Eli's Hospice Insider

How often are you taking measurements?

You can bulletproof your hospice patients’ claims against denials based on prognosis by using specifics in your documentation.

For patients who live longer than six months, medical reviewers often find it easy to deny claims based on ineligibility due to lack of terminal diagnosis (see related cover story). “Patients that have ceased to show on-going decline or who have plateaued from a trajectory of decline may no longer meet hospice eligibility guidelines despite a significant need for custodial care,” says HHH Medicare Administrative Contractor CGS in a recent article on its website.

You’ll need to show that your patient is still on the six-month path. Use these tips regarding measurements to safeguard your claims:

1. Establish a baseline. You can’t show decline if reviewers don’t know where the patient started. One of the most important metrics to capture upon admission is weight loss due to decreasing oral intake, CGS suggests. Since it “is often a good predictor of decline, it is essential that hospice staff document this information in the hospice medical record,” the MAC urges.

Obtaining weight information for a bedbound patient can be a challenge, acknowledges nurse consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C. But it is “of vital importance to do a thorough assessment at admission,” she stresses.

If your patient resides in a nursing facility, the job is a bit easier. Still, “if … bed scales, Hoyer lifts or other means of weighing the patient are accessible, impress upon the staff the importance of obtaining weights routinely,” CGS exhorts.

2. Include weight alternatives. While weight is very important to medical reviewers, other objective measurements can also do the job (along with painting a robust clinical picture of the patient) of proving ongoing terminal status. “Obtain anthropomorphic measurements such as, mid-arm circumference or abdominal girth on admission,” CGS advises. “Establishing baseline anthropomorphic measurements upon admission will provide objective data in which to show decline if weighing the patient no longer becomes an option.”

You can also use scores from standardized assessment tools such as Functional Assessment Staging (FAST), Karnofsky Performance Scale (KPS), and more (see box on this page), suggested physician David Fedor, a hospice and health system medical director, in a presentation at the Utah Hospice & Palliative Care Organization’s November convention.

Another measurable indicator is oral intake, CGS suggests. “Inadequate oral intake documented by decreasing food portion consumption” can be a decline factor. “Using specific portion sizes or percentages of food intake is more descriptive than a general comment, such as ‘intake declining.’”

3. Keep up the documentation. Don’t wait until recertification to take the next set of measurements, Laff recommends. Record new measurements at least monthly. “This will continually document gradual or rapid decline,” Laff tells Eli.

4. Heed Medicare policies. “The National Coverage Guidelines for specific hospice terminal diagnoses should be followed to a T,” Laff counsels.

MACs CGS and National Government Services have published Local Coverage Determinations for “Determining Terminal Status.” MAC Palmetto GBA has published hospice LCDs for seven diseases: HIV Disease, Liver Disease, Neurological Conditions, Renal Care, Alzheimer’s Disease & Related Disorders, Cardiopulmonary Conditions, and The Adult Failure To Thrive Syndrome.

Palmetto has also published two articles in the Medicare Coverage Database: “Going Beyond Diagnosis®: HOSPICE Cardiopulmonary Conditions LCD” and “Documenting Weight Loss for Beneficiaries with Non-Neoplastic Conditions.” NGS has an article “Determining Terminal Status — Supplemental Instructions Article.”

Resource: Links to the LCDs and articles are available in the MCD at www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx — in the “Quick Search” box on the right, select your state and enter “hospice” as the search term. Or for free links to and PDF copies of the policies, email editor Rebecca Johnson with “Hospice LCDs” and your MAC’s name in the subject line.

Remember: LCDs and MAC guidance are not the be all end all when it comes to coverage, Fedor said in his presentation. “You can admit or recertify patients who don’t meet enough criteria,” according to his slides. “You just have to be very specific in your narrative. Tell a story. I don’t know the patient, and why they are terminally ill. Make me see what you see.”

5. Avoid measurement pitfalls. For example, you might think you’re doing a great job by recording the patient’s percent of weight loss. But Palmetto may not agree. “If hospice organizations record ‘percent weight loss’ as an indicator of nutritional status, Palmetto GBA expects to see supporting documentation of the absolute weights used to calculate the percent decrease,” the MAC says in its MCD article on documenting weight loss. “The reporting of absolute weights strengthens documentation of percent change in weight over time,” the MAC continues. “Unsupported percent weight loss in the medical record may result in a denial if other documentation does not lend support to impaired nutritional status.”

Another one: Don’t use vague documentation such as “weight declining” without backing it up with measurements.

Cause-and-effect: Declining weight and/or oral intake won’t support terminal diagnosis if it is caused by other things, CGS says. Show that “the weight loss and decreased appetite is not caused by other factors such as medication.”