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Physician Documentation and the 2011 Medicare Hospice CoP Update

First Friday Phone Call December 3, 2010 Ronald J Crossno, MD FAAFP FAAHPM OdysseyHealthCare National Medical Director


· Center for Medicare & Medicaid Services (CMS) ­ has updated the Medicare Hospice Conditions of Participation · Places a significantly greater emphasis on the role of physicians within hospice · Physician has always been a "core member" of the interdisciplinary group

­ Now has more clearly defined roles that only the physician may perform


· Discussion applies to Medicare

­ Medicaid may apply similar rules (e.g. Mississippi) ­ Rules do not apply to other third party payers but similar documentation is recommended

­ Certification Process

· Physician Documentation

­ Other encounter documentation ­ Role within the IDG meetings

· Face-to-face encounters / Narratives / Certification

· Brief discussion of physician billing

· Payers

Who is looking?

· State

­ Medicare Administrative Contractors (MACs) ­ State surveyors ­ State OIG ­ ­ ­ ­ ­ Office of Inspector General (OIG) Comprehensive Error Rate Testing (CERT) Contractors Zone Program Integrity Auditors (ZPIC) Program Safeguard Contractors (PSC) Recovery Audit Contractors (RAC)

· Federal

Certification is a process

· More than just a signature! · CMS indicates that each certification or recertification is a process composed of several components · Each component must be present in order for the certification to be complete · The entire process for each certification must be completed by the same hospice physician · Admission certification is the only one requiring the attending physician input

­ Must be clearly labeled

Admission hospice certification

· Requires two (2) physicians · Requirements

­ ­ ­ ­ ­ ­ Attending physician (if there is one) ­ Hospice physician (may also be the attending) Can only be done by a physician (MD or DO), not NP Attending must be chosen by the patient Written or oral certification within 2d of admission Cannot bill until both written certifications completed No earlier than 15 days before the benefit period

· Standard to go by:

­ "Must specify that the individual's prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course."

Admission Certification Form

· Only performed by hospice physician (MD/DO) · All previous requirements still apply · Certification benefit periods

­ 1st benefit period, lasts up to 90 days ­ 2nd benefit period, lasts up to 90 days ­ 3rd benefit period, lasts up to 60 days ­ Subsequent benefit periods, each lasts 60 days

Hospice recertification

· All certifications/recertifications must

­ Be signed and dated by the physician(s) ­ Include the benefit period start and stop dates

Recertification Form

1st and 2nd benefit periods

· Physician narrative for every certification

­ Virtually always done by the hospice physician ­ "brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less" (§ 418.22) ­ Be composed by the physician signing the certification ­ "Reflect the patient's individual clinical circumstances and cannot contain check boxes or standard language used for all patients" ­ "statement above the physician's signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patient's medical record or, if applicable, his or her examination of the patient" ­ Update changes the attestation to `above' rather than below ­ Signed and dated

· Narrative attestation

· Certification

­ Signed and dated

3rd and subsequent benefit periods

· · · · Face-to-face encounter* Encounter attestation* Physician narrative (same as before) Narrative attestation (same as before)

­ Signed and dated

· Certification

­ Signed and dated

*more on the F2F encounters in upcoming slides

But first - more on narratives

· Self-contained explanation of why the pt's prognosis is a life expectancy of 6 months or less · Elements of an effective narrative include:

­ Diagnosis

· Primary + pertinent comorbid and secondary conditions

­ Functional and Structural status (with decline)

· PPS / BMI / FAST / ADLs / Time asleep / major impairments · Utilize items from the "General" and "Disease Specific" portions of the HPMG form

­ An explicit prognosis statement in your own words

· Do not include non-pertinent findings or discussion of treatment plans

Which elements to include?

· Typically, there are 4 ways to document eligibility based on the payer's Local Coverage Determinations

­ Meets specific LCD: document those elements ­ Almost meets LCD and has comorbids sufficient to indicate a terminal prognosis: document elements + comorbid ­ Almost meets LCD and has rapid decline sufficient to indicate a terminal prognosis: document elements & how pt is rapidly declining ­ No LCD for pt's terminal condition: explain elements you used to determine pt's terminal prognosis

· If there is not evidence of a terminal prognosis

­ Stop to obtain more clinical information, if needed ­ or ­ Begin planning for discharge from hospice

HPMG Forms

· The "top" and the "bottom" of the forms

­ Top provides you the elements that apply to that particular LCD ­ Bottom is the actual narrative, which is what counts

· Narrative must include the pertinent elements


A word about "debility"

· Debility should only be used when some other diagnosis is not obvious · If there is a major disease process that is leading to debility, that should be the diagnosis used · Even the Medical Director of one of our payers discourages the use of "debility"

Use of "Debility, Unspecified" contributes no specific information to the cognitive processes required of hospice physicians. . . . It would be of greater value to establish a more specific diagnosis (based on the hospice physician's evaluation) and use identified secondary and/or comorbid conditions to frame decision-making and communication around the management and "palliation" of the "terminal condition."

