Home Health & Hospice Week

Use these 7 tips to keep your rightful hospice reimbursement.

Chances are a reviewer's going to be looking over your hospice patients' records soon. Will they pass muster?

Even if you're operating by all the rules when furnishing Medicare-covered hospice care, you're still doing to draw attention if you exhibit any of a long list of red flags (see related story, p. 58), points out attorney Robert Markette Jr. with law firm Benesch Friedlander Coplan & Aronoff in Indianapolis.

Take these steps suggested by industry experts to survive the scrutiny:

1. Show the patient's decline. If your patient doesn't appear to be getting worse, reviewers are likely to rule her not terminal. "If it's not in the record, then as far as any reviewer is concerned, it didn't happen," reminds attorney Marie Berliner with Joy & Young in Austin, Texas.

Hard data is preferable to subjective (and vague) narrative statements to prove decline has occurred. Tools such as the Functional Assessment Scale (FAST) and Palliative Performance Scale (PPS) help clinicians document specifics.

Remember: You must collect data over time, not just at one timepoint (admission), advises consultant Joy Barry with Weatherbee Resources in Hyannis, Mass.

2. Go beyond scores. While FAST, PPS and other standardized tool scores are important, they aren't the only data your patient records should contain. Get specific with data about the patient's condition, Berliner and Barry urge.

For example: Don't just document whether the patient needs caregiver support for activities of daily living, Barry suggests. Also note how much support is required -- a support level that goes from moderate to total is a decline indicator.

Don't overlook factors that caregivers or clinicians may feel are unimportant, Berliner counsels. A decrease in how much eye contact the patient makes or how much she mumbles when speaking can be significant. "Little things taken as a whole can demonstrate overall decline," she tells Eli.

3. Consult all disciplines. It's not just nurses who need to document decline in the record, Berliner explains. Other visiting staff such as the chaplain may notice decline indicators, particularly if they don't see the patient as often as other caregivers. Include observations from family in the record as well.

4. Combat stable scores. FAST, PPS and other scores may stay stable, but that doesn't mean the patient isn't declining. You'll need to use the data you're collecting to show how the patient's condition is still getting worse despite stable scores.

Sometimes FAST scores, weight, or other data can't go down any further without the patient dying, Berliner notes. That's the time to use other less traditional indicators to show decline is still occurring.

For example: Maybe when a patient was admitted, he could eat 100 percent of his lunch in 15 minutes, Barry offers. Now he eats only 50 percent of his lunch over 60 minutes. Be sure to document that decline in the record.

Or for a patient with COPD, show how many steps she can take before shortness of breath, and how long her recovery time is. When the number of steps decrease or the recovery time increases, "that's decline," Barry stresses.

5. Educate visiting staff. Clinicians and other hospice staff won't magically know how to document decline to the best of their ability on their own. You need to educate the entire interdisciplinary team on the technical and clinical aspects of hospice eligibility, Barry recommends.

Tip: Focus on local coverage determination (LCD) guidelines and data collection, Barry advises.

6. Plan for discharges. There will be times that discharge is necessary if the patient is no longer eligible for the benefit. Make sure you have a streamlined, efficient discharge process in place to handle these cases, Barry urges.

Have a physician or nurse practitioner drive the process, Barry suggests. They should see the patient and make a determination of eligibility. If the doc or NP says the patient is still eligible, than the discharge plan can be halted.

"A tight and timely process for [discharge] is important," Barry stresses. Medicare will not cover services just because it took you a while to act after the patient became ineligible for the benefit.

Red flag: It looks suspicious if all of your discharges occur at the end of patients' benefit periods, Barry warns. Evaluating patients for eligibility and discharge is "an ongoing process," she says.

7. Don't rely on outcomes. Hospices have often had success convincing medical reviewers of a patient's terminal status when the patient died shortly after the services under review were furnished. Don't expect that to continue, Barry cautions.

Auditors from Zone Program Integrity Contractors are denying claims when the record doesn't support terminal illness, Barry reports. ZPIC denial letters will start "Even though Mr. X died 45 days later," she laments.

This means you need to beef up your documentation, even on short stay patients.