The hspice medical directr / hspice physician cmpses the brief narrative statement and signs the attestatin fr the statement. Timing f the recertificatin If the hspice cannt btain the written certificatin within 2 calendar days after a benefit perid begins, it must btain an ral certificatin within 2 calendar days and the written certificatin befre it submits a claim fr payment. Recertificatins may be cmpleted up t 15 days befre the next benefit perid begins. Required cmpnents f the recertificatin Recertificatin frm See NHPCO sample recertificatin frms Physician narrative statement Physician narrative attestatin (placed abve the physician signature) Billing cnsideratins Dcuments that must be cmpleted befre billing: Written / signed certificatin frm Physician narrative statement Narrative attestatin Hspices must use ccurrence span cde 77 t identify days f care that are nt cvered by Medicare due t untimely physician recertificatin. This is particularly imprtant when the nn-cvered days fall at the beginning f a billing perid If these requirements are nt met, n payment is made fr the days prir t the certificatin. Instead, payment begins with the day f certificatin, i.e., the date verbal certificatin (r written certificatin if that is dne first) is btained. If the physician frgets t date the certificatin a ntarized statement r sme ther acceptable dcumentatin can be btained t verify when the certificatin was btained Regulatry Citatins fr This Sectin CMS Hspice Face t-face Encunter Requirements effective January 1, 2011 with extensin t April 1, 2011 incrprated int (a)(4) Page 3 f 12

4 Medicare Hspice Regulatins with updated regulatry text at Certificatin f the Terminal Illness: Change Request 3686, Hspice Physician Recertificatin Requirements - Change request 7337, New Hspice Certificatin Requirements and Revised Cnditins f Participatin (CPs) March 2, NHPCO Resurces Recertificatin f Terminal Illness Audit Checklist (PDF) Revised 11/18/2010 Recertificatin f Terminal Illness Tip Sheet (PDF) Revised MAR 2011 Sample Recertificatin f Terminal Illness frms and instructins fr use (Wrd) Revised 11/18/2010 II. RECERTIFICATION OF TERMINAL ILLNESS FOR PATIENT ENTERING THE 3RD (1ST 60-DAY) OR SUBSEQUENT BENEFIT PERIOD A. CURRENT HOSPICE PATIENT WHO IS ELIGIBLE FOR HOSPICE SERVICES Wh cmpletes the recertificatin? Wh cmpletes the face-tface encunter? The hspice medical directr r hspice physician NOTES: Only the hspice medical directr r hspice physician is required t sign the recertificatin fr a new admissin t the secnd 90-day benefit perid unless therwise specified by state hspice licensure regulatins. If state law requires an attending physician t sign the recertificatin, the hspice medical directr/ hspice physician shuld cmpse the brief narrative statement. N ne ther than a medical dctr r dctr f stepathy can certify r re-certify a terminal illness. A nurse practitiner (NP) may nt recertify hspice terminal illness. The hspice medical directr r hspice physician The hspice physician may be a direct hspice emplyee, cntracted, r a vlunteer. Hspice nurse practitiner (NP) Nurse Practitiner (may nt be cntracted; must be a hspice W-2 emplyee r vlunteer). If the hspice is a subdivisin f an agency r rganizatin, an emplyee f the agency r rganizatin wh is assigned t the hspice is a hspice emplyee. NOTE: Clinical Nurse Specialists r Physician Assistants are nt authrized by CMS t cmplete a face-t-face visit. The recertificatin prcess The physician r NP cmpletes the face-t-face encunter, and signs the face-t-face encunter attestatin which includes the patient s name and the date f the encunter. Page 4 f 12

