Esther Liu, PharmD, MSIA
Centers for Medicare & Medicaid Services (CMS) has issued a Change Request (CR) 83581 which requires additional claim data reporting for hospices to support hospice payment reform as authorized by the Affordable Care Act, to be effective 2014. Hospices must report line-item visit data dates of service on or after April 1st, 2014, and they may voluntary begin this reporting as of January 1st, 2014. Hospices should make sure that the billing staff is aware of the changes. The additional data requested includes:
1) Visit reporting for general inpatient care (GIP),
2) Reporting of the service facility National Provide Identifier (NPI)
3) Reporting of infusion pumps and prescription drugs
These new requirements from CMS should come as no surprise because the Medicare Payment Advisory Commission (MedPAC), the Government Accountability Office (GAO), and the Office of the Inspector General (OIG) have all recommended over the past several years that CMS collect more comprehensive data in order to better evaluate trends in utilization of the Medicare hospice benefit. On several occasions, industry representatives have communicated to CMS that the required claims information was not comprehensive enough to accurately reflect hospice care. Industry stakeholders also commented that to understand hospice costs, CMS should consider non-labor costs, as these can be significant, and are largely comprised of data on drugs, Durable Medical Equipment (DME), and medical supplies. Finally, the Affordable Care Act gives CMS the authority to collect additional data as needed to revise payments for hospice care. The additional claims data collection is a step forward and will support the hospice payment reform that is coming down the pipeline.
New Reporting Requirement for GIP:
This includes visits reported by hospice nurses, aides, social workers, physical therapists, occupational therapists, and speech-language pathologists, on a line-item basis, with visit and visit length reported as is done for the home levels of care. It also includes certain calls by hospice social workers, with call and call length reported as is done for the home levels of care. CMS is not changing the existing GIP visit reporting requirements when the site of service is a hospice inpatient unit.
New Reporting Requirement for NPI:
This includes the NPI of any nursing facility, hospital, or hospice inpatient facility where the patient is receiving services, regardless of the level of care provided, when the site of service is not the billing hospice. The billing hospice must report the name, address, and NPI of the service facility where the service is being performed when the service is not performed at the same location as the billing hospice’s location.
New Reporting Requirement for drugs:
In most hospices, the requested information from CMS should already be recorded somewhere for administrative purposes. The heavy lifting work is about how to make it organized in a format that is ready for CMS claim submission. For some hospices, providing these data might mean additional billing staff to gather information and to file the CMS claim forms, or for the others, a change in IT infrastructure is needed to make sure the data are fed into the right places for billing. There is no unique solution for all hospices to follow; the bottom line is that your hospice needs to find a plan or protocol for your staff that will fit the work flow. And, the plan should also provide better coordination among all vendors involved in the data transmission process, such as your pharmacy benefit management (PBM) company, infusion pharmacy, the electronic medical record system and the Medicare contractor. For example, here at Outcome Resources, we provide invoices that package all the NDC coding for CMS submission and we work with our clients and their vendors to figure out a plan for data transmission if necessary. When your plan is in place, you should also take advantage of the voluntary reporting period and start testing your protocol for glitches on January 1st, 2014. That way, your hospice can resolve any issues now in order to avoid rejected claims later when data submission becomes mandatory on April 1st, 2014.
Do you want to further discuss your hospice's plan for achieving your goals in regards to the new reporting requirements for prescription drugs? Request More Information Today.
1) The official instruction, CR8358 issued to your Medicare contractor regarding this change may be viewed on the CMS website:
2) To view the Affordable Care Act, See the following:
Dr. Julia Harder, PharmD, CGP
The hospice community is buzzing with the news of the Centers for Medicare & Medicaid Services (CMS)’s Proposed Rule, released on May 10, regarding the use of Debility Unspecified and Adult Failure to Thrive (AFTT) as primary hospice diagnoses. This blog post will update you on what the Proposed Rule is, what it will mean for your hospice if implemented, and what you can do now to prepare for the possible change. To read the complete Proposed Rule, go to: http://www.gpo.gov/fdsys/pkg/FR-2013-05-10/pdf/2013-10389.pdf.
What is the Proposed Change?
Debility and AFTT would not be allowed as principal hospice diagnoses on the hospice claim form. When reported as a principal diagnosis, these would be considered questionable encounters for hospice care, and the claim would be returned to the provider for a more definitive principal diagnosis.
According to CMS, Debility and AFTT are non-specific, symptom diagnoses, classified under the ICD-9 category of “Symptoms, Signs and Ill-Defined Conditions.” Codes under the classification “Symptoms, Signs, and Ill-defined Conditions” are not to be used as the principal diagnosis when a related definitive diagnosis has been established or confirmed by the provider.
The principal diagnosis listed should be the diagnosis which is determined to be most contributory to the terminal condition. Debility and AFTT could be listed on the hospice claim as other, additional, or coexisting diagnoses if needed to support prognosis.
Why is CMS Proposing this Change?
