Medicare Home Health Clinical Updates from CGS January 14, 2015 Top 5 Reasons for Home Health Claim Denials Denials by Medical Review 2 Top HH Medical Review Denial Reasons Denial Reason Denial Reason Code 5FFTF Missing/incomplete/untimely faceto face documentation 5HMED Medical necessity of services not supported # Claims Denied (Jan Nov 2014) 1,834 (42%) 1,547 (36%) 56900 No/untimely response to ADR 552 (13%) 5HPLN Missing/incomplete/untimely plan 216 (5%) of care 5HHBD Homebound status not supported 188 (4%) 3 1
Essential Home Health Documentation OASIS and Coding Use LCD for Guidance Reasonable and Medically Necessary Skilled Service Intermittent Skilled Nursing or Therapies Homebound Documentation Technical Components: OASIS Submission, Certification/Orders/ FTF 4 Home Health Coverage Resources CMS Medicare Benefit Policy Manual (CMS Pub. 100-02) Ch. 7 Home Health www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Downloads/bp102c07.pdf CGS Home Health Coverage Guidelines webpage www.cgsmedicare.com/hhh/coverage/home_health_coverage_guid elines.html CGS LCDs & Coverage Home Health Physical Therapy http://www.cgsmedicare.com/hhh/coverage/index.html Click on Active LCDs on left side tool bar 5 Face-to-Face (5FFTF) and Physician Certification (5PCER) Denial Reason #1 (5FFTF) 6 2
Denial Reason #1: 5FFTF Face-to-Face Documents To be eligible for Medicare home health services, a patient must have Medicare Part A and/or Part B and: 1. Be confined to the home; 2. Need skilled services; 3. Be under the care of a physician; 4. Receive services under a plan of care established and reviewed by a physician; and 5. Have had a face-to-face encounter with a physician or allowed non-physician practitioner (NPP). 7 Denial Reason #1: 5FFTF Face-to-Face Documents Certifying physicians and acute/post-acute care facilities must provide, upon request, the medical record documentation that supports the certification of patient eligibility for the Medicare home health benefit to the home health agency, review entitles, and/or CMS. 42 CFR 424.22(c) 8 Denial Reason #1: 5FFTF Face-to-Face Documents Information from the HHA can be incorporated into the certifying physician s and/or the acute/post-acute care facility s medical record for the patient. Information from the HHA must be corroborated by other medical record entries and align with the time period in which services were rendered. The certifying physician must review and sign off on anything incorporated into the patient s medical record that is used to support the certification of patient eligibility. 9 3
Denial Reason #1: 5FFTF Face-to-Face Documents The certifying physician s medical record must contain information that justifies the referral for Medicare home health services. Including: 1. The need for the skilled services; and 2. Homebound status AND must contain the actual clinical note for the face-to-face encounter visit that demonstrates that the encounter: 3. Occurred within the required time frame; 4. Was related to the primary reason the patient requires home health services; and 5. Was performed by an allowed provider type. 10 Denial Reason #1: 5FFTF Face-to-Face Documents The Recertification document must be: 1. Signed and dated by the physician who reviews the plan of care. 2. Indicate the continuing need for skilled services 3. Estimate how much longer the skilled services will be required. 11 Denial Reason #1: 5FFTF Electronic Code of Federal Regulations: Title 42 CFR 424.22; Requirements for home health services http://www.ecfr.gov/cgibin/retrieveecfr?gp=&sid=c86654e32a4f36f15d70fab390124c29& n=pt42.3.424&r=part&ty=html#se42.3.424_122 12 4
Denial Reason #1: 5FFTF Performed By Whom? Face-to-face encounter may be performed by: Certifying physician (must be Medicare enrolled) Non-physician practitioner (NPP) in collaboration with the certifying physician Physician who cared for the patient in an acute/post-acute facility during a recent stay and has privileges in that facility 13 Denial Reason #1: 5FFTF When? For initial certifications only Recertifications do not require a face-to-face encounter Certifying physician must document FTF took place within 90 days prior to start of care (SOC), or 30 days after SOC Reminder: FTF must be related to primary reason for home health admission Exceptional circumstance: Patient death before FTF can be performed 14 Denial Reason #1: 5FFTF Face-to-Face The physician who cared for the patient in an acute or post-acute facility may choose to use documentation from the patient s medical record, (such as a discharge summary) to inform the certifying physician of the clinical findings from the face-to-face encounter. IF The compiled documentation is reflective of the clinical findings of the face-to-face encounter AND Serves as that physician s communication to the certifying physician 15 5