5 Required: If the NP r nn-certifying hspice physician cmpletes the face-t-face encunter, he/she cmmunicates the findings t the hspice certifying physician fr use in determining eligibility and cmpsing brief physician narrative. Certifying hspice medical directr / hspice physician signs the certificate f terminal illness frm. The certifying hspice medical directr / hspice physician cmpses the brief narrative statement and signs the narrative attestatin statement. NOTE: The same physician is nt required t cmplete all cmpnents f the face-t-face requirement and must cmmunicate findings t the physician wh is cmpleting the recertificatin dcuments. Timing f the recertificatin The face-t-face encunter must be cmpleted n mre than 30 calendar days prir t the 3rd benefit perid recertificatin, and n mre than 30 calendar days prir t every recertificatin thereafter. Recertificatins may be cmpleted up t 15 days befre the next benefit perid begins. Required cmpnents f the recertificatin Face-t-face encunter Face-t-face attestatin (placed abve the physician signature) that includes: The patient s name The date f the visit If the face-t-face encunter was prvided by a NP, the attestatin shuld include a statement that the clinical findings f that encunter have been prvided t the certifying physician fr use in determining cntinued eligibility fr hspice care. Signature & date by the NP r physician wh made the visit Recertificatin frm Physician brief narrative statement Physician narrative attestatin (placed abve the physician signature) NOTE: While there is n requirement that the visit als be dcumented in the clinical recrd, NHPCO recmmends that dcumentatin f the date and time f the visit, wh cnducted the visit, and clinical findings be included in the clinical recrd. Billing cnsideratins Befre billing: There must be a cmpleted face-t-face encunter and accmpanying attestatin statement. There must be a written / signed certificatin and befre a hspice prvider submits a claim fr payment. There must be a cmpleted physician narrative and physician narrative attestatin statement. Page 5 f 12

6 NOTE: If these requirements are nt met, n payment is made fr the days prir t the certificatin. Instead, payment begins with the day f certificatin, i.e., the date verbal certificatin (r written certificatin if that is dne first) is btained. If the physician frgets t date the certificatin a ntarized statement r sme ther acceptable dcumentatin can be btained t verify when the certificatin was btained. B. MISSED/ LATE FACE-TO-FACE ENCOUNTER FOR CURRENT PATIENT ENTERING THIRD (3 RD ) (1ST 60-DAY) OR SUBSEQUENT BENEFIT PERIOD Wh cmpletes the recertificatin? Wh cmpletes the facet-face encunter? The recertificatin prcess The hspice medical directr r hspice physician. The same physician is nt required t cmplete all cmpnents f the face-t-face requirement. Only the hspice medical directr r hspice physician is required t sign the recertificatin fr a new admissin t the secnd 90-day benefit perid unless therwise specified by state hspice licensure regulatins. NOTES: If state law requires an attending physician t sign the recertificatin, the hspice medical directr/ hspice physician shuld cmpse the brief narrative statement. N ne ther than a medical dctr r dctr f stepathy can certify r re-certify a terminal illness. A nurse practitiner (NP) may nt recertify hspice terminal illness. The hspice medical directr r hspice physician The hspice physician may be a direct hspice emplyee, cntracted, r a vlunteer. Hspice nurse practitiner (NP) Nurse Practitiner (may nt be cntracted; must be a hspice W-2 emplyee r vlunteer). If the hspice is a subdivisin f an agency r rganizatin, an emplyee f the agency r rganizatin wh is assigned t the hspice is a hspice emplyee. NOTE: Clinical Nurse Specialists r Physician Assistants are nt authrized by CMS t cmplete a face-t-face visit. If the patient remains eligible fr next benefit perid but the face-t-face encunter was missed/ late, the patient ceases t be eligible fr the Medicare Hspice Benefit and must be discharged frm the Medicare Hspice Benefit. An NP r physician must cmplete a face-t-face encunter prir t readmitting the patient back t the Medicare Hspice Benefit. The re-admissin shuld be treated as a new admissin t the Medicare Hspice Benefit. The physician r NP cmpletes the face-t-face encunter, and signs the face- Page 6 f 12

