It's been almost twenty years since the Health Care Finance Administration (now the Centers for Medicare and Medicaid Services ) sent a memo to hospices announcing the first widespread, in-depth review of hospice medical records and patient eligibility. Focused Medical Review, as it was called in 1994, was just the beginning of the government's search for fraud and waste in hospice.
Prior to this action, hospices that had largely avoided widespread regulatory scrutiny were suddenly being held accountable to a much higher documentation standard than ever before. During this audit, hospices struggled to demonstrate through their documentation that patients who had already died, often within days or weeks of admission, met eligibility requirements for hospice. In the days before Webinars or online education, hospices were challenged with the means to disseminate education to their staff to teach them to “paint the picture” of medical eligibility.
Today, hospices are once again facing intense scrutiny of their documentation as Medicare Administrative Contractors (MACs) are sending notices of Probe Edits and Additional Document Requests (ADRs). The burden on staff and financial resources to respond to these audits is taking a toll on hospices under review. Once again, many hospices are finding that they lack the documentation required to paint a picture of eligibility.
The criteria used to determine eligibility for the Hospice Medicare Benefit is specific to each MAC, and changes periodically based on new prognostication tools and research. Hospices should use the disease-specific criteria outlined in each MAC’s Local Coverage Determinations (LCDs) to determine if someone is or continues to be eligible for hospice under Medicare.
Documentation of disease-specific criteria, along with supporting information such as description of the patient’s illness trajectory, pertinent co-morbid and secondary conditions, severity of symptoms, declining functional, cognitive and nutritional status, and overall burden of illness are critical to depicting why this patient will probably die within six-months or less.
All hospice staff should be fully aware of and utilize their LCD guidelines and disease-specific criteria to document eligibility for each admission and every recertification.
Ask yourself the following questions to determine if your hospice team has the education and tools that they need to paint the picture of eligibility:
Are the LCDs easily accessible to all admission and IDT staff – either on their laptop, smartphone or in a handy printed resource?
Does your team refer to LCD criteria when discussing recertification during IDT meetings?
Does each patient’s medical record include documentation regarding his or her prognosis, both upon admission and in each recertification note?
Do your physician narratives contain key elements based upon LCD guidelines that lead the reader to the conclusion that the patient is terminally ill?
Do you conduct monthly chart audits to ensure that best practices for documenting medical eligibility are being followed?
Are ALL staff trained and regularly retrained on how to document to the LCDs, including documentation of co-morbid conditions to support medical eligibility?
If you answered “No” to any of the questions below, your hospice may be at risk for financial penalties in the event of an audit. Comprehensive documentation that paints the picture of initial and ongoing eligibility is paramount to the ongoing survival of your hospice. Training, along with ongoing chart reviews, is the best insurance you can have against future MAC audits, probes, and ADRs.
Looking for an efficient and cost-effective way to teach your entire team how to document to the LCDs? The Hospice Education Network’s Disease-Specific Hospice Eligibility Determination and Documentation Series is for you!
Do you need an objective review of your documentation or compliance system? Weatherbee Resources specializes in outsourced clinical record auditing and baseline compliance audits. The Weatherbee team can also create customized onsite staff training education or conduct webinars for your entire organization. Visit http://www.weatherbeeresources.com or call 508.778.0008 today!
Medicare Administrative Contractors MAC map
Review the Palmetto LCDs (be sure to select the hospice LCDs)
Posted by Terri Maxwell, PhD APRN Vice President, Strategic Initiatives, Weatherbee Resources, Inc. & Hospice Education Network Inc.