The HOPE of Wisconsin Annual Conference

November 12, 2013

Medical Directors’ WorkshopJames W. Cope, MD

Agenda

• CERT• Hospice Growth• Audits• Wage Index Final Rule for FY 2014• Additional Data Reporting• Face-to-Face Encounter• NGS LCD / Terminal Prognosis

CERT

• Comprehensive Error Rate Testing• Began 2003 (prior > OIG)• Random Sample ~ 50,000 FFS claims• ~ 75 RNs + coders• 2 Medical Directors• Result– Error Rates– Projected $$ in Error– Most recent = 8.5% = $29.6 Billion

CERT

• Hospice Error Rate ~ 10%• Projected Error Amount ~ $300M

• Main Issues– Certification / Recertification– Terminal Prognosis

Trends in Utilization• Beneficiaries – 513,000 in 2000– > 1.3 million in 2012

• Expenditures– $2.9 B in 2000– $14.7 B in 2012

CMS expects ~ 8% increase / year

CMS 2014 Wage Index Final Rule 8.7.2013

Diagnosis Trends

• Top 5 Diagnoses 2002– Lung cancer, CHF, Debility, COPD, Alzheimer’s

• Top 5 Diagnoses 2012– Debility, Lung cancer, Failure to Thrive, CHF, COPD (Debility + FTT = 19% of beneficiaries)

Audits

• Office of Inspector General– June 2012 – Part D paid for Rx instead of the

hospice– May 2013 – GIP

– 2013 work plan • Hospice Marketing Practices & Financial Relationships

with Nursing Facilities

Audits

• MACs– ask your Mac

• CERT– Ongoing / Random

• Recovery Audit contractors– No hospice activity yet

• ZPICs (fraud fighters)• Dept of Justice

2014 Hospice Final RuleAugust 7, 2013

• Diagnosis Reporting• Hospice Quality Reporting Program• Data Collection• Payment Reform

Diagnosis Reporting

• Must apply ICD-9-CM Coding Guidelines• Principle Diagnosis and all additional

diagnoses related to the terminal condition

• May not use nonspecific, symptom dxs & certain dementia dxs– Debility & FTT (RTP after 10/1/14)

Diagnosis ReportingDementia

• May not use codes from “Mental, Behavioral & Neurodevelopmental Disorders”– 290, 294– Nonspecific– Manifestations of other more specified conditions

• May use codes from “Diseases of the Nervous System & Sense Organs”– 331s > Alzheimer’s, Front-temporal dementia, Pick’s, Lewy Body

dementia

Diagnosis Reporting

• Principle Diagnosis• Select the condition most contributory to the

terminal prognosis

• *** Eligibility for the Medicare Hospice benefit is based on prognosis, not diagnosis !

Local Coverage Determination

• Determining Terminal Prognosis• Effective 12/7/2007

• Can be used to evaluate any beneficiary

• No diagnosis codes

Plan of Care

• Initial assessment within 48 hrs• Comprehensive assessment within 5 days• Updated no less than q 15 days• Plan of Care– Formulated by IDG– Specify care needed for terminal illness & related

conditions– Review, & revise as needed, no less than q 15 days

Related To ?

‘‘hospices are required to providevirtually all the care that is needed byterminally ill patients.’’

Hospice Final Rule 12/16/1983, page 56010

Related To ?

“…unless there is clear evidence that a condition is unrelated to the terminal prognosis,all services would be considered related.

It is also theresponsibility of the hospice physicianto document why a patient’s medicalneeds would be unrelated to theterminal prognosis.” (78 FR 48236)

Payment Reform & Data Collection

• MedPAC, OIG & GAO call for more data• Needed to better align costs &

reimbursements• Costs > U-shape curve• Costs highest at start & end of stay

Data Collection

• CR 8358 (7/26/2013)

• Additional Data Required

• Visit data for hospice staff providing GIP in SNFs or Hospitals– Nurse, Aide, PT, OT, SLP, SW (incl calls)

• Post-mortem visits on day of death– PM modifier– Eff 1/1/2014; enforced 4/1/2014

Data Collection

• Prescription Drugs• Infusion Pumps

• NPI for any facility where beneficiary is receiving care, if not the billing hospice

Face-to-Face Encounter

• Hospice physician or Hospice NP• Prior to 3rd benefit period• No more than 30 days prior to benefit period*• Attestation

• F2F visit = Administrative (i.e., not billable)

References

• Social Security Act §1861 dd• 42 CFR 418• Hospice Wage Index Final Rule 2014• CMS Benefit Policy Manual Pub.100-2, Ch. 9• CMS Claims Processing Manual Pub 100-4,

Ch. 11

Thank You