Denial Reason #1: 5FFTF Face-to-Face Signatures The document from the acute or post acute facility record Must be signed and dated by the certifying physician, Must indicate the certifying physician received the information from the physician who performed the face-to-face encounter, and Must show the certifying physician is using that documentation as his/her documentation of the face-to-face encounter 16 Denial Reason #1: 5FFTF Documentation Physician certification documentation requirements: The patient needs intermittent SN care, PT, and/or SLP services The patient is confined to the home A plan of care has been established and will be periodically reviewed by a physician Services will be furnished while the individual was or is under the care of a physician A face-to-face encounter 17 Denial Reason #1: 5FFTF Documentation The face-to-face encounter: occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care was related to the primary reason the patient requires home health services, and was performed by a physician or allowed non-physician practitioner Must be a separate and distinct section of, or an addendum to, the certification and Must be clearly titled, dated and signed by the certifying physician. 18 6
Denial Reason #1: 5FFTF Documentation Does the documentation clearly answer why home health and why now? Reminder: Good documentation should address: Objective clinical evidence of patient s individual need for care Progress or lack of progress Medical condition Functional losses 19 Denial Reason #1: 5FFTF Readmission If the patient is discharged, then readmitted, the same FTF document can be used if: The timeframe still meets requirements, AND There is not a 60 day or greater gap between episodes 20 Denial Reason #1: 5FFTF Electronic Code of Federal Regulations: Title 42 CFR 424.22; Requirements for home health services http://www.ecfr.gov/cgibin/retrieveecfr?gp=&sid=c86654e32a4f36f15d70fab390124c29& n=pt42.3.424&r=part&ty=html#se42.3.424_122 21 7
Denial Reason #1: 5FFTF Face-to-Face Regulations Medicare Benefit Policy Manual (CMS Pub. 100-02) Ch. 7, 30.5.1.1 http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Downloads/bp102c07.pdf 22 Examples of FTF Documentation Don ts Insufficient documentation Miscellaneous Diagnoses/clinical findings on FTF not related to home care ordered Altered documentation without acceptable notations for changes FTF signed by Non Physician Practitioner (NPP) only No date of FTF encounter Not clearly titled as face-to-face encounter 23 FTF Documentation: Important Reminders FTF is requirement for Medicare payment Missing/incomplete documentation results in entire claim being denied As the billing entity, the home health agency s (HHA s) responsibilities include: Facilitating and coordinating between patient and physician to ensure FTF occurs timely Ensuring all FTF requirements are met Ensuring physician s documentation is complete Delaying submission of claim until documentation complete 24 8
FTF Documentation The FTF encounter is an additional certification content requirement, and we (CMS) expect the HHA to coordinate with the physician and patient to ensure compliance. (CMS FAQ # 34) http://cms.gov/medicare/medicare-fee-for-service- Payment/HomeHealthPPS/Downloads/Home-Health-Questions- Answers.pdf (revised May 9, 2014) 25 Medical Necessity (5HMED) Denial Reason #2 26 Denial Reason #2 5HMED Medical Necessity All services (even skilled) must be reasonable and medically necessary related to the patient s condition Observation and assessment Teaching Therapy Refer to Physical Therapy (PT) Local Coverage Determinations (LCD) http://www.cgsmedicare.com/hhh/coverage/index.html (Select Active LCDs and then Submit ) 27 9
