Home Health & Hospice Week

Skilled diagnosis coding may ease your burden.

Hospices will have their hands full with yet another new requirement starting May 1 — the prior authorization process for drugs unrelated to the terminal illness (see related story, p. 82).

Consider these pointers from the experts to survive and thrive under the new mandate:

1. Get your diagnosis coding straight. Your difficulty transitioning to the new PA process for unrelated drugs will depend on how well you’ve laid the groundwork with your diagnosis coding, says consultant Susan Balfour of Hospice Funda-mentals. If you don’t already have a sound process in place to identify the terminal, related, and secondary and unrelated diagnoses — both at the time of admission and periodically throughout care — you need to get on it ASAP.

“Once that process is in place, it is much easier to properly categorize the medications by which party has financial responsibility — the hospice, Part D or the beneficiary — and complete the necessary paperwork and communications,” Balfour advises.

2. Be proactive at admission. Revisit and revise your intake process to focus on drug-related issues. Make sure you have the beneficiary’s correct Part D plan information so you can begin the straightforward hospice-initiated PA process immediately, Balfour recommends.

“Develop standardized procedures, guidelines, or forms to assist in evaluating all patient medications on admission and periodically thereafter,” instructs attorney Marie Berliner with Joy & Young in Austin.

3. Communicate with the doc ASAP. When a drug or biological is unrelated to the terminal illness, you need to immediately reach out to the prescribing physician and obtain a detailed explanation, counsels attorney Robert Markette Jr. with Hall Render in Indianapolis. Examples are for a heart medication for a patient whose terminal illness is lung cancer, or a Parkinson’s medication for a patient with pancreatic cancer, Markette offers.

“Review the process for how the hospice team communicates with care providers managing the non-related diagnoses,” Balfour suggests. “We’ve always been responsible for communicating with them, but the stakes are higher now. The process will not work if hospices are not keeping up their end.”

You may find you receive better responses if you spend some time now educating physicians on the new requirement, Markette suggests.

4. Create new forms. The PA process will be easier and its results more consistent if you use standardized forms. Consider creating a PA form that includes the data elements outlined by CMS in its memo (see related story, p. 83), plus other helpful information such as information required from the prescribing physician, Markette says.

Berliner recommends using forms to interact with your pharmacy and Part D plan partners. Use the forms “in communicating with pharmacies, Part D Sponsors and plans to provide written explanations of the relatedness decisions,” she advises.

5. Establish P&P on related decisions. You’re going to need to make the call on whether a drug is related to the terminal illness, and you’re going to have to back it up with documentation. “Develop a process, with the input of the medical director, other hospice physicians, pharmacist(s) or any clinical specialists, to guide discussions and decisions on relatedness,” Berliner counsels.

Hospices have always been responsible for determining unrelated drugs, Balfour points out. “But many hospices did not have a good handle on it until 2012, when CMS made it clear that claims needed to be coded to include related and secondary conditions as well as the terminal diagnosis,” she says.

Hospices that have a comprehensive diagnosis coding system in place will be well on their way to compliance with this requirement, while those still placing only one code on a claim will have a much heaver burden ahead of them to fulfill the PA duties this memo sets forth, Balfour notes.

Red flags: You may want to include extra details in your guidance on hot button drugs CMS and the HHS Office of Inspector General have identified in the past as problematic: analgesics, antinauseants, laxatives, and antianxiety drugs. Unlike in the initial drug coverage memo, CMS doesn’t mention the drugs specifically in the latest missive. But you can be sure these high-spending-related drugs will stay on the feds’ radar.

6. Individualize your determination decisions. You’ll have to look at the facts of a case to determine whether a drug is unrelated, Berliner urges. You can’t just say that you always cover a certain drug, or never do. The decision must be “individualized to the patient and their particular combination of conditions, signs, and symptoms,” she says. 

And your documentation of the decision should reflect that. Documentation can include “applicable references to any helpful objective documentation or criteria such as LCDs, articles or similar materials,” Berliner offers.

7. Sharpen your beneficiary communication skills. This PA process highlights the potential adversarial relationship between the hospice and the beneficiary related to coverage decisions under Medicare, Balfour notes. If your hospice patient takes a drug that you don’t cover — because it is no longer covered for the terminal illness, because you offer an alternative medication, or another reason — you will have to break that news to the beneficiary.

When the beneficiary is liable for a medication she wants, “who will be responsible for that communication and what is their skill level?” Balfour asks. “The conversations are about so much more than the medication itself and hospices cannot assume that everyone automatically has a skill or comfort level that they need.”

Bottom line: “Assess and train” for this scenario, Balfour advises.

8. Submit comments. CMS will issue a proposed rule outlining the dispute resolution process and perhaps more PA-related procedures for 2015. Keep an eye out for the rule and submit comments on it, Berliner urges. “It will be necessary for the hospice industry to voice concerns and suggest parameters for the process,” she says.

9. Check your PECOS status. CMS di-rects Part D plans to identify you via a PECOS-generated contact list. Make sure your PECOS record is updated through a link on the Medicare hospice center site at www.cms.gov/Center/Provider-Type/Hospice-Center.html — scroll down in the “Spot-lights” box for the link.