7 t-face encunter attestatin which includes the patient s name and the date f the encunter. Required: If the NP r nn-certifying hspice physician cmpletes the face-t-face encunter, he/she cmmunicates the findings t the hspice certifying physician fr use in determining eligibility and cmpsing narrative. Certifying hspice medical directr / hspice physician signs the certificate f terminal illness frm. The certifying hspice medical directr / hspice physician cmpses the brief narrative statement and signs the narrative attestatin statement. Timing f the recertificatin The face-t-face encunter must be cmpleted n mre than 30 calendar days prir t the 3rd benefit perid recertificatin, and n mre than 30 calendar days prir t every recertificatin thereafter. Recertificatins may be cmpleted up t 15 days befre the next benefit perid begins. Required cmpnents f Face-t-face encunter the recertificatin fr a Face-t-face attestatin (placed abve the physician signature) that includes: missed face-t-face The patient s name encunter The date f the visit If the face-t-face encunter was prvided by a NP, the attestatin shuld include a statement that the clinical findings f that encunter have been prvided t the certifying physician fr use in determining cntinued eligibility fr hspice care. Signature & date by the NP r physician wh made the visit While there is n requirement that the visit als be dcumented in the clinical recrd, NHPCO recmmends that dcumentatin f the date and time f the visit, wh cnducted the visit, and clinical findings be included in the clinical recrd. Recertificatin frm Physician narrative statement Physician narrative attestatin (placed abve the physician signature) Billing cnsideratins If there is a missed/late face-t-face encunter, billing t Medicare must discntinue at discharge. The patient remains n hspice service at the hspice prvider s expense until the required face-t-face encunter ccurs, enabling the hspice t re-establish Medicare eligibility. Billing t Medicare may resume after the cmpletin f the face- t face encunter fr the next benefit perid. Befre billing: There must be a cmpleted face-t-face encunter and accmpanying attestatin statement. There must be a written / signed certificatin and befre a hspice prvider submits a claim fr payment. There must be a cmpleted physician narrative and physician narrative attestatin statement. If these requirements are nt met, n payment is made fr the days prir t the Page 7 f 12

8 certificatin. Instead, payment begins with the day f certificatin, i.e., the date verbal certificatin (r written certificatin if that is dne first) is btained. If the physician frgets t date the certificatin a ntarized statement r sme ther acceptable dcumentatin can be btained t verify when the certificatin was btained. C. CURRENT HOSPICE PATIENT WHO IS NO LONGER ELIGIBLE FOR HOSPICE SERVICES If the patient is n lnger eligible fr hspice services, the hspice initiates the discharge prcess. Hspice prviders must prvide a minimum f 2 days ntice prir t discharge. If state regulatins are mre stringent fr discharge ntice, the prvider wuld adhere t the stricter requirement. (e) NEW ADMISSION TO THE THIRD 3RD (1ST 60-DAY) OR SUBSEQUENT BENEFIT PERIOD Wh cmpletes the recertificatin? Wh cmpletes the facet-face encunter? The recertificatin prcess The hspice medical directr r hspice physician NOTES: Only the hspice medical directr r hspice physician is required t sign the recertificatin fr a new admissin t the secnd 90-day benefit perid unless therwise specified by state hspice licensure regulatins. If state law requires an attending physician t sign the recertificatin, the hspice medical directr/ hspice physician shuld cmpse the brief narrative statement. N ne ther than a medical dctr r dctr f stepathy can certify r re-certify a terminal illness. A nurse practitiner (NP) may nt recertify hspice terminal illness. The hspice medical directr r hspice physician The hspice physician may be a direct hspice emplyee, cntracted, r a vlunteer. Hspice nurse practitiner (NP) Nurse Practitiner (may nt be cntracted; must be a hspice W-2 emplyee r vlunteer). If the hspice is a subdivisin f an agency r rganizatin, an emplyee f the agency r rganizatin wh is assigned t the hspice is a hspice emplyee. NOTE: Clinical Nurse Specialists r Physician Assistants are nt authrized by CMS t cmplete a face-t-face visit. The physician r NP cmpletes the face-t-face encunter, and signs the facet-face encunter attestatin which includes the patient s name and the date f the encunter. Required: If the NP r nn-certifying hspice physician cmpletes the face-t-face encunter, he/she cmmunicates the findings t the hspice certifying physician fr use in determining eligibility and cmpsing narrative. Certifying hspice medical directr / hspice physician signs the certificate f Page 8 f 12