Denial Reason #2 5HMED Medical Necessity Does the documentation clearly answer why home health and why now? Reminder: Good documentation should address: Objective clinical evidence of patient s individual need for care Progress or lack of progress Medical condition Functional losses Treatment goals Discharge planning 28 Denial Reason #2 5HMED Medical Necessity Covers all disciplines Nursing Physical therapy Occupational therapy Speech language pathology 29 Denial Reason #2 5HMED Medical Necessity Full denials OR Partial denials, resulting in Low Utilization Payment Adjustment (LUPA) or therapy downcodes Additional information http://www.cgsmedicare.com/hhh/coverage/hh_coverage_guideline s/1e.html 30 10
Denial Reason #2 5HMED Medical Necessity - Do s Identify skilled service, and reason skilled service is necessary for beneficiary in objective terms Wound care completed per POC to left great toe. No s/s of infection, but patient remains at risk due to diabetic status. Range of motion (ROM) is tolerated to lower extremities. Unsafe to teach caregiver ROM due to displaced fracture. 31 Denial Reason #2 5HMED Medical Necessity Do s Demonstrate medical necessity of skilled observation and assessment by documenting complexity of beneficiary s condition and co-morbidities affective outcomes. Lungs sound coarse throughout. Patient finished antibiotic therapy today for pneumonia, and seeing pulmonologist tomorrow for follow up to due to COPD and emphysema. Stasis wound on LLE continues to show 50% granulation and moderate serous drainage. Instructed patient on need to elevate legs and exercises related to peripheral vascular disease. 32 Denial Reason #2 5HMED Medical Necessity Don ts Skilled nursing fables: As long as you document teaching, it is a billable visit. As long as you document assessment, it is a billable visit. 33 11
Denial Reason #2 5HMED Medical Necessity Don ts Medicare Benefit Policy Manual (CMS Pub. 100-02) Ch. 7, 40.1 and 40.2 lists requirements in order for a service to be covered by Medicare as skilled. The service must: Require the skills of a nurse or qualified therapist Service is NOT skilled because it is performed by a nurse or qualified therapist Service does NOT become unskilled because it is taught Be reasonable and necessary to treat patient s illness or injury Patient s condition warrants the skilled care MUST BE evident in documentation 34 No Response to Additional Development Request (ADR) (56900) Denial Reason #3 35 Plan of Care (5HPLN) Denial Reason #4 36 12
Denial Reason #4: 5HPLN Plan of Care Medicare Benefit Policy Manual (Pub. 100-02) Ch. 7, 20.1.1, http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Downloads/bp102c07.pdf states: payment can be made only if a physician certifies the need for services and establishes a plan of care. 37 Denial Reason #4: 5HPLN Plan of Care Plan of care must be reviewed, signed and dated by physician who established the plan of care at least every 60 days, and prior to submitting the claim to Medicare. It is not acceptable for HHAs to wait until the end of a 60-day episode to obtain a completed certification. Orders must include Patient s name Disciplines being provided, including frequency, duration and modality 38 Denial Reason #4: 5HPLN Plan of Care Common denial reasons include: Dates: Verbal order, date of physician signature Incomplete orders/poc Timeliness: must be SIGNED and DATED by physician prior to billing Missing dates: Received date NOT accepted CGS: Physician Orders, Plan of Care and Certification webpage www.cgsmedicare.com/hhh/coverage/hh_coverage_guidelines/1 B.html 39 13
Denial Reason #4: 5HPLN Plan of Care Certification must be obtained when POC is established, or soon after; and must be complete, signed and dated by the physician who established the POC prior to submitting the claim. Required contents: CMS Medicare Benefit Policy Manual (Pub. 100-02) Ch. 7, 30.2.1 http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Downloads/bp102c07.pdf 40 Homebound Status (5HHBD) Denial Reason #5 41 Denial Reason #5: 5HHBD Homebound Criteria Medicare Benefit Policy Manual (CMS Pub. 100-02) Ch. 7, 30.1.1 defines confined to home (homebound) http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Downloads/bp102c07.pdf CGS Homebound Webpage www.cgsmedicare.com/hhh/coverage/hh_coverage_guidelines/1c.html 42 14