Dr. Harry Felciano, Palmetto GBA Coalition Q&A (8/19/2010)


· If a reviewer cannot read the narrative, it is useless and will likely result in a payment denial · If signature is not legible, must have the physician's name (legibly) printed · Date in physician's handwriting and legible · Presence of only one handwriting on the clinical parts of the form

­ Next to signature or on a separate signature log

Only one handwriting allowed


· Making dictation services available is high priority · Must ensure the integrity of the dictation

­ No one other than the composing physician may edit ­ Policy is now in place regarding dictation

· - Hospice Physician Dictation 22.1.doc

· Several available vendors

­ One recommended vendor is:

· Electronic/digital signatures and dates are permissible if they comply with other CMS regs

· TurboScribe by iMedX · Contact Michelle Makanani at [email protected]

Issues regarding dictation

· Tendency to say too much · Must proof-read, edit to ensure accuracy, and sign. · Actual example of what was said:

­ Pt was asleep, hunched forward when I found her; though she readily roused and it took a few seconds for her to make eye contact. ­ Pt was asleep, hunched forward. When I fondled her though, she readily aroused and it took a few seconds for her to make eye contact. ­ Narrative is only a narrative ­ Progress notes is only a progress note

· Actual example of what was typed:

· Do not combine different documents

What may be dictated?


Face-to-face Encounter


No (Our forms are the proof that a F2F encounter occurred) Yes (Narratives may be dictated and placed either directly on HPMG form or as addendum to an otherwise completed HPMG form) Yes (Dictation may be done, replacing our standard form, following that format) Yes (Dictation may be done, replacing our standard form, following that format) No (Each form serves a different purpose, and they must be separately completed)

Physician Narrative

Comprehensive Physician Note

Subsequent Physician Note

Combinations of the above

Narrative resources

· HPMG_Audit_Reference_material.docx · May 7, 2010 First Friday Phone Call (FFPC) recording

­ Available online at:

· (look for archives) ·, scroll down to <First Friday Archives> and select May 2010 · If difficulties accessing ­ contact [email protected]

­ Accompanies results of HPMG audits

· Your NMDR or RVPCA

Internal HPMG Audits and Compliance

· Insufficient improvement by some MDRs · Process for MDRs with inadequate narratives 1. Failure of an audit

­ ­ ­ ­ ­ ­ Review reference material & May 2010 FFPC Sign off that this is done and re-audit at next IDG ED to execute "win-win" agreement with personalized remediation plan Re-audit at next IDG ED to execute "CIF" with personalized remediation plan Re-audit: unable to certify/work for company if fails again

2. If fails to improve

3. If again fails to improve

Moving on now to Face-to-Face Encounters

Face-to-face (F2F) encounters

· In effect 1/1/2011 · "A hospice physician or hospice nurse practitioner must have a face-to-face encounter with each hospice patient, whose total stay across all hospices is anticipated to reach the 3rd benefit period, no more than 30 days prior to the 3rd benefit period recertification, and must have a face-to-face encounter with that patient no more than 30 calendar days prior to every recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care."

§ 418.22 Certification of Terminal Illness (final)


· F2F encounter (3rd and later benefit periods)

­ No earlier than 30 days before the start of the benefit period to which it applies ­ Must occur before the narrative / certification ­ For `readmissions' into 3rd or later benefit periods: must be done before the oral or written certification (i.e. before admission) ­ CMS has not indicated how to manage patient deaths before accomplishing the F2F encounter

We will not delay implementing care for eligible patients needing our assistance! · Narratives / Certifications

­ No earlier than 15 days prior to the start of the benefit period

Who may do the F2F encounter

· Hospice physician

­ Must be employed or contracted ­ Volunteers considered employed ­ Residents / Fellows ­ as long as employed or contracted ­ MUST BE THE SAME PHYSICIAN WHO DOES NARRATIVE & CERTIFICATION ­ Must be employed ­ May not be contracted

· Hospice nurse practitioner · May not be:

­ Physician Assistant, Nurse Clinician, RN, etc.

F2F encounter attestation

· New and different attestation from the narrative · Hospice physician or hospice nurse practitioner:

­ "Attest in writing that he or she had a face-to-face encounter with the patient, including the date of that encounter."

· Additional for hospice nurse practitioner, only:

­ "shall state that the clinical findings of that encounter were provided to the certifying physician"

· The date the attestation is signed does not have to be the same date as the actual encounter

Hospice Physician F2F Encounter Form

Hospice Nurse Practitioner F2F Encounter Form

What goes on the F2F Encounter Form?

· · · · · "Just the facts!" No need for assessments No need for prognosis No need for plans "Just the facts!"

­ Documentation of the assessment done purely for administrative purposes

Implementation of F2F

· Hospice Physician · Standard payment will be `by the encounter'

­ Can be Medical Director or Associate MDR ­ Can be Hospice Physician contract

· Documentation

­ One flat payment, inclusive of travel time ­ If additional services done, need separate documentation ­ No separate payment for billable services (double-dipping) ­ F2F encounter form ­ Invoice for F2F Encounters ­ Must be employee ­ F2F encounter form

· Nurse Practitioner

Invoice for Face-to-Face Visits

F2F resources

· · · · F2F forms posted on OdyInfo This FFPC is recorded for posting on OdyInfo F2F Encounter `FAQ' will be posted on OdyInfo NMDR / RVPCA

So, to review . . .

