Medicare Program; 2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements; and Updates on Payment Reform.
In the May Select Data ezine, we commented re the overall proposed rule. In this article, let’s discuss specifically the CMS clarification of a number of coding requirements.
Clarifying Diagnosis Coding in Hospice Claims
The proposed rule solicits comments with the intent of clarifying a number of coding requirements in Hospice; especially regarding non specific diagnoses such as Debility and Adult Failure to Thrive (AFTT).
Longstanding policy requires that hospices as well as home health agencies adhere to ICD-9-CM coding guidelines. CMS clarifies that hospice providers should not use certain non-specific diagnoses such as Debility and Adult Failure to Thrive which are essentially symptom syndromes and that, under coding guidelines, are not principal diagnoses. Claims submitted with these diagnoses would be returned to the provider, under the proposed rule, for a more definitive appropriate diagnosis. Hospices should code the principal diagnosis using the underlying condition that is the main focus of the patient’s care. However, Debility and Adult Failure to Thrive can be listed on claims as secondary diagnoses that can support prognosis, if appropriate.
According to the Proposed Rule, these actions are being taken as root causes are not being listed in at least 13.9% of Hospice claims where Debility has been the principal diagnoses listed on claims. CMS stated concern that individualized patient-centered plans of care are difficult to develop for patients with ill defined principal diagnosis and that the patient may not receive the full hospice benefit allowed. CMS is interested in gaining a better understanding of those who are served by the Medicare hospice program.
What is the Impact of this Segment of the Proposed Rule?
Agencies should cease the use of Debility and Adult Failure to thrive as primary diagnoses as, at the very least, the diagnoses are symptom codes and when used as a primary diagnosis, are not in keeping with ICD-9-CM Coding Guidelines. Instead, choose a primary diagnosis that is more descriptive of the patient’s disease and/or describes the disease trajectory and end-of-life palliative interventions.
Use other comorbidities and health conditions that support the prognosis, as needed.
Agencies should use, if appropriate, these Debility and Adult Failure to Thrive diagnoses in a secondary diagnosis position on the claim.
When assessing to code, remember to review the full Plan of Care to determine body system, signs and symptoms, psychological, emotional, and spiritual issues that have been identified as requiring the greatest need for palliative interventions. Review physician orders as well as the medication profile. Each of these segments contribute to the primary and overall focus of care.
Patients under the Hospice benefit with ill defined diagnosis will soon have claims rejected under this proposed rule. Ill defined diagnoses and a POC that has changed little for a long period of time will soon be chosen for audit or claim denial. Don’t let your agency have claims denied because of poor coding. Take steps NOW!
Medicare Program; 2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements; and Updates on Payment Reform
In the May Select Data ezine, we commented re the overall proposed ruled. In this article, let’s discuss specifically the CMS “Hospice Item Set for the Collection of Data Pertaining to the Hospice Quality Reporting Program.” For those of you who are familiar with OASIS in home care, you will note data set similarity.
Section 3004 of The Affordable Care Act (ACA) authorizes the establishment of a new quality reporting program for hospices. CMS is preparing for implementation of this tool next summer.
Implementation of the Hospice Item Set
For the fiscal year 2016 payment determination, CMS proposes the implementation of the standardized patient-level data collection instrument called the Hospice Item Set (HIS).
Hospices would be required to be have this tool completed at admission and discharge on all patients admitted to hospice starting July 1, 2014. The item set consists of data elements to collect standardized patient –level data for specific domains of care that include:
- Respiratory Status
- Patient Preferences
- Beliefs and Values
HIS data submission would affect the payment determination for FY 2016. The survey would include questions on hospice provider communications with patients and families; hospice provider care, and overall rating of hospice. The HIS is needed in order to allow CMS to collect quality data from hospices in a standardized fashion and be compliant with Section 3004 of the ACA.
Hospices must submit the data effective July 1, 2014 or be subjected to a 2% reduction in the market basket update for FY 2014 and ongoing. The data will be utilized by CMS and posted for public review and use.
Hospices will be able to collect the data on paper and then data enter the information into an electronic format. Hospices will use the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system for data submission. The ASAP system is already used by Skilled Nursing Facilities (SNFs) and Long Term Care Hospitals (LTCHs).
The data must be transmitted electronically, similar to the home health OASIS data set. Hospices will be required to attest to the accuracy of the data collected.
CMS does not view the HIS as a duplicate effort. The HIS will be used to collect data specific to the seven NQF endorsed measures. The data will be collected upon admission and discharge for every patient. New measures may be added at a later date.
CMS projects a collection time frame of 14 minutes for the admission and 5 minutes for the discharge data collection.
The initial section of the data set is focused on logistical data with 13 items.
The next section entitled Preferences covers CPR, life-sustaining treatment, hospitalization, spiritual/existential concerns, along with principal diagnosis.
The following sections cover the health data sets of pain, respiratory status, and medications.
Agencies should download the data set now and become familiar with the new tool, developing educational sessions for their clinicians as to data gathering required. Get comfortable with the form and look to weave it into your established processes.
2014 will be a very busy year; updated OASIS data set, new HIS assessment tool and the implementation of ICD-10-CM. Agencies must plan now for changes, changes, changes for they are certainly coming.