9 Timing f the recertificatin Required cmpnents f the recertificatin terminal illness frm. The certifying hspice medical directr / hspice physician cmpses the brief narrative statement and signs the narrative attestatin statement. NOTE: The same physician is nt required t cmplete all cmpnents f the face-t-face requirement and must cmmunicate findings t the physician wh is cmpleting the recertificatin dcuments. The face-t-face encunter must be cmpleted prir t the start f the benefit perid. If the hspice cannt btain the written certificatin within 2 calendar days, after a benefit perid begins, it must btain an ral certificatin within 2 calendar days and the written certificatin befre it submits a claim fr payment. Recertificatins may be cmpleted up t 15 days befre the next benefit perid begins. Face-t-face encunter Face-t-face attestatin (placed abve the physician signature) that includes: The patient s name The date f the visit If the face-t-face encunter was prvided by a NP, the attestatin shuld include a statement that the clinical findings f that encunter have been prvided t the certifying physician fr use in determining cntinued eligibility fr hspice care. Signature & date by the NP r physician wh made the visit While there is n requirement that the visit als be dcumented in the clinical recrd, NHPCO recmmends that dcumentatin f the date and time f the visit, wh cnducted the visit, and clinical findings be included in the clinical recrd. Recertificatin frm Physician narrative statement Physician narrative attestatin (placed abve the physician signature) Billing cnsideratins Befre billing: There must be a cmpleted face-t-face encunter and accmpanying attestatin statement. There must be a written / signed certificatin and befre a hspice prvider submits a claim fr payment. There must be a cmpleted physician narrative and physician narrative attestatin statement. If these requirements are nt met, n payment is made fr the days prir t the certificatin. Instead, payment begins with the day f certificatin, i.e., the date verbal certificatin (r written certificatin if that is dne first) is btained. If the physician frgets t date the certificatin a ntarized statement r sme ther acceptable dcumentatin can be btained t verify when the certificatin was btained. Page 9 f 12

10 Regulatry Citatins fr This Sectin CMS Hspice Face t-face Encunter Requirements effective January 1, 2011 with extensin t April 1, 2011 incrprated int (a)(4) Medicare Hspice Regulatins with Updated regulatry text at Certificatin f the Terminal Illness Change Request 3686, Hspice Physician Recertificatin Requirements - Change request 7337, New Hspice Certificatin Requirements and Revised Cnditins f Participatin (CPs) March 2, FY 2012 Final Hspice Wage Index,CMS F, AUG 4, /pdf/ pdf CR 7478, CMS, Octber 7, CR 7677, CMS, February 3, NHPCO Resurces Recertificatin f Terminal Illness Audit Checklist (PDF) Revised 11/18/2010 Recertificatin f Terminal Illness tip sheet (PDF) Revised March 2011 Sample Recertificatin f Terminal Illness frms and instructins fr use (Wrd) Revised 11/18/2010 The Medicare Regulatins The fllwing table utlines the recent regulatry revisins and the implementatin year. Recertificatin regulatins Effective date Link t regulatin Physician narrative Octber 1, requirement Face-t-face encunter January 1, final rule Change Request 7337 March 23, Change Request 7478 January 9, Change Request 7677 July Sec Certificatin f terminal illness. (a) Timing f certificatin (1) General rule. The hspice must btain written certificatin f terminal illness fr each f the perids listed in , even if a single electin cntinues in effect fr an unlimited number f perids, as prvided in (c). (2) Basic requirement. Except as prvided in paragraph (a)(3) f this sectin, the hspice must btain the written certificatin befre it submits a claim fr payment. Page 10 f 12