Denial Reason #5: 5HHBD Homebound Criteria MLN Matters article MM8444, Home Health Clarification to Benefit Policy Manual Language on Confined to the Home Definition, http://www.cms.gov/outreach-and-education/medicare- Learning-Network- MLN/MLNMattersArticles/Downloads/MM8444.pdf Clarifies definition of patient being confined to home Reflects definition in Social Security Act (Section 1835(a)) Removes vague terms to ensure clear and specific definition Not a change in homebound definition 43 Denial Reason #5: 5HHBD Homebound Criteria Two criteria are used to determine homebound status Criteria-One: The patient must either: Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence. OR Have a condition such that leaving his or her home is medically contraindicated. 44 Denial Reason #5: 5HHBD Homebound Criteria Two criteria are used to determine homebound status (cont) Criteria-Two: There must exist a normal inability to leave home AND Leaving home must require a considerable and taxing effort 45 15
Denial Reason #5: 5HHBD Homebound Criteria The patient may be considered homebound (confined to the home) if absences from the home are: infrequent; for periods of relatively short duration; for the need to receive health care treatment; for religious services; to attend adult daycare programs; or for other unique or infrequent events 46 Denial Reason #5: 5HHBD Homebound Criteria Documentation must support homebound status throughout Beware of vague descriptions: taxing effort, unable to leave home Utilize objective, measurable language After ambulating 20 feet, patient has increased dyspnea and complains of back pain. Patient has unsteady gait, and must sit to rest after 20 feet of ambulation. 47 Denial Reason #5: 5HHBD Homebound Criteria Does the documentation clearly answer why home health and why now? Reminder: Good documentation should address: Objective clinical evidence of patient s individual need for care Progress or lack of progress Medical condition Functional losses 48 16
Denial Reason #5: 5HHBD Homebound Criteria The patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relative short duration, or are attributable to the need to receive health care treatment. Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7, 30.1.1) http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Downloads/bp102c07.pdf 49 Denial Reason #5: 5HHBD Homebound Criteria The patient may have more than one home Vacation home Home of caregiver Seasonal home 50 CGS Home Health Denial Fact Sheets - NEW! Available from Home Health Quick Resource Tools webpage http://www.cgsmedicare.com/hhh/education/materials/hh_qrt.ht ml 5HHBD Homebound Status http://www.cgsmedicare.com/hhh/education/materials/pdf/hh_5hhbd_ factsheet.pdf 5FFTF Face-to-Face Encounter http://www.cgsmedicare.com/hhh/education/materials/pdf/hh_5fftf _FactSheet.pdf 51 17
CGS Home Health Denial Fact Sheets NEW! 5HMED Medical Necessity http://www.cgsmedicare.com/hhh/education/materials/pdf/hh_5hme D_FactSheet.pdf 5HNOA No OASIS http://www.cgsmedicare.com/hhh/education/materials/pdf/hh_5hnoa_ factsheet.pdf 5HPLN/5HORD Missing Plan of Care or Orders http://www.cgsmedicare.com/hhh/education/materials/pdf/hh_5hpl N-5HORD_FactSheet.pdf 52 Are We On the Same Page?? Provide staff with the requirements; Information is Power!! Guide decisions and empower clinicians with coverage criteria. Education on coverage and documentation standards. Oversight of documentation. Ensure technical pieces are covered. 53 Questions? CGS Provider Contact Center 1-877-299-4500 (Option 1) 54 18
Thank You! Please complete the Event Evaluation Attendance Form Post-Test 55 Medicare Hospice Clinical Updates from CGS January 14, 2015 Top Hospice Medical Review Denial Reasons Top 5 Denial Reason Codes Denial Reason Claims Denied by These Codes (Jan Nov 14) 5PTER Six month prognosis not supported 2,581 (62%) 5PPOC POC does not meet requirements 579 (14%) 5PCER Missing/incomplete/untimely certification/recertification 477 (12%) 56900 No response to ADR 313 (7%) 5PRLM Reduced level of care 200 (5%) 57 19
Medical Review Hierarchy Physician visits Level of care Terminal status Plan of Care (POC) including review of the POC every 15 days Certifications including face to face (FTF) 58 Election Statement 58 CR 8877 Overview of Changes 59 CR 8877 Hospice Manual Update for Diagnosis Reporting and Filing Hospice Notice of Election (NOE) and Termination or Revocation of Election http://www.cms.gov/regulations-and- Guidance/Guidance/Transmittals/Downloads/R3032CP.pdf Effective for dates of service on/after October 1, 2014 Prohibits use of Symptoms, Signs, and Ill-defined Conditions diagnosis codes as principal diagnosis 60 20
