Home Health & Hospice Week

If you wait for medical reviewers to ferret out your problems with the new physician hospice narrative requirement, you could be in a world of hurt payment-wise.

Hospices actually seem to be doing OK with the narrative portion of the new requirement that went into effect Oct. 1, indicates regional home health intermediary Cahaba GBA. "Many hospices are complying with the use of the physician narrative requirement," the intermediary reports in an email message to providers.

Background: Under the new requirement, the Centers for Medicare & Medicaid Services requires the certifying physician to include a brief narrative explanation of the clinical findings that supports a life expectancy of six months or less. The narrative can be part of, or an addendum to, the cert/recert form. "The narrative must reflect the patient's individual clinical circumstances and cannot contain check boxes or standard language used for all patients," CMS says on its Web site. The same physician who certifies the patient must compose the narrative, Cahaba adds.

But the attestation part of the narrative requirement is throwing hospices for a loop. Often, "the attestation statement is missing," Cahaba says.

"Our medical review staff will deny hospice claims which do not include this attestation statement on the narrative for the certification/recertification."

What it is: The attestation is a statement under the physician's signature that says "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," RHHI Palmetto GBA notes in an article on its Web site.

Hospices are likely confusing the narrative and the attestation components of the new requirement, suspects hospice expert Jay Mahoney with Summit Business Group in Penfield, N.Y. "I'm not sure that all hospices fully understand that there is a difference between the attestation statement and the narrative," says Mahoney, former head of the National Hospice Organization. "Some hospices may be assuming that the physician narrative is the attestation statement."

And some hospices simply may not be up to speed on the requirement yet, Mahoney adds. "While I don't think it is a valid excuse, some hospices ... just haven't fully processed the requirement," Mahoney tells Eli. "If they continue to have their claims paid, they may not yet understand that they are not in full compliance."

Such hospices could be in big reimbursement trouble if medical reviewers begin to review their claims. "They could be in for a rude awakening," Mahoney warns.

Hospices may also be confused because CMS hasn't mandated specific language for the attestation. "Any language under the physician's signature which attests 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 meets the attestation regulatory requirement," CMS said in a question-and-answer on the topic last fall.

Do this: Hospices should decide on the language they want physicians to use in the attestation and preprint it on their cert/recert forms, Mahoney advises. "There has been so much more emphasis on obtaining the physician narrative that some hospices have likely neglected to change their forms to contain the attestation," he says. "This may also be an issue with computerized forms."

Take a look at Cahaba's recently updated sample hospice certification form for guidance. At the bottom of the form, it says "Attestation Statement: By signing this certification, the physician, named above, confirms that he/she composed the narrative based on his/her review of the patient's medical record or his/her examination of the patient."

Resource: For a copy of the form, go online to www.cahabagba.com/rhhi/education/materials/quick_hospice_certification.pdf or see Eli's HCW, Vol. XVIII, No. 32, p. 252.

The bottom line: No matter how great the physician narrative is, reviewers will deny your claims if the narrative doesn't include the attestation, Cahaba stresses. And judging from Cahaba's initial analysis, the missing attestations are widespread enough to impact a lot of hospices. "The problem ... is that there is no grace period," Mahoney notes. "Certifications and recertifications that are lacking the attestation statements are technically non-compliant and the hospices could face some significant payment problems."