Insights from an Expert Hospice Clinical Record Reviewer: Part I
The hospice industry is experiencing unprecedented payment-related scrutiny by the Centers for Medicare and Medicaid Services (CMS) to ensure proper payment for the provision of the Medicare Hospice Benefit. In response to the scrutiny, hospice organizations across the country are asked to submit documentation to demonstrate compliance with the Medicare conditions of payment through clinical record documentation. All too often, a hospice’s clinical record documentation does not sufficiently support the nature, severity, and progression of the patient’s terminal disease and related illnesses; therefore, payment for hospice services is denied.
When reviewing interdisciplinary group’s (IDG) documentation I frequently find that the documentation paints the picture of a chronically ill rather than terminally ill patient. In other words, the documentation demonstrates a patient who is severely debilitated and completely dependent on assistance for all activities of daily living (ADLs); however, there is little or no documentation that demonstrates disease progression or terminal prognosis.
The most common reason for this is that the patient’s significant disability and care needs has been misjudged as hospice clinical eligibility.
Discerning and documenting the clinical factors that differentiate chronic illness from terminal illness is challenging; however, assessment and documentation of the following can lend support to the patient’s clinical eligibility for hospice:
- Hospice Local Coverage Determination (LCD) Guidelines - Each Medicare Administrative Contractor (MAC) defines its own LCD guidelines for terminal diagnoses and, although they are only guidelines, they carry significant weight in determining a patient’s hospice clinical eligibility and subsequent claim payment. All IDG members should use the LCD guidelines from their MAC as a “road map” for documenting initial and ongoing eligibility with particular focus on disease progression over time.
- Terminal disease progression – Custodial care patients require maximum assistance in order to exist; however, terminally ill patients will demonstrate disease progression despite optimal care. Although the documentation of the patient’s debility and ADL dependence is important, documentation of disease progression despite optimal care is essential to demonstrate a patient’s terminal prognosis.
- Symptom palliation - During each visit, the IDG members must clearly document the symptom(s) that the hospice is managing. If no palliation is necessary, the patient’s initial or ongoing clinical eligibility needs to be questioned.
- Secondary conditions - As disease progression occurs, patients exhibit conditions that are a direct result of the terminal illness (e.g., multiple stage III decubitus wounds in a bed-bound patient with Alzheimer’s disease; recurrent upper respiratory infections in a patient with Chronic Obstructive Pulmonary Disease (COPD); or anasarca in patients with end-stage liver failure). Secondary conditions demonstrate the worsening nature of the patient’s hospice-qualifying terminal illness and the number and frequency of secondary conditions help to differentiate terminal illness from chronic illness.
- Comorbid conditions exist simultaneously but are independent of the terminal diagnosis. Despite the independent nature of comorbid conditions from the terminal illness, the number and severity of comorbid illnesses affect a patient’s prognosis. In addition to documenting the factors that support eligibility for the patient’s hospice-qualifying terminal diagnosis, all IDG members need to document the presence, severity, and symptom management of the patient’s comorbid conditions.
In order to mitigate current and future payment-related scrutiny, hospice organizations must ensure that each patient’s clinical record contains sufficient documentation to support initial and ongoing hospice clinical eligibility. Particular focus should be given to patients who have chronic illnesses (e.g., heart disease, Alzheimer’s disease, pulmonary disease, and liver disease) to ensure that the clinical record documentation clearly differentiates the terminal versus chronic nature of the disease.
Don't forget to ensure you have a valid business associate agreement for any contracted consultant who will be reviewing your clinical records. Learn more about that in our latest HIPAA blog.
Related Hospice Education Network Courses:
Disease-Specific Hospice Eligibility Determination and Documentation Series (1900/1901), 8-part series, based upon Local Coverage Determination (LCD) guidelines for CGS/NHIC/NGS and Palmetto. The Palmetto series also illustrates ways to document based upon the International Classification of Functioning, Disability and Health (ICF).
Posted by: Carrie Cooley, RN, MSN, Consulting Coordinator, Weatherbee Resources, Inc. & Hospice Education Network Inc.