CR 8877: Diagnoses Codes prohibited as principal diagnosis 799.3 and 780.79 (Debility) 783.7 (Adult failure to thrive) Multiple dementia codes See CR 8877 Attachment A for complete list Claims with prohibited codes will be returned to provider (RTPd) with reason code 30727 61 CR 8877 Resources Change Request 8877, http://www.cms.gov/regulations-and- Guidance/Guidance/Transmittals/Downloads/R3032CP.pdf Medicare Learning Network (MLN) Matters Article MM8877, http://www.cms.gov/outreach-and-education/medicare-learning- Network-MLN/MLNMattersArticles/Downloads/MM8877.pdf 62 CR 8877 CGS HHH Medicare Bulletins, http://www.cgsmedicare.com/hhh/pubs/mb_hhh/index.html CGS ListServ messages Recent News webpage, http://www.cgsmedicare.com/hhh/pubs/news/index.html Join/Update Listserv, http://www.cgsmedicare.com/medicare_dynamic/ls/001.asp 63 21
Six Months or Less Terminal Prognosis (5PTER) Hospice Denial Reason #1 64 Denial Reason #1: 5PTER Six Months or Less Terminal Prognosis Results in full denial Medical necessity is always based on the patient s condition Is it the patient or the documentation Make the reviewer see the patient Documentation is expected to show significant changes in the beneficiary s condition and the plan of care For more helpful guidance on hospice documentation: http://www.cgsmedicare.com/hhh/coverage/coverage_guidelines/ho spice_documentation.html 65 Denial Reason #1: 5PTER Six Months or Less Terminal Prognosis Documentation must paint the picture, especially for long-term hospice patients, or those with chronic illness and general decline Use quantifiable values and measurements to show changes in: Weight Document patient s weight at least monthly and more often if possible Measurements Arm/girth/leg measurements starting at admission Even if able to weigh patient Include policy in documentation that shows how and where measurements are taken 66 22
Denial Reason #1: 5PTER Six Months or Less Terminal Prognosis Use quantifiable values and measurements to show changes in: Pain Level of pain Expressed in the way patient/family member understands Document any extenuating circumstances Responsiveness Does the patient react to your presence? Does the patient remember you from last visit? 67 Denial Reason #1: 5PTER Six Months or Less Terminal Prognosis Use quantifiable values and measurements to show changes in: Levels of Activities of Daily Living (ADL) dependence What can they do SAFELY? Are they impulsive? Vital signs Respiration rate, blood pressure, pulse, temperature Graph easily shows change 68 Denial Reason #1: 5PTER Six Months or Less Terminal Prognosis Strength Ask the patient to squeeze your hands Is the patient able to stand? How long? Lucidity Can the patient carry on a lucid conversation? Can the patient make decisions? 69 23
Denial Reason #1: 5PTER Six Months or Less Terminal Prognosis Intake/output Make sure the serving size is appropriate Is there a system in place to measure output that is workable for the patient/family? Skin condition Broken skin? Stage wounds whenever possible Redness? Itching? 70 Denial Reason #1: 5PTER Six Months or Less Terminal Prognosis Pitfalls in terminal prognosis documentation: Paradigm shift for medical professionals Have been trained to show improvement not decline Amount and detail dependent upon situation Chronic, deteriorating condition vs. rapid progression 71 Denial Reason #1: 5PTER Six Months or Less Terminal Prognosis Failing to show big picture Send in relevant documentation outside of period requested Should be able to identify person from the documentation without seeing the name Obtain history and physical information May come from more than one source Recent hospital stay? Lives or lived at facility? 72 24
Denial Reason #1: 5PTER Six Months or Less Terminal Prognosis Use functional scale, as appropriate (don t round numbers) Karnofsky Performance Scale (KPS) 30%, 40%, 50%, etc. Palliative Performance Scale (PPS) 30%, 40%, 50%, etc. Functional Assessment Staging (FAST) New York Heart Association (NYHA) Must be stated by physician 73 73 Denial Reason #1: 5PTER Six Months or Less Terminal Prognosis Don t forget documentation from the interdisciplinary group (IDG) meetings Information from other staff members May have different perspectives Different staff members see patient at different times and in different circumstances 74 74 Denial Reason #1: 5PTER Six Months or Less Terminal Prognosis Refer to Local Coverage Determination (LCD) for guidance Use observations and data, not conclusions Clinical indicators of decline Weight loss, infections, changes in mobility, etc. Review terminal admitting diagnosis Reassessment is ongoing Remember quality versus quantity 75 25