The Proposed Rule gives data showing the changes in diagnosis patterns among Medicare hospice enrollees, with a growing percentage of beneficiaries being admitted under the non-specific diagnoses of Debility and AFTT. In the past 10 years, Debility Unspecified has moved from the 3rd most common hospice diagnosis (6% of all patients) to the #1 most common diagnosis, accounting for 12% of hospice patients. AFTT has moved from #8 (3% of patients) up to #3 (7% of patients). In 2012, Debility and AFTT, the #1 and #3 most common hospice diagnoses, collectively accounted for about one in five hospice patients. See Chart here.
Simultaneously, the average lifetime length of stay for beneficiaries has increased, from 54 days in 2000 to 86 days in 2010, an increase of 59 percent. While this is undoubtedly partially due to the earlier identification of patients who are eligible for hospice services and increased awareness among Medicare beneficiaries of the availability of the hospice benefit, it is probably also due in part to the increased number of patients being admitted with Debility and AFTT, as these patients tend to have longer length of stays in hospice.
Furthermore, CMS expressed concern that if a nonspecific, ill-defined diagnosis is reported as the principal hospice diagnosis, a comprehensive, individualized plan of care may be difficult to accurately develop and implement, and, as a result, the hospice beneficiary may not receive the full benefit of hospice services. The comprehensive hospice plan of care should start with an accurate and thorough assessment and identification of the conditions contributing to the terminal illness and decline so that the patient will receive the best and most patient-specific care.
What Should Our Hospice Do Now?
It is important to understand that this is still a Proposed Rule and is not yet in effect, so you may still submit claims under Debility and AFTT. Because we do not yet know what the Final Rule will be, it may not be necessary to make sweeping changes now. However, many hospices have already reduced, or completely ceased, their use of Debility and AFTT as primary diagnoses, and some are even changing the primary diagnosis for existing beneficiaries currently admitted under Debility or AFTT. Your hospice will need to decide how you want to proceed at present. Consider making some changes now to prepare your hospice and reduce the impact when the Final Rule is released.
Try to reduce or even cease the use of Debility and AFTT as primary hospice diagnoses. Instead, select a primary diagnosis that is most contributory to the patient’s terminal disease trajectory. Reviewing the Plan of Care, the patient’s medical history, and the patient’s drug profile may help you determine which diagnosis is most contributing to the patient’s overall decline and will require the greatest amount of palliative interventions. List this medical condition as the primary diagnosis, and include Debility or AFTT as an additional diagnosis if needed to support prognosis.
CMS is accepting comments on the Proposed Rule until June 28, 2013. You may submit a comment:
• Online at http://www.regulations.gov. Follow the “Submit a Comment” instructions and refer to file code CMS–1449–P.
• By mail to Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS–1449–P, P.O. Box 8010, Baltimore, MD 21244–8010.
And please leave us a comment here on the blog… What impact has this Proposed Rule had on your hospice?
After a recently completed investigation, the Office of the Inspector General (OIG) has issued a report entitled “Medicare Could Be Paying Twice for Prescription Drugs for Beneficiaries in Hospice.” This report draws attention to the fact that hospices may not be paying appropriately for their patients’ medications.
Hospice care is a Medicare Part A benefit. To be eligible for Medicare hospice care, a beneficiary must be entitled to Part A of Medicare and be certified as terminally ill (i.e., having a life expectancy of 6 months or less). The Medicare hospice benefit includes a per diem payment made by the Centers for Medicare & Medicaid Services (CMS) to a hospice organization for each day that a beneficiary is in hospice care, regardless of the number of services furnished. Drugs used primarily for symptom control and the relief of pain related to the individual’s terminal illness are covered under the hospice benefit, and the cost of providing these drugs is included in the per diem rate. As a result, hospice organizations should pay the dispensing pharmacies for these drugs.
Medications NOT related to the patient’s terminal diagnosis or to general end-of-life symptom management are paid for by the patient’s Medicare Part D benefit, another private insurance plan, or out-of-pocket by the patient themselves. But what the OIG has found is that Medicare Part D has been paying for medications that should have been paid for by the hospice, out of the per diem provided by CMS. In other words, the Medicare program paid twice for these medications. In addition, patients may have paid a copay that they shouldn’t have had to pay.
During calendar year 2009, the OIG identified 198,543 hospice beneficiaries who received 677,022 prescription drugs through the Medicare Part D program that potentially should have been covered under the per diem payments made to hospice organizations. These drugs were prescription analgesic, anti-nausea, laxative, and anti-anxiety drugs, as well as prescription drugs used to treat COPD and ALS. Medicare Part D paid pharmacies over $33 million for these prescription drugs, and beneficiaries paid nearly $4 million in copayments.