11 (3) Exceptins. (i) If the hspice cannt btain the written certificatin within 2 calendar days, after a perid begins, it must btain an ral certificatin within 2 calendar days and the written certificatin befre it submits a claim fr payment. (ii) Certificatins may be cmpleted n mre than 15 calendar days prir t the effective date f electin. (iii) Recertificatins may be cmpleted n mre than 15 calendar days prir t the start f the subsequent benefit perid. (4) Face-t-face encunter. As f January 1, 2011, a hspice physician r hspice nurse practitiner must have a face-t-face encunter with each hspice patient whse ttal stay acrss all hspices is anticipated t reach the 3 rd benefit perid. The face-t-face encunter must ccur prir t, but n mre than 30 days prir t, the 3 rd benefit perid recertificatin, and every benefit perid recnciliatin thereafter, t gather clinical findings t determine cntinued eligibility fr hspice care. (b) Cntent f certificatin. Certificatin will be based n the physician s r medical directr s clinical judgment regarding the nrmal curse f the individual s illness. The certificatin must cnfrm t the fllwing requirements: (1) The certificatin must specify that the individual s prgnsis is fr a life expectancy f 6 mnths r less if the terminal illness runs its nrmal curse. (2) Clinical infrmatin and ther dcumentatin that supprt the medical prgnsis must accmpany the certificatin and must be filed in the medical recrd with the written certificatin as set frth in paragraph (d)(2) f this sectin. Initially, the clinical infrmatin may be prvided verbally, and must be dcumented in the medical recrd and included as part f the hspice s eligibility assessment. (3) The physician must include a brief narrative explanatin f the clinical findings that supprts a life expectancy f 6 mnths r less as part f the certificatin and recertificatin frms, r as an addendum t the certificatin and recertificatin frms. (i) If the narrative is part f the certificatin r recertificatin frm, then the narrative must be lcated immediately prir t the physician s signature. (ii) If the narrative exists as an addendum t the certificatin r recertificatin frm, in additin t the physician s signature n the certificatin r recertificatin frm, the physician must als sign immediately fllwing the narrative in the addendum. (iii) The narrative shall include a statement directly abve the physician signature attesting that by signing, the physician cnfirms that he/she cmpsed the narrative based n his/her review f the patient s medical recrd r, if applicable, his r her examinatin f the patient. (iv) The narrative must reflect the patient s individual clinical circumstances and cannt cntain check bxes r standard language used fr all patients. (v) The narrative assciated with the 3 rd benefit perid recertificatin and every subsequent recertificatin must include an explanatin f why the clinical findings f the face-t-face encunter supprt a life expectancy f 6 mnths r less. (4) The physician r nurse practitiner wh perfrms the face-t-face encunter with the patient described in (a) (4) f this sectin must attest in writing that he r she had a face-t-face encunter with the patient, including the date f that visit. The attestatin f the nurse practitiner r a nn- Page 11 f 12

12 certifying hspice physician shall state that the clinical findings f that visit were prvided t the certifying physician fr use in determining cntinued eligibility fr hspice care. (5) All certificatins and recertificatins must be signed and dated by the physician(s), and must include the benefit perid dates t which the certificatin r recertificatin applies. (c) Surces f certificatin. (1) Fr the initial 90-day perid, the hspice must btain written certificatin statements (and ral certificatin statements if required under paragraph (a)(3) f this sectin) frm-- (i) The medical directr f the hspice r the physician member f the hspice (ii) interdisciplinary grup; and The individual's attending physician if the individual has an attending physician. The attending physician must meet the definitin f physician specified in f this subchapter. (2) Fr subsequent perids, the nly requirement is certificatin by ne f the physicians listed in paragraph (c)(1)(i) f this sectin. [48 FR 56026, Dec. 16, 1983, as amended 70 FR 45144, August 4, 2005] (d) Maintenance f recrds. Hspice staff must-- (1) Make an apprpriate entry in the patient's medical recrd as sn as they receive an ral certificatin; and (2) File written certificatins in the medical recrd. Link t Federal Regulatins: 42 CFR Page 12 f 12