Denial Reason #1: 5PTER Six Months or Less Terminal Prognosis Local Coverage Determination (LCD) information from CMS website www.cgsmedicare.com/hhh/coverage/coverage_guidelines/lcd.html Click on Hospice Determining Terminal Status The LCD is intended to provide guidance to both the medical community and CMS contractors 76 Denial Reason #1: 5PTER Six Months or Less Terminal Prognosis Terminal diagnosis documentation opportunities Admission Course of care (every visit) IDG meetings Change in level of care or plan of care Recertification 77 Plan of Care (5PPOC) Hospice Denial Reason #2 78 26
Denial Reason #2: 5PPOC Plan of Care Plan of care (POC) must be reviewed and updated by the hospice provider s interdisciplinary group (IDG) At intervals specified in POC, but at least every 15 days Send all POCs that pertain to claim s dates of service with documentation POC may be dated prior to dates of service being reviewed Submit sign-in sheet that shows who attended Must participate: Nurse Social worker Physician Spiritual care 79 Denial Reason #2: 5PPOC Plan of Care CGS webpage Hospice Plan of Care www.cgsmedicare.com/hhh/coverage/coverage_guidelines/plan_ of_care.html 80 Certifications (5PCER) Hospice Denial Reason #3 81 27
Denial Reason #3: 5PCER Certifications Every certification/recertification must include: Statement that the individual s medical prognosis is that their life expectancy is 6 months or less if the terminal illness runs its normal course The specific dates of the benefit period Example: January 1, 2014 through March 2, 2014 82 Denial Reason #3: 5PCER Certifications Physician(s) signature(s) and date Physician signature must be hand signed and hand dated or validated dated electronic signature The signature(s) must be legible or verified If narrative is an addendum, physician(s) must sign addendum also Only the initial certification must be signed by the attending physician (if there is one) AND the hospice medical director or IDG physician Attestation statement that indicates who composed narrative Example: I certify that I composed this narrative Nurse practitioners CANNOT sign the certification or recertification 83 Denial Reason #3: 5PCER Certifications Hospice certification requirements: Timeline No later than 2 calendar days after the start of the benefit period» By the end of the third day of the benefit period May be up to 15 days before start of care Can be verbal certification Hospice staff must make an appropriate entry in the patient s medical record as soon as they receive the verbal certification Must be signed/dated by physician prior to billing 84 28
Denial Reason #3: 5PCER Certifications CGS Signature Guidelines for Home Health & Hospice Medical Review quick resource tool www.cgsmedicare.com/hhh/medreview/sig_guidelines.pdf 85 Denial Reason #3: 5PCER Certifications Physician must include a narrative of clinical findings that supports a life expectancy of 6 months or less as part of the (re)certification, or as an addendum to the certification and recertification forms May be based on review of clinical records and/or assessment Shows supported progression of decline If the narrative exists as an addendum, the physician must sign both the certification and the addendum 86 Denial Reason #3: 5PCER Certifications Attestation statement follows the narrative Confirms composition of the narrative Based on assessment of patient and/or Review of medical records Must reflect individual clinical circumstances Cannot contain check boxes or standard language used for all patients 87 29
5FFTF - Face-to-Face Prior to the third benefit period, and with each subsequent recertification, beneficiaries must have a documented face-toface encounter with a hospice physician, or nurse practitioner Note: All prior hospice elections/benefit periods are counted 88 5FFTF - Face-to-Face Face-to-face encounter can be up to 30 days prior to the recertification date AND must occur prior to certifying physician composition of narrative and signing of certification Recertification window remains 15 days prior, or by 2 nd day after benefit period begins 89 5FFTF - Face-to-Face Documentation must include: Physician/NP attestation that FTF occurred FTF documentation clearly titled If FTF is performed by NP, attestation must indicate clinical findings were communicated to certifying physician Date and legible signature of physician/np who performed encounter Note: Face-to-face encounter and certification must be signed, along with certification, prior to billing claim 90 30