Components of the certification

1st & 2nd benefit periods · Attending physician certification (for new admits) · Hospice physician narrative · Hospice physician narrative attestation · Hospice physician's certification

Each component should be clearly labeled, including the start / end dates of the benefit period Signatures must be dated by the signer

Components of the certification

3rd & subsequent benefit periods

· Attending physician certification

(for new admits)

· · · · ·

F2F encounter documentation F2F encounter attestation Hospice physician narrative Hospice physician narrative attestation Hospice physician's certification

Each component should be clearly labeled, including the start / end dates of the benefit period Signatures must be dated by the signer

Another way of thinking of the documentation for certification

· Think "SOAP" notes · S/O: F2F encounter · A: Narrative · P: Separate orders or included in a "real" billable visit note

Are F2F encounters billable?

· CMS states these are not separately billable

­ Considered an administrative function, as a component of the certification process, which is paid through the hospice per diem

However . . . · CMS does state that if non-administrative, reasonable and necessary physician-level services are provided in addition to the administrative encounter, that portion would be billable

­ Must have documentation supporting the claim ­ NPs may only bill if designated as the attending by the pt in those states where such designation is allowed

Documentation of billable visits

· For any billable visit, must complete:

­ Progress note (see examples) ­ Billing form (see example)

· This is in addition to any F2F encounter documentation

Physician Progress Note: Comprehensive

Physician Progress Note: Subsequent

Hospice Physician Billing Form

An overview of physician billing

· Based upon materials provided by AAFP, AAHPM, AMDA · Medically reasonable & necessary

­ "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member"

42 U.S.C. § 1395y(a)(1)(A)

· Examples of reasonable & necessary

­ Upon request of patient, family, or other professional (? non-hospice ?) ­ Establish professional relationship with patient ­ Evaluate, diagnose, or prognosticate for purposes of determining treatment, providing recommendations, or providing counseling ­ Includes physician-level monitoring effects of treatments and ordering new or different treatments (both based on direct examination and physician level decision-making)

Billing of for physician E&M codes

· Physician `Evaluation & Management' codes are billed either by time or based upon components · Time-based billing

­ If >50% of the time spent during a visit is for counseling or coordination of care, then can bill based on time ­ Times and what was discussed must be clearly documented in the clinical record ­ All E&M codes have times assigned for such use ­ Time-based billing is often used in the HPM setting

Component-based physician billing

· Billing is dependent on levels of documentation for three components (or sometimes, just two) · History (4 types for billing purposes)

­ Reason for visit ("Chief Complaint") ­ Present illness ­ Past Hx (Review of systems, Family Hx, Social Hx) ­ 4 types of thoroughness for billing purposes ­ 4 types of complexity for billing purposes

· Examination

· Medical Decision-making

· Levels chosen must be medically reasonable & necessary

Other considerations for billing

· Place of service

­ Office / Home / Hospital / NF / ALF ­ Hospital / NF: Initial / Subsequent ­ Office / Home / ALF: New / Established

· Relationship of visit

· Hospice physician billing is Medicare Part A

­ Physician billing otherwise is usually Part B ­ Special considerations for Rural Health Clinics / SNF Part A Beds

Who you are matters in billing

· Hospice physicians must bill through hospice for all care related to terminal condition · Unrelated care may be billed directly to Carrier / MAC using <GW> modifier code

­ Whether or not hospice physician is attending

­ Should be completely unrelated, with supporting documentation ­ Cannot submit two bills (one related and one unrelated)

Words also matter in billing

· Major organizations, such as AMDA and AAHPM have provided teaching materials that offer the following guidance for what items reviewers look for when auditing documentation · Reason for visit

­ ­ ­ ­ ­ ­ "Mandated face-to-face visit" likely not to be billable "Seen at patient request" likely to be billable "Eligibility evaluation" not likely to be billable "Pain needs better control" likely to be billable "Routine rounds" not likely to be billable "Newly admitted to NF for care" likely to be billable

Other documentation considerations

from AMDA teaching materials

· Component-based billing

­ Patient condition and documentation must be sufficient to justify billing code chosen ­ Two or more chronic problems count towards a moderate or high complexity decision-making ­ "Pain is now well managed with . . ." ­ "Pt has end-stage dementia with caregivers in place to provide ADL support" ­ "Pt has the following problems: 1 . . . 2 . . . 3 . . ." etc.

· Document medical decision-making

Next Steps

· Ongoing evaluation of site's needs for F2F · Ensure workforce to meet demand

· Hospice physician · Hospice nurse practitioner

· Prepare plan to make all visits · Ensure appropriate documentation is completed · Ongoing internal audits to ensure compliance




Ethical Issues in HPM

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