In response to these findings, the OIG has made a number of recommendations to CMS. The OIG recommends that CMS:
• educate hospices, pharmacies and Medicare Part D sponsors that Medicare Part D should NOT pay for drugs related to a hospice patient’s terminal illness
• perform oversight to ensure that Part D is not paying for drugs that Medicare has already covered under the per diem payments made to hospice organizations
• require Medicare Part D sponsors to develop controls that prevent Part D from paying for drugs that are already covered under the per diem payments.
What might this report mean for your hospice? The government has already been cracking down on hospices due to increasing reports of Medicare fraud, and with this new alert issued by the OIG, it is likely that these investigations will continue, if not increase in frequency. It is extremely important that hospices make the correct determination regarding which of a patient’s medications to cover, and that they document the rationale behind each coverage decision made. Once coverage decisions have been made, the hospice should have procedures in place to assure that billing is happening properly, so that medications are not inadvertently being paid for twice.
The decision of whether to pay for a particular medication is often a complicated one. We have guidelines that may help. In the last two editions of the Outcome Resources drug information newsletter, The Clinician, we have reviewed, in a two-part series, our Guidelines for Covered Medications in Hospice Patients. These guidelines may help your hospice ensure that you are making the proper decisions regarding medication coverage for each of your hospice patients. If you don’t have a copy of the newsletter, please contact us to request one.
| July 10, 2011Oh, I love that picture. That may be my fartvioe.The human body does some miraculous things as we die, including giving us one last rally. This may be what your mom is doing. The last rally provides an opportunity for everyone to gather and share one last time.If I might make a suggestion: I believe your mom is ready. I think she felt better about leaving once Hospice became involved because she knew you would have help and support. I'm sure you've done this alreay But, just in case: If you could let her know that you're okay, that it's okay that she leaves, then you would truly be giving her an incredible gift. Hope this helps.
Posted 2/14/2013 12:26:56 PM
|COPD and Lung cancer are two distinct conditions, but they definitely are related. Most patients who have lung cancer also have COPD (estimates have been published that up to 80% of lung cancer patients also have COPD). It has been established that COPD raises the risk for Lung Cancer. The symptoms of Lung Cancer and COPD are very similar and overlap. Medicare regs require the hospice to cover drug therapy that is necessary for management of the terminal illness (in this case Lung Cancer) AND related conditions (in this case COPD). There is no question in my mind that Lung Cancer and COPD are related and therefore, the meds commonly used for management of COPD should be covered for the patient with a hospice diagnosis of Lung Cancer. You are right, Sonjia:: much education needs to occur.
-- Jim Joyner
Posted 7/24/2012 10:22:29 AM
Thanks for your question. I think the sentence you are referring to is this one: "Medications NOT related to the patientâ€™s terminal diagnosis or to general end-of-life symptom management are paid for by the patientâ€™s Medicare Part D benefit, another private insurance plan, or out-of-pocket by the patient themselves." I apologize if this was not clear. What I mean is that the hospice should pay for medications related to the terminal diagnosis or EOL symptom management; everything else should be paid for by Medicare Part D, private insurance, or the patient themselves. Medicare Part D should NOT be billed for medications related to general EOL symptom management.
I agree with you that education is a must. It's a very complicated issue and we get questions all the time regarding what should and should not be covered. Regarding your lung cancer/COPD question: I've seen hospices do both, and I think you could make a convincing argument not to cover long-standing COPD meds in a patient with newly diagnosed lung cancer. But in a patient with shortness of breath from lung cancer, I think you may have a hard time making the argument that the bronchodilators you are using for COPD are not providing symptom management for the lung cancer -- patients with lung cancer frequently end up using meds like inhaled bronchodilators and inhaled corticosteroids to manage their disease, so could you convince an auditor that the patient's albuterol is not related to the terminal diagnosis? In the OIG's report, COPD meds were one of the groups of medications identified as being frequently paid for by Medicare Part D when they should have been paid for by the hospice. I don't know what the patients' terminal diagnoses were in these cases, but I think the point is that there is significant confusion -- or differing opinions -- surrounding when and when not to cover inhaled medications.
Thanks again for your comments!
-- Julia Harder
Posted 7/24/2012 06:44:36 AM
|Much education needs to occur to get a clear understanding of this. I have heard both extremes - the medical director of a FI told me a few years ago that I should be covering eye drops for glaucoma for the dx of debility (I disagree) and a hospice told me hospice should only cover meds for pain, SOB, nausea, etc and never meds such as albuterol for COPD (I disagree again).
In your last issue, you stated that a pt with a hospice dx of lung cancer and who also has COPD should have their inhalers covered. If that pt has been using inhalers for years for COPD and now has lung cancer why would hospice cover them? They are unrelated diseases.
-- Sonjia Hauser
Posted 7/23/2012 01:48:49 PM
|I'm not sure what you mean when you state above that "general end of life symptom management" is covered by Part D. How would you distinguish that type of symptom management from that related to the terminal diagnosis? Can you please provide examples of general EOL symptom management that the hospice would not be responsible for? Thanks.
-- Terri Maxwell
Posted 7/20/2012 06:12:38 AM
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