No Response to Additional Development Request (ADR) (56900) Hospice Denial Reason #4 91 Levels of Care (5PRLM) Hospice Denial Reason #5 92 Denial Reason #5: 5PRLM Levels of Care Routine General Inpatient Care (GIP) Respite Care Continuous Care 93 31
Denial Reason #5: 5PRLM Levels of Care General inpatient care may be required for procedures necessary for pain control or acute or chronic symptom management that cannot feasibly be provided in other settings. Medicare Benefit Policy Manual (CMS Publication 100-02), Ch. 9, Section 41.1.5 94 Denial Reason #5: 5PRLM Levels of Care GIP is short term care for management of s/s that can not be controlled in another setting Documentation should show what other measures have been tried prior to GIP Documentation must substantiate higher level of care for all days billed at GIP level of care Payment may be made for a portion of GIP days depending upon supporting documentation 95 Denial Reason #5: 5PRLM Levels of Care General inpatient care documentation requirements: Precipitating crisis Interventions tried at home that were unsuccessful Supportive data that crisis is ongoing Interventions attempted to resolve crisis Patient s response Quantitative data Ex: vital signs, pain ratings, respiratory distress 96 32
Denial Reason #5: 5PRLM Levels of Care Symptom changes: Sudden deterioration requiring skills of nurse Uncontrolled nausea/vomiting Unmanageable respiratory distress New or increased delirium, agitation 97 Denial Reason #5: 5PRLM Levels of Care Pain requiring skills of nurse: Frequent evaluation Frequent medication adjustment Aggressive treatment to control pain Transfusions 98 98 Denial Reason #5: 5PRLM Levels of Care Discharge planning begins before admission Medicare does not pay for additional days of GIP for discharge planning 99 33
Denial Reason #5: 5PRLM Levels of Care Respite Care Caregiver relief, up to five consecutive days per respite period Can be more than one respite stay per billing period Based on need for caregiver to have respite from demands of caring for hospice patient 100 Medical Review Standards CMS Medicare Benefit Policy Manual (CMS Publication 100-02) Chapter 9 - Hospice http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/bp102c09.pdf CGS Hospice Coverage Guidelines webpage www.cgsmedicare.com/hhh/coverage/hospice_coverage_guidelin es.html 101 Medical Review Standards Hospice Local Coverage Determination: Determining Terminal Status www.cgsmedicare.com/hhh/coverage/coverage_guidelines/lcd.html Click on Hospice Determining Terminal Status 102 34
CGS Hospice Denial Fact Sheets - NEW! Available from Hospice Quick Resource Tools webpage, http://www.cgsmedicare.com/hhh/education/materials/hospice_q RT.html 5FFTF Face-to-Face Encounter, http://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_5 FFTF_factsheet.pdf 5PCER Certification/Recertification, http://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_5 PCER_factsheet.pdf 5PPOC Plan of Care http://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_5 PPOC_factsheet.pdf 103 CGS Hospice Denial Fact Sheets - NEW! 5PNOE Election Statement, http://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_5 PNOE_factsheet.pdf 5PRLM Reduced Level of Care, http://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_5 PRLM_factsheet.pdf 5PTER Six-month Terminal Prognosis, http://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_5 PTER_factsheet.pdf 104 Other Resources CGS Hospice Quick Resource Tools www.cgsmedicare.com/hhh/education/materials/hospice_qr T.html CGS Frequently Asked Questions www.cgsmedicare.com/hhh/education/faqs/index.html 105 35
On the Same Page?? Provide staff with the rules - Information is Power!! Guide decisions and empower clinicians with coverage criteria Education on coverage and documentation standards Oversight of documentation Ensure the technical pieces are covered 106 106 Questions? CGS Provider Contact Center 877-299-4500 (Option 1) 107 Thank You! Please complete the Event Evaluation Attendance Form Post-Test 108 36